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Venous Catheter Line Complications
hosted by Dr. Em Gootee & Dr. Todd Ponsky
Chapter 1 of 4 · Case-Based Learning
Line request protocols
Communication failures in line placement and institutional solutions
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Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
At Cleveland Clinic, a separate form must be filled out for any line placement specifying exactly what type of line is wanted and how many lumens
The line request form includes who the responsible attending is and their contact number, and cases are not booked until the form is scanned into the patient's chart
When calling about line placement questions, the team calls the responsible attending (e.g., nephrology attending) rather than the primary pediatric service
An Epic order set exists for line requests that includes contact information for the resident and attending responsible for the patient
The line request form documents every line that was previously present in the patient
A broviac or cuffed central venous catheter can be placed in the femoral vein via saphenous vein cutdown even in active patients
Most practitioners would place a single-lumen cuffed central venous line for a 5-year-old with acute lymphoblastic leukemia via right internal jugular using ultrasound guidance
Percutaneous central line placement is performed in almost all patients except tiny micropremies, who still receive cutdowns
In micropremies requiring cutdown, the jugular vein is accessed with a needle and a catheter is threaded through rather than ligating the vein, to preserve future access
Micropuncture needles are used as a technique for central line placement
When a subclavian catheter is malpositioned, the decision to reattempt at the same site versus going to the contralateral side depends on whether a large dilator was placed, which could cause a hematoma
Fluoroscopy should be used when troubleshooting malpositioned catheters to avoid ending up with a hemothorax on one side and pneumothorax on the other
Facial vein cutdowns can be used for central venous access
A 13-year-old with hemolytic uremic syndrome was taken to the OR for a vascular catheter, but there was confusion between the surgical team, primary team, and nephrology about whether a temporary dialysis catheter or peritoneal dialysis catheter was needed
A right internal jugular temporary dialysis catheter was initially placed, then two days later the patient returned to the OR for placement of a peritoneal dialysis catheter
Peritoneal dialysis is usually performed for hemolytic uremic syndrome
A 16-year-old with sickle cell disease on a transfusion protocol had complications and would likely receive a bone marrow transplant today
MRV showed both subclavian veins and both internal jugular veins were clotted off, with reconstitution of the superior vena cava via the azygous vein
Under thoracoscopic guidance, a needle can be placed in the right neck and tracked along the superior vena cava to access where it reconstitutes with the azygous vein, using a spinal needle which is longer than the needle in standard kits
A patient kept a thoracoscopically-placed superior vena cava line for about one to two years before it required replacement, and the procedure was successfully repeated
Marcus Jarboe reported performing superior vena cava access using interventional radiology with radiographic or ultrasound guidance rather than thoracoscopic guidance
In a case in Birmingham, the clot extended into the upper atrium, requiring access into the distal atrium followed by balloon dilation of the clot to create a channel that would not immediately re-thrombose
Some practitioners are using ultrasound for subclavian access via a supraclavicular approach
The pneumothorax rate with ultrasound-guided supraclavicular subclavian access is still higher than with internal jugular access
There is mixed data about whether internal jugular access has a higher infection rate than subclavian access, and this does not pan out in many studies
There is not a significant difference in intravascular complications between subclavian and internal jugular access sites
Sean Saint Peter's paper from Kansas City showed that using ultrasound guidance for internal jugular access had better outcomes, which led to a practice change
Carolina Milan, a pediatric surgeon from Argentina, taught techniques for performing percutaneous central line placement in younger patients including newborns
External jugular vein access can be used as a primary site for central venous catheter placement when the vein is present and large
Mark Rowe taught external jugular access as a primary approach, but getting to the junction of the external jugular and internal jugular is not as easy as it seems, with catheters potentially getting hung up or going the wrong direction