Subclavian approach without ultrasound guidance is safe and effective for pediatric central venous access

The American College of Surgeons (ACS) recommends US guided internal jugular (IJ) approach for central venous access devices (CVADs); however, this is suboptimal in children. We use the subclavian without US guidance for access in children and adolescents and young adults (AYAs) at a high-volume oncology center.

We undertook a prospective observational study of patients ≤ 26 years undergoing CVAD placement between 1/1/15-9/30/23. US guidance was used in IJ but not in subclavian CVADs, and all procedures were performed by or under direct attending supervision following a standardized protocol. Adverse events (AEs) within 180 days were collected. Multivariate logistic regression model was applied to determine risk factors for predicting AEs.

Seven hundred and thirteen patients were included. Overall AE rate was 25.7%. Ninety-nine patients had early AEs, and 84 had late AEs. Most common AEs included thrombosis (7.9%), migration (6.5%) and mechanical malfunction (6.9%). Central line-associated blood stream infection (CLABSI) rate was 4.1%. Most (83%, n = 590) CVADs were subclavian without US guidance, and pneumothorax and bleeding rates were extremely low (0.3% and 0.7%). IJ CVADs had increased CLABSI and thrombosis rates compared to subclavian (8.4% vs 3.5% and 16.8% vs 8.9%, p< 0.05). BMI ≥ 30 and steroid use were associated with all AEs (p< 0.001 and p= 0.003).

Our results suggest utilizing the subclavian without US guidance is safe and effective for children and AYAs with cancer. This challenges the 2011 ACS recommendation for the use of US guidance in all CVAD placements.