Insertion of long lines in the pediatric emergency department

The purpose of this study was: 1) to evaluate the role of the pediatric emergency department (PED) in placing peripherally inserted midline or central catheters (long lines), and 2) to review indications and complications to use this technology to reduce the number and duration of admissions and provide an alternative method for administering intravenous therapy.

Retrospective chart review of all patients taken from a procedure log who had long lines placed in the emergency department of a children's hospital.

Twenty-eight patients had 30 long line insertions over a 36-month period. Fourteen were female; age ranged from 1 to 36 years with a median of 9 and a mean of 11.1 +/- 8.4. The indication for insertion was for parenteral antibiotics in 27 of 28 (96%) patients and for parenteral nutrition in 1 (4%) patient. The catheters varied in length from 8 to 60 cm. Twelve of 30 (40%) catheters terminated centrally in the subclavian or superior vena cava, while 18 (60%) were in the peripheral cephalic, basilic, or axillary veins. Chest radiography confirmed positioning in 12 of 12 inserted centrally and in 15 of 18 (83%) in the peripheral circulation. Half of the patients received no premedication for the procedure; 10 (33%) received topical anesthetic cream; 2 (7%) local infiltration of anesthetic, and 2 (7%) parenteral sedation. Twenty-one of 30 (70%) patients were discharged directly from the emergency department; 3 (10%) were discharged after admission to the hospital to complete treatment at home with their long lines, and 6 (20%) used their long lines for in-hospital therapy only. Eight of 30 (27%) placements were for patients specifically referred to the PED for placement or replacement of a long line. Twelve of 30 (40%) lines were placed in children presenting for intravenous therapy for cellulitis. These patients received a long line with home i.v. therapy instead of the traditional admission. The duration of intravenous treatment documented for all patients ranged from 1 to 62 days with a median of 10.5, and a mean of 16.2 +/- 17.8, compared with the duration of the line ranging from 1 to 28 days with a median of 4, and a mean of 7.3 +/- 8.0. Ten of 30 (33%) had their line for 3 days or less. The short duration was due to problems with line function in 5 of 10, and intentional removal secondary to improved cellulitis in 5. There were no significant complications with the lines reported during placement or while in use; however, 8 of 30 (27%) of the lines placed developed problems with function, requiring repair or replacement.

1) Long lines can be inserted in the pediatric emergency department by physicians with different levels of training with minor complications and no adverse clinical effects; 2) the placement of long lines can eliminate the need for hospitalization in some cases, reduce the duration of hospitalization in others, and lessen the need for repeated venipunctures for routine peripheral catheter replacement in patients requiring i.v. therapy; 3) the planned duration of therapy as well as other factors not analyzed in this study should be considered when selecting patients for long line placement in the emergency department.