Cardiac invasive lines (Paediatric)
An Anaesthesia guideline for invasive lines are required in cardiac surgical patients for monitoring and treatment. All lines have risks associated with insertion, use, and removal and for each line this needs to be weighed against the benefit of such a line.
Rationale
Invasive lines are required in cardiac surgical patients for monitoring and treatment. All lines have risks associated with insertion, use, and removal and for each line this needs to be weighed against the benefit of such a line.
Central Venous Lines (CVLs)
Rationale
Minimise infection risk by:
Adhering to the Central Line Associated Bacteraemia (CLAB) guidelines during insertion and ongoing use.
Removing the line as soon as possible.
Minimise thrombosis risk by:
Using the smallest possible line.
Removing the line as soon as possible.
Running a low dose heparin infusion through the line in patients <5kg.
Monitoring Superior Vena Cava (SVC) pressure is advisable during Cardiopulmonary Bypass (CPB) so that SVC obstruction can be detected and rectified. These lines are usually inserted via the right internal jugular vein (R IJV) and ideally positioned at the Superior Vena Cava - Right Atrial (SVC-RA) junction (this may interfere with surgical cannulation of the SVC and may need to be pulled back during the surgery).
If an umbilical venous line is in situ and in good position this can be used as the perioperative CVL but consider placing a R IJV line for monitoring.
Upper body CVLs need to have their position confirmed by a chest x-ray (CXR).
If there is limb swelling associated with an indwelling CVL the patient should have an ultrasound of the affected limb looking for venous occlusion. NB: following insertion of a femoral CVL it is not unusual to get some immediate leg swelling due to venous congestion - this IS NOT an indication to remove the line nor get an immediate ultrasound examination.. The leg should be elevated and observed.
If thrombosis is confirmed the patient should be anticoagulated for 2-3 days prior to line removal if this is feasible. This is to minimize the risk of embolism occurring when the line is removed and is especially important if there is potential for R to L shunt - DO NOT anticoagulate postoperative patients without discussion with the surgeon first.
Post line removal the patient will require ultrasound follow up with or without anticoagulation.
Policy
All cardiac surgical patients requiring central venous access will have a R IJV line placed perioperatively regardless of whether they have other CVLs at the time.
These other CVLs may be used perioperatively but will be removed as soon as possible postoperatively so do not use for inotropes.
Femoral CVLs will not be placed routinely. If in situ at the time of operation, place and use a R IJV CVL. The femoral CVL will be removed as soon as possible postoperatively.
All CVLs will be removed as soon as possible postoperatively with the goal of removal within 48 hours. NB Older patients (15 years+) will return postoperatively to ward 42 where the policy is to retain the CVL and remove peripheral IVs. Therefore DO NOT remove CVLs in these patients prior to discharge to the ward.
Patients requiring longer term central venous access ( > 1 week) will have a surgically placed central line or a PICC line.
Single Ventricle Patients
Norwood Patients
R IJV line 2-3 lumen. No other CVL. Aim to remove 48 hours postoperatively.
Direct atrial line placed by surgeon (4F 8cm 2 lumen). This may be done initially or at chest closure.
Remove all other CVLs postoperatively in PICU day 0 eg umbilical or femoral CVLs.
Bidirectional Glenn and Fontan patients
R IJV by anaesthetist.
No femoral CVL.
Remove all lines as soon as possible post operatively.
If longer term central access required PICC.
Direct Atrial Lines
These are surgically placed at the time of operation. The commonest indication is for potential left ventricle (LV) problems and the line is placed in the left atrium (LA). These should be removed as soon as they are no longer required after discussion with the surgeon. They should not be removed in unstable patients as removal of these lines can cause major cardiovascular instability.
A direct atrial line will be placed in some Norwood patients by the surgeon.
Direct Pulmonary Artery Lines
These are surgically placed at the time of operation and are used in patients with the potential to have postoperative pulmonary hypertension. They should be treated as per direct LA lines. They are rarely used.
Arterial Lines
The preferred site is the right radial artery and failing this the femoral then brachial then axillary artery. Avoid the side of any previous modified Blalock-Taussig shunt (MBTS). Patients undergoing selective cerebral perfusion need an arterial line in the right upper limb.
Rarely, two arterial lines may be required in patients undergoing aortic surgery e.g. interrupted aortic arch. The risk:benefit of two arterial lines especially in neonates needs to be taken into account. If only one arterial line is placed then ensure this is proximal to any obstruction.
Two arterial lines are necessary in patients undergoing left atrial - femoral artery (LA-FA) bypass.
Any arterial line that causes distal blanching or ischaemia should be removed immediately and the limb closely observed. If there is inadequate distal perfusion immediately inform the cardiac surgeon.
Post removal of arterial lines the limb needs to be monitored as per the nursing protocol.