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Peripherally Inserted Central Catheter Placement in Infants and Children
Peripherally Inserted Central Catheter Placement in Infants and Children Leah E. Braswell, MD The most common venous access procedure performed in children and infants is the peripherally inserted central catheter, or “PICC.” Placement of a PICC affords patients stable long-term venous access for medication administration and blood draws. The Interventional Radiology team faces particular challenges in the placement and management of these catheters in a pediatric population. This article discusses our institution’s step-bystep approach to operating a hospital-wide PICC service. Tech Vasc Interventional Rad 14:204-211 © 2011 Elsevier Inc. All rights reserved. KEYWORDS PICC, infants, children, interventional radiology, technique
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Preprocedure Evaluation and Planning
Pediatric Interventional Radiology, Department of Radiology, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR. Address reprint requests to Leah E. Braswell, MD, Arkansas Children’s Hospital, Department of Radiology, One Children’s Way, Little Rock, AR 72202. E-mail: [email protected]
The first steps of PICC placement take place long before a given patient arrives in the angiography suite. When a request for PICC placement is received, a member of the IR team, typically a registered nurse with IR training, reviews the pertinent clinical information by telephone conversation with the requesting provider. Indications for long-term venous access include need for administration of antibiotics (eg, in the case of osteomyelitis or pulmonary infection related to cystic fibrosis), chemotherapy, parenteral nutrition, or other medications. Many patients have tenuous peripheral venous access that is inadequate for the expected length of therapy or inpatient stay. In other cases, a PICC is the procedure that allows a patient to be discharged for completion of intravenous therapy at home. In our patients who have had multiple previous PICCs, care is taken to avoid chronic vein injury and stenosis. The prior IR procedure notes are reviewed. Note is made of which arm was chosen, which vein was accessed, and if there has been any difficulty in placement. For example, a patient with 7 previous PICCs (4 on the right, 3 on the left, known basilic vein stenosis on the right, and most recent PICC on the right) will first be attempted on the left arm. We alternate arms in patients who present for repeat procedure in an attempt to reduce formation of stenoses. Occasionally, the decision to use alternate forms of venous access is made in conjunction with the referring team; examples include children with renal failure and anticipated need for upper extremity dialysis fistulas.4 Any additional pertinent clinical history is also reviewed. For children with a history of congenital heart disease, there
any infants and children require central venous access during the course of an acute or chronic illness. The placement and maintenance of central venous lines are especially difficult in the pediatric population due to small patient size and inability or unwillingness to cooperate with an invasive procedure. Given its safety and reliability as a method to efficiently obtain central access, the peripherally inserted central catheter (PICC) has emerged as a favorable procedure in children.1-3 It is our institutional experience that the Interventional Radiology service provides more PICCs than all other central lines combined. We as interventional radiology (IR) practitioners possess comprehensive skills in delivering image-guided care and are uniquely suited to perform this common and potentially difficult access procedure. With high success and safety rates comes increased demand for comprehensive access delivery and maintenance, and yet few centers have IR services specifically dedicated to the care of pediatric patients. Whether for the practitioner establishing or expanding a pediatric PICC program, this article provides practical tips that have allowed our IR service to deliver comprehensive PICC care.
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Peripherally inserted central catheter placement in infants and children
205 with continual cardiopulmonary monitoring in the presence of nurses skilled in sedation techniques. Although PICC placement is not a highly painful procedure, anxiolysis and stillness are of the utmost importance when the operator is working to access a very small vein. In some cases, anesthesia and/or Child Life Services are present to assist with PICC placement. Some centers rely heavily on these resources, potentially decreasing the need for sedation.6 When patients from the neonatal intensive care unit or pediatric intensive care unit are in our laboratory, we require that their nurse is present for the procedure to assist in the monitoring and clinical care of the patient.
Patient Positioning Figure 1 Tourniquet and arm positioning. The tourniquet is placed loosely before drape placement, and then tightened by an IR laboratory assistant. Topical LMX had been placed within a circular area drawn by the IR specialty nurse. (Color version of figure is available online.)
may be altered central venous anatomy related to congenital or postsurgical conditions. These include situs anomalies, presence of duplicated superior vena cava (SVC) or left-sided SVC, and the presence of surgical shunts (eg, Glenn cavopulmonary shunt). Many other possibilities exist, and preoperative or postoperative imaging studies may be reviewed. In some of these cases, the eventual tip position of the PICC we place is in the medial subclavian or upper inominate vein rather than the typical SVC or cavoatrial junction placement to avoid catheter thrombosis near the pulmonary arteries or infusion of solutions or medications into the venous shunt.5 Once a procedure is planned, our specialty nurse has a face-to-face conversation with the patient and family members. At this time, initial line care education takes place, all questions are answered, and informed consent is obtained.
Once in the laboratory, the patient is positioned on the IR procedure table. Before timeout, confirmation of the appropriate side (right vs left arm) is made. For some children, television can be a useful distraction. A tourniquet is loosely positioned at the level of the shoulder (Fig. 1). The arm is held vertically and prepped circumferentially from the axilla to the mid forearm. Once the arm is laid on the arm board extension, we place a “seatbelt” that fastens the supinated hand firmly to the board with tape wound multiple times, and then the sterile prep is completed (Fig. 2). A second “seatbelt” is placed across the lower extremities. We have found that these are necessary in all patients, even those who seem to be cooperative and well-sedated. Before the procedure begins, the physician performs a sterile scrub and follows full gown and glove protocol. We dim the overhead lights for all PICC placements as soon as the prep is complete. This frequently helps calm infants and young children, who are typically receiving their first dose of sedation at this point. Dimming the lights also serves to optimize the ultrasound monitor image by reducing glare. During positioning and room setup and throughout the procedure, we avoid words such as “needle” or “sharp.” In our laboratory, “device” is our team members’ term for the IV
Sedation The patient is assessed for ability to cooperate, and a sedation plan is formulated in conjunction with the patient and family. This plan is a crucial component of our care. Whereas adults typically require no sedation for PICC placement, many children and their caregivers have considerable anxiety and fear related to any invasive procedure. In our experience, there are many children over 7 years who need no medical sedation for PICC placement. The percentage of patients who tolerate nonsedation increases with age. We prefer IV sedation in most patients younger than that age range. During this evaluation and consent visit, we place topical lidocaine cream (LMX) on the soft tissues of the medial upper arms. This step alleviates pain at the skin site, and many children remark that they did not feel a needle puncture at all. Our IR physicians are approved administrators of midazolam, ketamine, and fentanyl. In infants and young children, our most frequent combination uses midazolam and ketamine. These are administered in alternating titrated doses
Figure 2 Supinated hand. To secure the upper extremity and reduce patient motion, we firmly wrap the patient’s hand with tape. (Color version of figure is available online.)
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access needle, “silver” refers to the 18-gauge puncture needle, and “-otomy” replaces “scalpel.”
Vein Selection and Planning There is a steep learning curve for the technically challenging ultrasound-guided venipuncture in the very small veins of infants and young children. Repetition, both initially and on an ongoing basis, is helpful. Appropriate planning before the puncture is of the utmost importance. A targeted preliminary ultrasound (linear 7-MHz transducer) with moderately tight tourniquet is used to map the available veins and choose a skin site for the appropriate vein. Tourniquet pressure is ideally such that the veins are distended for better visualization and puncture, but not so high that arterial blood flow is compromised.5 We exclusively use transverse imaging before and during the procedure. Although longitudinal imaging techniques have been described for PICC venipuncture,2 we recognize the potential pitfalls, particularly of arterial puncture, and image in the transverse plane. Vein compressibility is confirmed, and color Doppler can be used if necessary. Some centers make use of small foot plate high-frequency probes.5 In small infants, it is helpful to schematically divide the longitudinal extent of the upper extremity (between elbow and axilla) into 3 compartments: proximal, mid, and distal. The first attempt at venipuncture is the most distal; if this initial attempt fails and there is damage to the vein with accompanying hematoma, there is space in the mid and then proximal compartments for 1 to 2 more attempts proximal to the vein injury. This is particularly helpful in a training situation, when a fellow, radiology assistant, or other trainee is performing the first attempt. If present and reasonably sized on ultrasound, the basilic vein is preferred for initial access attempt. The vein takes a relatively straight course to the central venous system and is
Figure 3 Skin site selection. With the aid of initial targeted ultrasound, a skin site is chosen. It is marked with a plastic sheath as a landmark for subsequent steps. If possible, this skin site resides within the LMX treatment area. (Color version of figure is available online.)
Figure 4 Skin incision. With an 18-gauge needle, the skin is punctured while applying gentle back traction to the soft tissues. This allows for gentle Angiocath needle entry in the subsequent step. Note the shallow angle. A deep puncture could injure the underlying vein. (Color version of figure is available online.)
usually the largest deep vein of the arm. The basilic is solitary and superficial along the medial aspect of the arm. The cephalic vein is prone to spasm during the procedure, has an acute angulation in its course at the level of the axilla, and is often small; some centers thereby place the cephalic lowest on their list of preferable veins.5 It can frequently be cannulated successfully, however, particularly in patients with stenoses related to previous basilic vein PICC placement. In many infants, the cephalic vein is larger than the basilic. It also runs a relatively superficial course and is typically solitary. Our experience is that the cephalic vein access should be attempted before brachial vein attempt. Suitability of the brachial veins is limited by the proximity and position of adjacent brachial artery and median nerve, and therefore, the brachial vein is lowest on our hierarchy of preferable vein
Figure 5 Venipuncture. The operator holds the ultrasound transducer in the transverse position with the left hand, while slowly advancing the Angiocath needle with the right. The Angiocath is inserted with bevel directed up. (Color version of figure is available online.)
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Figure 8 Guidewire placement. With 1 hand stabilizing the IV catheter, the stylet is removed and a guidewire gently advanced. (Color version of figure is available online.) Figure 6 Needle localization. To localize the needle tip in the ultrasound image, the acoustic fall-off that forms behind the shaft of the needle is used as a landmark. Arrows mark the lack of echoes in this distribution. (Color version of figure is available online.)
choice. Inadvertent arterial placement is most likely with this vein. In addition, some patients with brachial PICCs endure neuropathy that is due to the direct proximity of the median nerve.
Venipuncture and PICC Placement Once a vein site is chosen with ultrasound, the skin is marked with a plastic packaging sheath (Fig. 3). This step is important for maintaining consistent skin site localization during the subsequent steps. Since this step can be mildly painful, it also affords the operator an idea of how well the patient is sedated. With a 25-gauge needle, a very small amount of
Figure 7 Target sign. The tip of the needle is maintained in the center of the vein.
superficial 1% lidocaine is placed. If lidocaine is injected too deeply, vein spasm can result. Next, the skin is gently punctured with an 18-gauge needle as a small incision to allow IV catheter placement into the skin (Fig. 4). For these preliminary steps, the needle is held at an angle as close to parallel to the skin as possible to avoid injury to the vein. For venipuncture, a 22-gauge sheathed Angiocath IV catheter (BD, Franklin Lakes, NJ) is used and positioned with the bevel up (Fig. 5). A shallow angle of the access needle has been shown to optimize ultrasound visualization of the echogenic tip.7 The course of the needle tip should be visualized at all times as it approaches and enters the superficial wall of the vein. If the tip is difficult to visualize, the transducer is placed nearer to the hub of the needle, and the acoustic “fall-off” is localized (Fig. 6). The fall-off can be followed as a landmark as very small motions of the transducer guide visualization nearer and nearer to the needle tip. Once the echogenic tip is visualized entering and then within the vein, an image is
Figure 9 Dilating soft tissues. A 4-Fr dilator is advanced over the guidewire to dilate the soft tissues. The operator supports the adjacent soft tissues with a pinch technique to allow smooth advancement of equipment. (Color version of figure is available online.)
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Connolly et al observed that tip position changes with arm position. We frequently perform a provocative adduction maneuver at the time of wire measurement and/or final PICC position to judge the potential migration of PICC tip with arm positioning.8 If the tip descends to the level of the right atrium with this maneuver, a shorter length is chosen. The PICC is inserted over a guidewire through the peel-away sheath with fluoroscopic guidance, and a fluoroscopic image is saved to document tip position (Fig. 10). After placement, heparin solution is flushed into the lumen and a needleless cap is placed. The hub of the PICC is secured to the skin with 2 sutures. A BIOPATCH (Ethicon, Somerville, NJ) antimicrobial disk is placed and sterile dressing applied (Fig. 11).
PICC Selection
Figure 10 PICC tip in SVC. Tip position is acceptable in the SVC, as demonstrated here, or slightly more inferiorly at the level of the cavoatrial junction. (Color version of figure is available online.)
saved to document ultrasound guidance (Fig. 7). The hub of the needle is completely flattened to avoid back-wall puncture. A series of 3 to 4 longitudinal advances is made to thread the needle tip and gain stable venous purchase. If this step is foregone, the needle tip could be placed within the vein while the sheath remains in the soft tissues. Care is taken to maintain the tip in the center of the vein lumen. Once the Angiocath tip has been advanced, there is visual confirmation of blood return, and the inner stylet is removed. The tourniquet is released. Through the Angiocath sheath, a 0.018-inch platinum guidewire is advanced (Fig. 8). Early fluoroscopic confirmation of venous placement is helpful, particularly in small children and infants, or when arterial placement is suspected. With the guidewire in place, slightly deeper subcutaneous lidocaine is given, and a small skin incision is made with a blade. Dilatation with a 4-Fr pediatric dilator is performed. For tissue support, the soft tissues of the arm are pinched as the dilator is advanced (Fig. 9). A 4-Fr peel-away sheath is similarly placed, and the tip of the wire is advanced into the SVC at a level at or above the cavoatrial junction under fluoroscopic guidance. The length of the wire from skin to tip is estimated and marked with clamped hemostat, and the wire is removed for PICC measurement. At this step, the sheath is capped with a saline-filled syringe to reduce the small risk of air embolism, and a saline flush can be administered. The PICC is cut to length, and the length is documented in the patient’s chart. Particularly in small infants, precise measurements of length are required; the difference of a few millimeters too short or too long can be quite significant.
In children, a small-caliber PICC is preferable when navigating small veins. We use a 3-Fr single-lumen catheter (Cook, Bloomington, IN) in almost all cases. Lines of even smaller caliber (1.9 Fr) are available. It has been shown that increasing catheter diameter is significantly associated with increasing risk for venous thrombosis.9 Catheter material is also important. We prefer silicone, which is soft and pliable, in an attempt to reduce the risk of potential cardiac tamponade or vascular rupture. For limited indications and when requested in older children and adults, we do place dual lumen and/or power-injectable PICCs. We typically use a 4-Fr polyurethane dual lumen injectable PICC. With this polyurethane catheter, we do not accept right atrial placement of the tip, given that the stiffer composition increases the risk for myocardial injury.10
Figure 11 Final dressing. The PICC is secured with skin sutures and K-lock adhesive device. An antimicrobial disk is placed at the hub, and a transparent sterile dressing covers all. (Color version of figure is available online.)
Peripherally inserted central catheter placement in infants and children
Limiting Radiation Dose In children, the As Low As Reasonably Achievable (ALARA) principle guides all applications of radiation exposure. The “Image Gently, Step Lightly Pediatric Interventional Radiology Safety Checklist” is available via http://www.imagegently. org. As listed there, steps, such as collimation, last image hold, patient positioning, low-dose techniques, and others, are used before and during each case.
Troubleshooting ●
The smallest infants
Several factors contribute to the difficulty in obtaining venous access in these patients. Of course, the most salient of these is the small size of venous targets. The ultrasoundguided venipuncture is a difficult skill to master; repetition is key. Infants also have mobile, soft tissues that tend to push away from needles and equipment. This is true at the time of initial skin puncture with a lidocaine needle; it is also true when advancing the access needle into the vein and the dilator through the subcutaneous tissues. For these reasons, we emphasize deliberate, firm, yet controlled, small movements with equipment. Equipment size also lends unique challenges to the infant PICC placement. The dilator and peelaway sheath, although short, are long enough in small infants to reach the central vessels and abut mediastinal structures. We monitor these steps with fluoroscopy to avoid vascular injury. We also carefully monitor PICC tip position in small infants and make adjustments as necessary. A right atrium tip is never accepted in infants. We exclusively place silicone single-lumen catheters in these patients, keeping in mind the potential for cardiac tamponade. ●
Poorly Hydrated Infant
If an infant presents for PICC placement in a dehydrated state, vascular access can be unusually difficult. These are the patients who demonstrate that the IR team is a crucial component of vascular access for ongoing care and rehydration. We have developed an intravenous fluid bolus technique that can be used in this situation. If an IV is available, a systemic fluid bolus (5 mL/kg) is delivered at the outset of the procedure. We have shown that this technique increases the diameter of the basilic vein on ultrasound before initial needle puncture. The IV bolus technique may lead to an increased success rate.11 ●
Spasm and Stenosis
Often, an initially successful venipuncture is followed by difficulty in platinum tip wire passage to the central venous system. Whenever resistance is met at any step, imaging with fluoroscopy is required. At the level of the axilla, venospasm related to tourniquet placement is often the culprit. If this is the case, pausing the procedure for 1 minute or so can be beneficial. Vascular stenosis, however, is frequently encountered in patients who have had previous PICC or central venous lines.12 Stenosis or occlusion can occur at any point along the length of the venous system. When the initial
209 guidewire does not pass, even with gentle manipulation under fluoroscopy, conversion is then made to a short 0.018inch hydrophilic guidewire. Many areas of stenosis can be successfully traversed with a hydrophilic guidewire. If so, the wire is left in place across the lesion for the subsequent placement of a peel-away sheath. Measurement from the back of the wire to the skin and subtraction from the total length of the wire is performed to appropriately determine the PICC length. If a luminal narrowing or irregularity persists after conversion to a hydrophilic guidewire, a venogram is performed by gentle injection through a short 4-Fr dilator. The venogram demonstrates more definitively the patient’s vascular anatomy and provides guidance for wire manipulation. If the venogram demonstrates vascular occlusion and numerous collaterals, it becomes the operator’s decision whether to leave a “short” noncentral PICC with tip, for example, in the medial subclavian vein or an adjacent well-developed venous collateral. This PICC may become the only stable access for the child, but noncentral tip placement is associated with increased complication rates.13 Tip placement should be documented and communicated to the ordering medical team. Some medications, electrolyte replacements, and hypertonic fluids may not be given via a noncentral line. Alternatively, access and placement can be attempted on the opposite arm.
Complications Although serious complications are rare, there are several complications to consider, including cardiac arrhythmias, air embolism, and eventual line fragmentation, dislodgment, or malfunction. These are not unique to PICCs, and their rates do not appear to be increased compared with conventional central venous lines. ●
Infection
Infection rates in the pediatric population have been reported at 0.93 per 1000 catheter days1 and 3.02 per 1000 catheter days.14 In a series by Safdar et al of 251 adult PICCs, infection rates in the inpatient setting had increased rate of infection (2.1 per 1000 catheter days) when compared with outpatient PICCs (0.4 per 1000 catheter days).15 Hospital-wide adherence to strict guidelines during line maintenance is necessary to avoid bloodstream infection. ●
Brachial Artery and Nerve Complications
In the small arms of infants, the inherent size of vessels leaves a low margin of error. The brachial artery may be inadvertently punctured during the initial steps of PICC placement, especially when the brachial vein is the target. If this is the case, arterial flow may not be especially brisk due to tourniquet placement and the small caliber of the artery. A high index of suspicion is necessary so that 0.018-inch guidewire advancement can be monitored under fluoroscopy. Wire projection to the left of midline (Fig. 12) may indicate arterial puncture. At this point, the IV catheter sheath and wire should be removed and direct pressure applied to the arterial puncture site for several minutes. Therefore, if brachial vein
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Line Management
Figure 12 Arterial puncture. Fluoroscopic image demonstrates guidewire tip to the left of midline; inadvertent arterial puncture occurred. (Color version of figure is available online.)
access is necessary, we maintain the needle tip in the portion of vein lumen remote from the artery while the IV catheter is being threaded. This highlights the necessity of imaging in the transverse plane and monitoring needle tip position at all times so that it does not puncture the arterial sidewall. Known complications of inadvertent arterial puncture include brachial arteriovenous fistula,16 pseudoaneurysm formation,17 and potential for distal arterial flow compromise. Damage to the median nerve is a possible yet uncommon complication, typically presenting as pain in the forearm and hand. Reposition is required in these cases. Alomari and Falk reported a case of median nerve bisection because of brachial venous access for PICC placement.18 ●
Venous thrombosis and chronic stenosis
The placement of a PICC does put a patient at increased risk for venous thrombosis. Dubois et al reported a thrombosis rate of 9.3% (determined by serial ultrasound examination), but only 1 patient in the series had symptomatic deep vein thrombosis.14 Grove and Pevec reported a rate of 3.9%. The only factor significantly related to venous thrombosis in that series was increasing catheter diameter.9 Other patients at particular risk include those with clotting disorders and cystic fibrosis.19 We encountered central venous stenosis in 7.9% of our population of children who had previously received 3-Fr PICCs, and in 13% of patients with 4- to 7-Fr PICCs.12 Therefore, the possibility of subsequent stenosis is discussed with families during the attainment of consent, and our team must keep in mind the potential for future difficulty in placement or exhaustion of access sites. In our series, risk factors for stenosis include larger caliber of PICC and age ⬍2 years. We have observed that the cephalic and brachial veins in a given patient’s arm may be larger when the basilic is peripherally obliterated from previous PICCs.
In our experience, children are quite prone to dislodge any and all tubes and lines that accompany their medical care. PICCs are no exception, and we place a great deal of emphasis on securing our lines. We place skin sutures via the wings at the hub of the PICC and place an adhesive stabilization device (Grip-Lok, Zefon, Ocala, FL). In older children who do not require IV sedation, we use a StatLock “post and door” design fixation device (Bard, Murray Hill, NJ) and do not place sutures. After placement of a BIOPATCH antimicrobial disk, the entire area is covered with a sterile occlusive dressing (Fig. 11), which is changed weekly by trained hospital or home health personnel. Heparin is given at the time of placement to flush the lumen. We administer 3 mL of heparin in graduated doses based on patient weight (1 U/mL for patients in the neonatal intensive care unit; 10 U/mL for children ⬍15 kg; and 100 U/mL for children ⬎15 kg) into each lumen. Our standard post PICC placement orders indicate that this heparin dose is used at the completion of any infusion, on an as needed basis, and at least weekly. In the event of clotting, 1 mg of tissue plasminogen activator is administered and allowed to dwell for 1 hour. PICCs may be maintained indefinitely; it is not unusual for one to be in place for weeks or months. Any questions or concerns related to the function, position, or integrity of the line are handled initially by an IR nurse telephone discussion, and necessary imaging or intervention can be planned at that time. At the completion of therapy, PICCs are removed without difficulty, and the length of removed catheter can be compared with that reported in the IR procedure note.
References 1. Crowley JJ, Pereira JK, Harris LS, et al: Peripherally inserted central catheters: experience in 523 children. Radiology 204:617-621, 1997 2. Donaldson JS: Pediatric vascular access. Pediatr Radiol 36:386-397, 2006 3. Dubois J, Garel L, Tapiero B, et al: Peripherally inserted central catheters in infants and children. Radiology 204:622-626, 1997 4. Vo JN, Hoffer FA, Shaw DW: Techniques in vascular and interventional radiology: pediatric central venous access. Tech Vasc Interv Radiol 13:250-257, 2010 5. Krishnamurthy G, Keller MS: Vascular access in children. Cardiovasc Interven Radiol 2010 [published online 26, May 2010] 6. Leahy S, Kennedy RM, Hesselgrave J, et al: On the front lines: lessons learned in implementing multidisciplinary peripheral venous access pain-management programs in pediatric hospitals. Pediatrics 122 (suppl):161-170, 2008 7. Nichols K, Wright L, Spencer T, et al: Changes in ultrasonographic echogenicity and visibility of needles with changes in angles of insonation. J Vasc Interven Radiol 14:1553-1557, 2003 8. Connolly B, Amaral J, Walsh S, et al: Influence of arm movement on central tip location of peripherally inserted central catheters (PICCs). Pediatr Radiol 36:845-850, 2006 9. Grove JR, Pevec WC: Venous thrombosis related to peripherally inserted central catheters. J Vasc Interv Radiol 11:837-840, 2000 10. Towbin R: The bowed catheter sign: A risk for pericardial tamponade. Pediatr Radiol 38:331-335, 2008 11. Bhutta ST, James CA, Roberson PK, et al: Challenging infant PICCs: does a procedural fluid bolus increase vein size? Pediatr Radiol 34(suppl):77, 2004 12. Bhutta ST, James CA, Schmidt MB, et al: Repeat PICC placement incidence of central venous occlusive disease: J Vasc Interven Radiol 14 (suppl):53, 2003 [abstract]
Peripherally inserted central catheter placement in infants and children 13. Racadio JM, Doellman DA, Johnson ND, et al: Pediatric peripherally inserted central catheters: complication rates related to catheter tip location. Pediatrics 107:E28, 2001 14. Dubois J, Rypens F, Garel L: Incidence of deep vein thrombosis related to peripherally inserted central catheters in children and adolescents. J Vasc Surg 47:1120, 2008 [abstract] 15. Safdar N, Maki DG: Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest 128:489-495, 2005 16. Tran HS, Burrows BJ, Zang WA, et al: Brachial arteriovenous fistula as a complication of placement of a peripherally inserted central venous
211 catheter: a case report and review of the literature. Am Surg 72:833-836, 2006 17. Dzepina I, Unusic J, Mijatovic D, et al: Pseudoaneurysms of the brachial artery following venipuncture in infants. Pediatr Surg Int 20:594-597, 2004 18. Alomari A, Falk A: Median nerve bisection: a morbid complication of a peripherally inserted central catheter. J Vasc Access 7:129-131, 2006 19. Hogan MJ, Coley BD, Shiels WE, et al: Recurrent deep venous thrombosis complicating PICC line placement in two patients with cystic fibrosis and activated protein C-resistance. Pediatr Radiol 28:552-553, 1998
M
Preprocedure Evaluation and Planning
Pediatric Interventional Radiology, Department of Radiology, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR. Address reprint requests to Leah E. Braswell, MD, Arkansas Children’s Hospital, Department of Radiology, One Children’s Way, Little Rock, AR 72202. E-mail: [email protected]
The first steps of PICC placement take place long before a given patient arrives in the angiography suite. When a request for PICC placement is received, a member of the IR team, typically a registered nurse with IR training, reviews the pertinent clinical information by telephone conversation with the requesting provider. Indications for long-term venous access include need for administration of antibiotics (eg, in the case of osteomyelitis or pulmonary infection related to cystic fibrosis), chemotherapy, parenteral nutrition, or other medications. Many patients have tenuous peripheral venous access that is inadequate for the expected length of therapy or inpatient stay. In other cases, a PICC is the procedure that allows a patient to be discharged for completion of intravenous therapy at home. In our patients who have had multiple previous PICCs, care is taken to avoid chronic vein injury and stenosis. The prior IR procedure notes are reviewed. Note is made of which arm was chosen, which vein was accessed, and if there has been any difficulty in placement. For example, a patient with 7 previous PICCs (4 on the right, 3 on the left, known basilic vein stenosis on the right, and most recent PICC on the right) will first be attempted on the left arm. We alternate arms in patients who present for repeat procedure in an attempt to reduce formation of stenoses. Occasionally, the decision to use alternate forms of venous access is made in conjunction with the referring team; examples include children with renal failure and anticipated need for upper extremity dialysis fistulas.4 Any additional pertinent clinical history is also reviewed. For children with a history of congenital heart disease, there
any infants and children require central venous access during the course of an acute or chronic illness. The placement and maintenance of central venous lines are especially difficult in the pediatric population due to small patient size and inability or unwillingness to cooperate with an invasive procedure. Given its safety and reliability as a method to efficiently obtain central access, the peripherally inserted central catheter (PICC) has emerged as a favorable procedure in children.1-3 It is our institutional experience that the Interventional Radiology service provides more PICCs than all other central lines combined. We as interventional radiology (IR) practitioners possess comprehensive skills in delivering image-guided care and are uniquely suited to perform this common and potentially difficult access procedure. With high success and safety rates comes increased demand for comprehensive access delivery and maintenance, and yet few centers have IR services specifically dedicated to the care of pediatric patients. Whether for the practitioner establishing or expanding a pediatric PICC program, this article provides practical tips that have allowed our IR service to deliver comprehensive PICC care.
204
1089-2516/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1053/j.tvir.2011.05.004
Peripherally inserted central catheter placement in infants and children
205 with continual cardiopulmonary monitoring in the presence of nurses skilled in sedation techniques. Although PICC placement is not a highly painful procedure, anxiolysis and stillness are of the utmost importance when the operator is working to access a very small vein. In some cases, anesthesia and/or Child Life Services are present to assist with PICC placement. Some centers rely heavily on these resources, potentially decreasing the need for sedation.6 When patients from the neonatal intensive care unit or pediatric intensive care unit are in our laboratory, we require that their nurse is present for the procedure to assist in the monitoring and clinical care of the patient.
Patient Positioning Figure 1 Tourniquet and arm positioning. The tourniquet is placed loosely before drape placement, and then tightened by an IR laboratory assistant. Topical LMX had been placed within a circular area drawn by the IR specialty nurse. (Color version of figure is available online.)
may be altered central venous anatomy related to congenital or postsurgical conditions. These include situs anomalies, presence of duplicated superior vena cava (SVC) or left-sided SVC, and the presence of surgical shunts (eg, Glenn cavopulmonary shunt). Many other possibilities exist, and preoperative or postoperative imaging studies may be reviewed. In some of these cases, the eventual tip position of the PICC we place is in the medial subclavian or upper inominate vein rather than the typical SVC or cavoatrial junction placement to avoid catheter thrombosis near the pulmonary arteries or infusion of solutions or medications into the venous shunt.5 Once a procedure is planned, our specialty nurse has a face-to-face conversation with the patient and family members. At this time, initial line care education takes place, all questions are answered, and informed consent is obtained.
Once in the laboratory, the patient is positioned on the IR procedure table. Before timeout, confirmation of the appropriate side (right vs left arm) is made. For some children, television can be a useful distraction. A tourniquet is loosely positioned at the level of the shoulder (Fig. 1). The arm is held vertically and prepped circumferentially from the axilla to the mid forearm. Once the arm is laid on the arm board extension, we place a “seatbelt” that fastens the supinated hand firmly to the board with tape wound multiple times, and then the sterile prep is completed (Fig. 2). A second “seatbelt” is placed across the lower extremities. We have found that these are necessary in all patients, even those who seem to be cooperative and well-sedated. Before the procedure begins, the physician performs a sterile scrub and follows full gown and glove protocol. We dim the overhead lights for all PICC placements as soon as the prep is complete. This frequently helps calm infants and young children, who are typically receiving their first dose of sedation at this point. Dimming the lights also serves to optimize the ultrasound monitor image by reducing glare. During positioning and room setup and throughout the procedure, we avoid words such as “needle” or “sharp.” In our laboratory, “device” is our team members’ term for the IV
Sedation The patient is assessed for ability to cooperate, and a sedation plan is formulated in conjunction with the patient and family. This plan is a crucial component of our care. Whereas adults typically require no sedation for PICC placement, many children and their caregivers have considerable anxiety and fear related to any invasive procedure. In our experience, there are many children over 7 years who need no medical sedation for PICC placement. The percentage of patients who tolerate nonsedation increases with age. We prefer IV sedation in most patients younger than that age range. During this evaluation and consent visit, we place topical lidocaine cream (LMX) on the soft tissues of the medial upper arms. This step alleviates pain at the skin site, and many children remark that they did not feel a needle puncture at all. Our IR physicians are approved administrators of midazolam, ketamine, and fentanyl. In infants and young children, our most frequent combination uses midazolam and ketamine. These are administered in alternating titrated doses
Figure 2 Supinated hand. To secure the upper extremity and reduce patient motion, we firmly wrap the patient’s hand with tape. (Color version of figure is available online.)
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access needle, “silver” refers to the 18-gauge puncture needle, and “-otomy” replaces “scalpel.”
Vein Selection and Planning There is a steep learning curve for the technically challenging ultrasound-guided venipuncture in the very small veins of infants and young children. Repetition, both initially and on an ongoing basis, is helpful. Appropriate planning before the puncture is of the utmost importance. A targeted preliminary ultrasound (linear 7-MHz transducer) with moderately tight tourniquet is used to map the available veins and choose a skin site for the appropriate vein. Tourniquet pressure is ideally such that the veins are distended for better visualization and puncture, but not so high that arterial blood flow is compromised.5 We exclusively use transverse imaging before and during the procedure. Although longitudinal imaging techniques have been described for PICC venipuncture,2 we recognize the potential pitfalls, particularly of arterial puncture, and image in the transverse plane. Vein compressibility is confirmed, and color Doppler can be used if necessary. Some centers make use of small foot plate high-frequency probes.5 In small infants, it is helpful to schematically divide the longitudinal extent of the upper extremity (between elbow and axilla) into 3 compartments: proximal, mid, and distal. The first attempt at venipuncture is the most distal; if this initial attempt fails and there is damage to the vein with accompanying hematoma, there is space in the mid and then proximal compartments for 1 to 2 more attempts proximal to the vein injury. This is particularly helpful in a training situation, when a fellow, radiology assistant, or other trainee is performing the first attempt. If present and reasonably sized on ultrasound, the basilic vein is preferred for initial access attempt. The vein takes a relatively straight course to the central venous system and is
Figure 3 Skin site selection. With the aid of initial targeted ultrasound, a skin site is chosen. It is marked with a plastic sheath as a landmark for subsequent steps. If possible, this skin site resides within the LMX treatment area. (Color version of figure is available online.)
Figure 4 Skin incision. With an 18-gauge needle, the skin is punctured while applying gentle back traction to the soft tissues. This allows for gentle Angiocath needle entry in the subsequent step. Note the shallow angle. A deep puncture could injure the underlying vein. (Color version of figure is available online.)
usually the largest deep vein of the arm. The basilic is solitary and superficial along the medial aspect of the arm. The cephalic vein is prone to spasm during the procedure, has an acute angulation in its course at the level of the axilla, and is often small; some centers thereby place the cephalic lowest on their list of preferable veins.5 It can frequently be cannulated successfully, however, particularly in patients with stenoses related to previous basilic vein PICC placement. In many infants, the cephalic vein is larger than the basilic. It also runs a relatively superficial course and is typically solitary. Our experience is that the cephalic vein access should be attempted before brachial vein attempt. Suitability of the brachial veins is limited by the proximity and position of adjacent brachial artery and median nerve, and therefore, the brachial vein is lowest on our hierarchy of preferable vein
Figure 5 Venipuncture. The operator holds the ultrasound transducer in the transverse position with the left hand, while slowly advancing the Angiocath needle with the right. The Angiocath is inserted with bevel directed up. (Color version of figure is available online.)
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Figure 8 Guidewire placement. With 1 hand stabilizing the IV catheter, the stylet is removed and a guidewire gently advanced. (Color version of figure is available online.) Figure 6 Needle localization. To localize the needle tip in the ultrasound image, the acoustic fall-off that forms behind the shaft of the needle is used as a landmark. Arrows mark the lack of echoes in this distribution. (Color version of figure is available online.)
choice. Inadvertent arterial placement is most likely with this vein. In addition, some patients with brachial PICCs endure neuropathy that is due to the direct proximity of the median nerve.
Venipuncture and PICC Placement Once a vein site is chosen with ultrasound, the skin is marked with a plastic packaging sheath (Fig. 3). This step is important for maintaining consistent skin site localization during the subsequent steps. Since this step can be mildly painful, it also affords the operator an idea of how well the patient is sedated. With a 25-gauge needle, a very small amount of
Figure 7 Target sign. The tip of the needle is maintained in the center of the vein.
superficial 1% lidocaine is placed. If lidocaine is injected too deeply, vein spasm can result. Next, the skin is gently punctured with an 18-gauge needle as a small incision to allow IV catheter placement into the skin (Fig. 4). For these preliminary steps, the needle is held at an angle as close to parallel to the skin as possible to avoid injury to the vein. For venipuncture, a 22-gauge sheathed Angiocath IV catheter (BD, Franklin Lakes, NJ) is used and positioned with the bevel up (Fig. 5). A shallow angle of the access needle has been shown to optimize ultrasound visualization of the echogenic tip.7 The course of the needle tip should be visualized at all times as it approaches and enters the superficial wall of the vein. If the tip is difficult to visualize, the transducer is placed nearer to the hub of the needle, and the acoustic “fall-off” is localized (Fig. 6). The fall-off can be followed as a landmark as very small motions of the transducer guide visualization nearer and nearer to the needle tip. Once the echogenic tip is visualized entering and then within the vein, an image is
Figure 9 Dilating soft tissues. A 4-Fr dilator is advanced over the guidewire to dilate the soft tissues. The operator supports the adjacent soft tissues with a pinch technique to allow smooth advancement of equipment. (Color version of figure is available online.)
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Connolly et al observed that tip position changes with arm position. We frequently perform a provocative adduction maneuver at the time of wire measurement and/or final PICC position to judge the potential migration of PICC tip with arm positioning.8 If the tip descends to the level of the right atrium with this maneuver, a shorter length is chosen. The PICC is inserted over a guidewire through the peel-away sheath with fluoroscopic guidance, and a fluoroscopic image is saved to document tip position (Fig. 10). After placement, heparin solution is flushed into the lumen and a needleless cap is placed. The hub of the PICC is secured to the skin with 2 sutures. A BIOPATCH (Ethicon, Somerville, NJ) antimicrobial disk is placed and sterile dressing applied (Fig. 11).
PICC Selection
Figure 10 PICC tip in SVC. Tip position is acceptable in the SVC, as demonstrated here, or slightly more inferiorly at the level of the cavoatrial junction. (Color version of figure is available online.)
saved to document ultrasound guidance (Fig. 7). The hub of the needle is completely flattened to avoid back-wall puncture. A series of 3 to 4 longitudinal advances is made to thread the needle tip and gain stable venous purchase. If this step is foregone, the needle tip could be placed within the vein while the sheath remains in the soft tissues. Care is taken to maintain the tip in the center of the vein lumen. Once the Angiocath tip has been advanced, there is visual confirmation of blood return, and the inner stylet is removed. The tourniquet is released. Through the Angiocath sheath, a 0.018-inch platinum guidewire is advanced (Fig. 8). Early fluoroscopic confirmation of venous placement is helpful, particularly in small children and infants, or when arterial placement is suspected. With the guidewire in place, slightly deeper subcutaneous lidocaine is given, and a small skin incision is made with a blade. Dilatation with a 4-Fr pediatric dilator is performed. For tissue support, the soft tissues of the arm are pinched as the dilator is advanced (Fig. 9). A 4-Fr peel-away sheath is similarly placed, and the tip of the wire is advanced into the SVC at a level at or above the cavoatrial junction under fluoroscopic guidance. The length of the wire from skin to tip is estimated and marked with clamped hemostat, and the wire is removed for PICC measurement. At this step, the sheath is capped with a saline-filled syringe to reduce the small risk of air embolism, and a saline flush can be administered. The PICC is cut to length, and the length is documented in the patient’s chart. Particularly in small infants, precise measurements of length are required; the difference of a few millimeters too short or too long can be quite significant.
In children, a small-caliber PICC is preferable when navigating small veins. We use a 3-Fr single-lumen catheter (Cook, Bloomington, IN) in almost all cases. Lines of even smaller caliber (1.9 Fr) are available. It has been shown that increasing catheter diameter is significantly associated with increasing risk for venous thrombosis.9 Catheter material is also important. We prefer silicone, which is soft and pliable, in an attempt to reduce the risk of potential cardiac tamponade or vascular rupture. For limited indications and when requested in older children and adults, we do place dual lumen and/or power-injectable PICCs. We typically use a 4-Fr polyurethane dual lumen injectable PICC. With this polyurethane catheter, we do not accept right atrial placement of the tip, given that the stiffer composition increases the risk for myocardial injury.10
Figure 11 Final dressing. The PICC is secured with skin sutures and K-lock adhesive device. An antimicrobial disk is placed at the hub, and a transparent sterile dressing covers all. (Color version of figure is available online.)
Peripherally inserted central catheter placement in infants and children
Limiting Radiation Dose In children, the As Low As Reasonably Achievable (ALARA) principle guides all applications of radiation exposure. The “Image Gently, Step Lightly Pediatric Interventional Radiology Safety Checklist” is available via http://www.imagegently. org. As listed there, steps, such as collimation, last image hold, patient positioning, low-dose techniques, and others, are used before and during each case.
Troubleshooting ●
The smallest infants
Several factors contribute to the difficulty in obtaining venous access in these patients. Of course, the most salient of these is the small size of venous targets. The ultrasoundguided venipuncture is a difficult skill to master; repetition is key. Infants also have mobile, soft tissues that tend to push away from needles and equipment. This is true at the time of initial skin puncture with a lidocaine needle; it is also true when advancing the access needle into the vein and the dilator through the subcutaneous tissues. For these reasons, we emphasize deliberate, firm, yet controlled, small movements with equipment. Equipment size also lends unique challenges to the infant PICC placement. The dilator and peelaway sheath, although short, are long enough in small infants to reach the central vessels and abut mediastinal structures. We monitor these steps with fluoroscopy to avoid vascular injury. We also carefully monitor PICC tip position in small infants and make adjustments as necessary. A right atrium tip is never accepted in infants. We exclusively place silicone single-lumen catheters in these patients, keeping in mind the potential for cardiac tamponade. ●
Poorly Hydrated Infant
If an infant presents for PICC placement in a dehydrated state, vascular access can be unusually difficult. These are the patients who demonstrate that the IR team is a crucial component of vascular access for ongoing care and rehydration. We have developed an intravenous fluid bolus technique that can be used in this situation. If an IV is available, a systemic fluid bolus (5 mL/kg) is delivered at the outset of the procedure. We have shown that this technique increases the diameter of the basilic vein on ultrasound before initial needle puncture. The IV bolus technique may lead to an increased success rate.11 ●
Spasm and Stenosis
Often, an initially successful venipuncture is followed by difficulty in platinum tip wire passage to the central venous system. Whenever resistance is met at any step, imaging with fluoroscopy is required. At the level of the axilla, venospasm related to tourniquet placement is often the culprit. If this is the case, pausing the procedure for 1 minute or so can be beneficial. Vascular stenosis, however, is frequently encountered in patients who have had previous PICC or central venous lines.12 Stenosis or occlusion can occur at any point along the length of the venous system. When the initial
209 guidewire does not pass, even with gentle manipulation under fluoroscopy, conversion is then made to a short 0.018inch hydrophilic guidewire. Many areas of stenosis can be successfully traversed with a hydrophilic guidewire. If so, the wire is left in place across the lesion for the subsequent placement of a peel-away sheath. Measurement from the back of the wire to the skin and subtraction from the total length of the wire is performed to appropriately determine the PICC length. If a luminal narrowing or irregularity persists after conversion to a hydrophilic guidewire, a venogram is performed by gentle injection through a short 4-Fr dilator. The venogram demonstrates more definitively the patient’s vascular anatomy and provides guidance for wire manipulation. If the venogram demonstrates vascular occlusion and numerous collaterals, it becomes the operator’s decision whether to leave a “short” noncentral PICC with tip, for example, in the medial subclavian vein or an adjacent well-developed venous collateral. This PICC may become the only stable access for the child, but noncentral tip placement is associated with increased complication rates.13 Tip placement should be documented and communicated to the ordering medical team. Some medications, electrolyte replacements, and hypertonic fluids may not be given via a noncentral line. Alternatively, access and placement can be attempted on the opposite arm.
Complications Although serious complications are rare, there are several complications to consider, including cardiac arrhythmias, air embolism, and eventual line fragmentation, dislodgment, or malfunction. These are not unique to PICCs, and their rates do not appear to be increased compared with conventional central venous lines. ●
Infection
Infection rates in the pediatric population have been reported at 0.93 per 1000 catheter days1 and 3.02 per 1000 catheter days.14 In a series by Safdar et al of 251 adult PICCs, infection rates in the inpatient setting had increased rate of infection (2.1 per 1000 catheter days) when compared with outpatient PICCs (0.4 per 1000 catheter days).15 Hospital-wide adherence to strict guidelines during line maintenance is necessary to avoid bloodstream infection. ●
Brachial Artery and Nerve Complications
In the small arms of infants, the inherent size of vessels leaves a low margin of error. The brachial artery may be inadvertently punctured during the initial steps of PICC placement, especially when the brachial vein is the target. If this is the case, arterial flow may not be especially brisk due to tourniquet placement and the small caliber of the artery. A high index of suspicion is necessary so that 0.018-inch guidewire advancement can be monitored under fluoroscopy. Wire projection to the left of midline (Fig. 12) may indicate arterial puncture. At this point, the IV catheter sheath and wire should be removed and direct pressure applied to the arterial puncture site for several minutes. Therefore, if brachial vein
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Line Management
Figure 12 Arterial puncture. Fluoroscopic image demonstrates guidewire tip to the left of midline; inadvertent arterial puncture occurred. (Color version of figure is available online.)
access is necessary, we maintain the needle tip in the portion of vein lumen remote from the artery while the IV catheter is being threaded. This highlights the necessity of imaging in the transverse plane and monitoring needle tip position at all times so that it does not puncture the arterial sidewall. Known complications of inadvertent arterial puncture include brachial arteriovenous fistula,16 pseudoaneurysm formation,17 and potential for distal arterial flow compromise. Damage to the median nerve is a possible yet uncommon complication, typically presenting as pain in the forearm and hand. Reposition is required in these cases. Alomari and Falk reported a case of median nerve bisection because of brachial venous access for PICC placement.18 ●
Venous thrombosis and chronic stenosis
The placement of a PICC does put a patient at increased risk for venous thrombosis. Dubois et al reported a thrombosis rate of 9.3% (determined by serial ultrasound examination), but only 1 patient in the series had symptomatic deep vein thrombosis.14 Grove and Pevec reported a rate of 3.9%. The only factor significantly related to venous thrombosis in that series was increasing catheter diameter.9 Other patients at particular risk include those with clotting disorders and cystic fibrosis.19 We encountered central venous stenosis in 7.9% of our population of children who had previously received 3-Fr PICCs, and in 13% of patients with 4- to 7-Fr PICCs.12 Therefore, the possibility of subsequent stenosis is discussed with families during the attainment of consent, and our team must keep in mind the potential for future difficulty in placement or exhaustion of access sites. In our series, risk factors for stenosis include larger caliber of PICC and age ⬍2 years. We have observed that the cephalic and brachial veins in a given patient’s arm may be larger when the basilic is peripherally obliterated from previous PICCs.
In our experience, children are quite prone to dislodge any and all tubes and lines that accompany their medical care. PICCs are no exception, and we place a great deal of emphasis on securing our lines. We place skin sutures via the wings at the hub of the PICC and place an adhesive stabilization device (Grip-Lok, Zefon, Ocala, FL). In older children who do not require IV sedation, we use a StatLock “post and door” design fixation device (Bard, Murray Hill, NJ) and do not place sutures. After placement of a BIOPATCH antimicrobial disk, the entire area is covered with a sterile occlusive dressing (Fig. 11), which is changed weekly by trained hospital or home health personnel. Heparin is given at the time of placement to flush the lumen. We administer 3 mL of heparin in graduated doses based on patient weight (1 U/mL for patients in the neonatal intensive care unit; 10 U/mL for children ⬍15 kg; and 100 U/mL for children ⬎15 kg) into each lumen. Our standard post PICC placement orders indicate that this heparin dose is used at the completion of any infusion, on an as needed basis, and at least weekly. In the event of clotting, 1 mg of tissue plasminogen activator is administered and allowed to dwell for 1 hour. PICCs may be maintained indefinitely; it is not unusual for one to be in place for weeks or months. Any questions or concerns related to the function, position, or integrity of the line are handled initially by an IR nurse telephone discussion, and necessary imaging or intervention can be planned at that time. At the completion of therapy, PICCs are removed without difficulty, and the length of removed catheter can be compared with that reported in the IR procedure note.
References 1. Crowley JJ, Pereira JK, Harris LS, et al: Peripherally inserted central catheters: experience in 523 children. Radiology 204:617-621, 1997 2. Donaldson JS: Pediatric vascular access. Pediatr Radiol 36:386-397, 2006 3. Dubois J, Garel L, Tapiero B, et al: Peripherally inserted central catheters in infants and children. Radiology 204:622-626, 1997 4. Vo JN, Hoffer FA, Shaw DW: Techniques in vascular and interventional radiology: pediatric central venous access. Tech Vasc Interv Radiol 13:250-257, 2010 5. Krishnamurthy G, Keller MS: Vascular access in children. Cardiovasc Interven Radiol 2010 [published online 26, May 2010] 6. Leahy S, Kennedy RM, Hesselgrave J, et al: On the front lines: lessons learned in implementing multidisciplinary peripheral venous access pain-management programs in pediatric hospitals. Pediatrics 122 (suppl):161-170, 2008 7. Nichols K, Wright L, Spencer T, et al: Changes in ultrasonographic echogenicity and visibility of needles with changes in angles of insonation. J Vasc Interven Radiol 14:1553-1557, 2003 8. Connolly B, Amaral J, Walsh S, et al: Influence of arm movement on central tip location of peripherally inserted central catheters (PICCs). Pediatr Radiol 36:845-850, 2006 9. Grove JR, Pevec WC: Venous thrombosis related to peripherally inserted central catheters. J Vasc Interv Radiol 11:837-840, 2000 10. Towbin R: The bowed catheter sign: A risk for pericardial tamponade. Pediatr Radiol 38:331-335, 2008 11. Bhutta ST, James CA, Roberson PK, et al: Challenging infant PICCs: does a procedural fluid bolus increase vein size? Pediatr Radiol 34(suppl):77, 2004 12. Bhutta ST, James CA, Schmidt MB, et al: Repeat PICC placement incidence of central venous occlusive disease: J Vasc Interven Radiol 14 (suppl):53, 2003 [abstract]
Peripherally inserted central catheter placement in infants and children 13. Racadio JM, Doellman DA, Johnson ND, et al: Pediatric peripherally inserted central catheters: complication rates related to catheter tip location. Pediatrics 107:E28, 2001 14. Dubois J, Rypens F, Garel L: Incidence of deep vein thrombosis related to peripherally inserted central catheters in children and adolescents. J Vasc Surg 47:1120, 2008 [abstract] 15. Safdar N, Maki DG: Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest 128:489-495, 2005 16. Tran HS, Burrows BJ, Zang WA, et al: Brachial arteriovenous fistula as a complication of placement of a peripherally inserted central venous
211 catheter: a case report and review of the literature. Am Surg 72:833-836, 2006 17. Dzepina I, Unusic J, Mijatovic D, et al: Pseudoaneurysms of the brachial artery following venipuncture in infants. Pediatr Surg Int 20:594-597, 2004 18. Alomari A, Falk A: Median nerve bisection: a morbid complication of a peripherally inserted central catheter. J Vasc Access 7:129-131, 2006 19. Hogan MJ, Coley BD, Shiels WE, et al: Recurrent deep venous thrombosis complicating PICC line placement in two patients with cystic fibrosis and activated protein C-resistance. Pediatr Radiol 28:552-553, 1998