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Peripherally Inserted Central Venous Catheters: Success of Scalp-Vein Access in Infants and Newborns

¹ Department of Radiology, Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229-3039.

	Abstract

TOP Abstract Introduction Materials and Methods Results Discussion References

 
The authors assessed the feasibility of placing peripherally inserted central venous catheters via scalp veins in infants and newborns. In 60 newborns and infants, aged 3 days to 10 months, placement of 62 2-F peripherally inserted central venous catheters was attempted with scalp-vein access. The tip location was central in 30 of the 62 catheters (48%) and long peripheral intravenous in 17 (27%); access failed in 15 (24%). Scalp-vein access for peripherally inserted central venous catheters offers a safe and effective alternative route for gaining central venous access in infants and newborns.

Index terms: Catheters and catheterization, central venous access, 117.1269 • Catheters and catheterization, in infants and children, 117.1269 • Interventional procedures, in infants and children, 117.1269

	Introduction

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Traditionally, peripherally inserted central venous catheters in the pediatric patient have been placed via the antecubital fossa by using the basilic or cephalic veins or, occasionally, the great saphenous vein. Donaldson et al (1) described increased success with ultrasonographic guidance as compared to that with contrast material–enhanced fluoroscopic guidance or with palpation of an antecubital vein. In infants and newborns, these routes of access can be especially difficult due to the small caliber of the vessels and venous damage from prior phlebotomy. We developed a technique for inserting 2-F peripherally inserted central venous catheters via scalp veins in newborns and infants. To our knowledge, this has not been previously described in the literature. This access method is effective and safe and offers an alternative route of access for peripherally inserted central venous catheters in this challenging pediatric population.

	Materials and Methods

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Peripheral insertion of central venous catheters was attempted with scalp-vein access in patients in whom extremity access had failed or in whom suitable peripheral veins could not be visually located or palpated. The initial access attempt was performed by a member of the clinical nurse team for vascular access under direct radiologist supervision. The extremities were carefully reexamined visually by a radiologist or other member of the vascular-access team prior to attempting scalp-vein access for a central venous catheter. Whether this repeat examination was performed by a radiologist or a clinical nurse from the vascular-access team was not specifically recorded.

This group of patients was not selected but was clinically referred. Since 1993 at our institution, all attempts at peripheral insertion of a central venous catheter have been documented. These records are separate from the patient's formal medical chart and include the following data: indication for use of a peripherally inserted central venous catheter; patient name, age, and medical record number; catheter insertion and removal dates, insertion site, and tip location; and complications. We reviewed the records for all patients who underwent peripheral insertion of a central venous catheter with scalp-vein access (62 catheters in 60 patients, aged 3 days to 10 months; mean age, 55 days) over an 18-month period (December 1995 through May 1997).

The patients were brought to the fluoroscopy suite and swaddled (Papoose; Olympic Medical, Seattle, Wash). No sedation or local anesthesia was used. After visual identification of a scalp vein of adequate caliber (usually the superficial temporal or posterior auricular veins), catheter length was measured from the selected vein to a site two finger widths below the suprasternal notch for superior vena cava placement. We found that scalp-vein anatomy was variable, and on two occasions veins on the posterior two-thirds of the scalp were used that were of adequate caliber but did not follow the typically expected course of the superficial temporal or posterior auricular veins. Veins in the anterior one-third of the scalp, including the supratrochlear or supraorbital veins, were avoided because of their relationship to the orbit and potential communication with intracranial veins.

After limited shaving of the scalp entry site and preparation of the skin with an alcohol and 1.0% povidone-iodine solution, a common unsterile rubber band was used as a scalp tourniquet and placed around the margins of the hairline (Fig 1). Standard sterile technique—including the use of sterile gloves, gown, and mask—was used in all cases. The scalp vein was accessed, by means of direct visualization, with a 22-gauge needle and cannula with a peel-away sheath (Per-Q-Cath; Bard Access Systems, Salt Lake City, Utah) by using a technique similar to that for traditional insertion of a peripheral intravenous catheter (Fig 2). With intermittent fluoroscopic assistance as needed, a 2-F single-lumen silicone peripherally inserted central venous catheter (Bard Access Systems) was advanced caudally into the superior vena cava via the external or internal jugular vein. If any difficulty was encountered while the catheter was being threaded past the ear or upper neck, a gentle inferior massaging or milking of the catheter tip by an assistant would often allow further advancement, with intermittent fluoroscopic confirmation (Fig 3). After the catheter was placed in all cases, the tip location was documented with a single spot radiograph, which was occasionally enhanced by injecting 1–2 mL of radiographic contrast material (Optiray 240; Mallinckrodt Medical, St Louis, Mo). The catheter was then secured to the scalp access site (Steristrips and Tegaderm; 3M, St Paul, Minn). The average time to complete peripheral insertion of a central venous catheter with scalp-vein access was approximately 30 minutes. This is the same amount of time we use to peripherally insert a central venous catheter with extremity-vein access (unpublished data).

View larger version (211K): [in this window] [in a new window]   Figure 1. A common unsterile rubber band (arrowheads) is used as a scalp tourniquet. An affixed piece of tape (*) facilitates tourniquet removal.

View larger version (189K): [in this window] [in a new window]   Figure 2. With the cannula in place, a 2–F peripherally inserted central venous catheter is threaded into the scalp vein.

View larger version (156K): [in this window] [in a new window]   Figure 3. Gentle massaging of the neck by an assistant while the catheter is being advanced can facilitate threading past the ear or upper neck.

	Results

TOP Abstract Introduction Materials and Methods Results Discussion References

 
The clinical indication for peripheral insertion of a central venous catheter was the need for intravenous antibiotics (eg, meningitis, sepsis, pyelonephritis) for 59 of the 62 (95%) catheters. Other indications included seizures, total parenteral nutrition, and prostaglandin E infusion for the remaining three catheters.

The final catheter tip position is presented in the Table. Catheters with tips in the superior vena cava or the brachiocephalic vein were considered central catheters. Catheters with tips in all other locations were considered long peripheral intravenous catheters. Thus, central access was successful with 30 of the 62 (48%) catheters. In addition, the 13 (21%) catheters with tips beyond the inferior third of the external or internal jugular vein but not quite to the superior vena cava or brachiocephalic vein were adequate for their intended purpose (antibiotics), remained in place for their intended duration, and caused no complications. Venous access failure or inability to pass the catheter occurred in 15 (24%) of the 62 catheters. If peripheral insertion of a central venous catheter was unsuccessful with scalp-vein access, the referring physician was notified, and options were reassessed. In general, if antibiotic therapy was to last less than 14 days, intravenous catheters were used with extremity access (ie, hand, antecubital fossa), which necessitated changing the intravenous site every 3 days. If therapy was to last more than 21 days, a catheter was placed surgically.

	Discussion

TOP Abstract Introduction Materials and Methods Results Discussion References

 
Peripheral venous access in infants and newborns is not only technically challenging but also inadequate in several clinical situations. Specifically, some intravenous antibiotics, total parenteral nutrition, and chemotherapy can cause discomfort, irritation, and chemical phlebitis in a peripheral vein, and usually require central venous access. Conventional placement of central venous catheters and surgical tunneling of catheters and ports, however, are not without risk. Peripherally inserted central venous catheters are less invasive and far less expensive and have lower morbidity and mortality (2). They have a lower risk at initial placement (3) and no risk of pneumothorax and are easy to remove. Peripheral insertion of central venous catheters to provide short- to intermediate-term vascular access (1 week to 2 months) in the pediatric population has been found to hasten discharge and reduce monetary cost (4).

Other authors have reported success rates in the range of 90% for traditional peripheral insertion of central venous catheters in children, but their study populations are usually much older, with a mean age of approximately 5 years. Specifically, Chait et al (5) reported a success rate of 92%, but stated that their success rate was lower in younger children. Of the 11 failed attempts in that study, five were in children aged less than 1 year. Crowley et al (6) described a 93% success rate, but more than half of the failed attempts were in patients younger than 24 months or weighing less than 5 kg. In a recent study, however, Dubois et al (7) report a 96% success rate in patients aged less than 1 year, with contrast-enhanced venographic guidance and catheter insertion inferior to the elbow. With the exception of results in their study, however, our success rates for 62 peripheral insertions with scalp-vein access of 30 (48%) central placements, 17 (27%) long intravenous placements, and 15 (24%) cases of failed access are comparable to success rates reported for traditional peripheral insertion of central venous catheters in this age group. Our rate for phlebitis of one (2%) of 47 catheters is comparable to rates reported previously from 0% to 23% (1,2,8,9). Infection rates related to peripheral insertion of central venous catheters vary in the literature from 0% to 6% (1,2,5,7,8,10,11), but we had no catheter-related infections. Our thrombosis rate of one (2%) of 47 catheters is also comparable to that reported in the literature, from 0.3% to 5% (1,5,7).

Short-term scalp-vein access for intravenous catheters is already a standard procedure in most neonatal centers (12). The technique for establishing access in scalp veins is no more difficult than that for extremity veins. In fact, scalp veins are often more visible in infants and newborns than are extremity veins. Since the scalp veins for peripheral insertion of central venous catheters are so superficial, a gentle massaging of the catheter tip, particularly around the ear or upper neck, often aids in advancement. Right-sided attempts were more successful than left-sided attempts, probably because the venous course is more direct. In a patient we saw recently, who is not included in this study, we used a guide wire (0.010 Quick Silver; Medtronics, Sunnyvale, Calif) to unloop a catheter tip in the external jugular vein. Perhaps success rates for scalp-vein access can be even higher if a guide wire is used in difficult cases in the future.

Scalp-vein access for peripherally inserted central venous catheters offers a safe and effective alternative route for gaining central venous access in infants and newborns aged less than 1 year. The success rates for scalp-vein access, complications, and catheter duration are comparable to those for traditional extremity placement in this special age group.

	Footnotes

 
Address reprint requests to J.M.R.

Author contributions: Guarantor of integrity of entire study, N.D.J.; study concepts, N.D.J., J.M.R., D.A.D.; study design, N.D.J.; definition of intellectual content, N.D.J., J.M.R.; literature research, J.M.R., N.D.J.; clinical studies, N.D.J., J.M.R., D.A.D.; data acquisition, D.A.D., J.M.R.; data analysis, J.M.R., N.D.J.; manuscript preparation, J.M.R., N.D.J.; manuscript editing, N.D.J., J.M.R.; manuscript review, N.D.J., J.R.M., D.A.D.

Received September 15, 1997; revision requested November 24, 1997; revision received September 11, 1998; accepted October 7, 1998.

	References

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