Paeds · investigations-procedures-and-technology
Central venous and arterial access in children
Also known as Paediatric central line insertion · Central venous catheterisation in children · Paediatric arterial line · Ultrasound-guided vascular access in children
A fellowship approach to central venous and arterial access in children: choose the site by indication and bleeding risk, use ultrasound to identify the target vessel and its companion artery, run the Seldinger sequence (needle, guidewire, dilator, catheter), aim the central catheter tip at the cavoatrial junction, and prevent the complications of arterial puncture, pneumothorax, haematoma, thrombosis and central line-associated bloodstream infection with a full sterile insertion bundle and a daily review of line necessity.
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Red flags
- Bright pulsatile blood on what should be a venous attempt — arterial puncture; withdraw, hold firm proximal pressure, reassess under ultrasound
- Sudden desaturation, hypotension or dyspnoea during or after an internal jugular or subclavian attempt — pneumothorax or venous air embolism until proven otherwise
- A guidewire or catheter advanced too far with ectopy on the monitor — atrial or ventricular irritation; withdraw the wire
- A cold, pale, pulseless distal limb after arterial line insertion — acute limb ischaemia; remove the line and escalate immediately
- Fever, exit-site redness or purulence in a child with an indwelling central line — central line-associated bloodstream infection; culture and consider removal
- Central catheter tip curled in the internal jugular, contralateral subclavian or a ventricle on the post-procedure chest radiograph — malposition; reposition or replace
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- Procedural skills and safety
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- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
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A 3-year-old in septic shock needs reliable access to run adrenaline and draw frequent blood gases. A peripheral cannula will not deliver concentrated vasoactives safely, and repeated attempts only burn her veins. The decision to place a central or arterial line is the decision to give a sick child a stable bridge for the next hours to weeks, and the next few minutes — choosing the site, finding the vessel with ultrasound, and running the Seldinger sequence without injuring the artery or dropping a pneumothorax — are where the line is made safe or harmful. This page teaches the whole procedure: the sites, technique, sizing, and what to do when it goes wrong. [1] [8]
Needle to vessel · Wire through needle · Dilate · Catheter over wire · Aspirate and flush · Tip confirmed. Every central line is these six steps; the safety lives in never skipping the wire check and never losing sight of where the artery sits. [1]
Overview & Definition
Imagine you must put a large-bore line into a central vein of a sick child, or an arterial line to watch her blood pressure beat by beat. The veins are small, they roll and collapse under a probe, and an artery lies beside every central vein you want. Central venous and arterial access is the set of techniques built to place these lines safely despite those obstacles. A central venous access device is any catheter whose tip ends in a great vein near the heart — the cavoatrial junction — so that irritant, concentrated, or vasoactive infusions are diluted in a high-flow vessel rather than burning a small peripheral vein. An arterial line is a cannula placed in a systemic artery to transduce continuous pressure and allow frequent blood-gas sampling. [1] [8]
The defining principle of modern paediatric access is ultrasound. The international evidence-based recommendations on ultrasound-guided vascular access, and the Cochrane reviews that support them, moved paediatric central cannulation from a landmark-and-hope technique to one in which the operator sees the vessel, confirms it is a vein by its compressibility and non-pulsatile flow, and watches the needle enter it. Lamperti and colleagues framed ultrasound guidance as the standard of care, and that framing is the lens through which the whole procedure is now taught and examined. [1] [2]
The key idea a candidate must hold is the compressibility and the artery. In an elective adult line a landmark technique sometimes works; in a child the vessels are small enough that feeling for a pulse and guessing the vein underneath it is a gamble. Ultrasound answers two questions before the needle moves: is the target vessel present and patent, and where does the artery lie relative to it. Every decision that follows — site, approach, the response to bright blood — flows from those two answers. [4]
References12ShowHide
- [1]Lamperti M International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med, 2012.PMID 22614241
- [2]Brass P Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev, 2015.PMID 25575244
- [3]Brass P Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev, 2015.PMID 25575245
- [4]Sigaut S Ultrasound guided internal jugular vein access in children and infant: a meta-analysis of published studies. Paediatr Anaesth, 2009.PMID 19863734
- [5]Aouad-Maroun M Ultrasound-guided arterial cannulation for paediatrics. Cochrane Database Syst Rev, 2016.PMID 27627458
- [6]Quan Z Acoustic Shadowing Facilitates Ultrasound-guided Radial Artery Cannulation in Young Children. Anesthesiology, 2019.PMID 31634245
- [7]Ullman AJ Pediatric central venous access devices: practice, performance, and costs. Pediatr Res, 2022.PMID 35136199
- [8]Duesing LA Central Venous Access in the Pediatric Population With Emphasis on Complications and Prevention Strategies. Nutr Clin Pract, 2016.PMID 27032770
- [9]Nardi N Effectiveness and complications of ultrasound-guided subclavian vein cannulation in children and neonates. Anaesth Crit Care Pain Med, 2016.PMID 26924612
- [10]Pang H A Randomized Trial of Ultrasound- versus Fluoroscopy-Guided Subclavian Vein Catheterization in Children with Hematologic Disease. Indian J Pediatr, 2019.PMID 31332603
- [11]Zito Marinosci G ECHOTIP-Ped: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in pediatric patients. J Vasc Access, 2023.PMID 34256613
- [12]Buetti N Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol, 2022.PMID 35437133