VABC Pediatric Access 3 — Questions and Answers
Question 1: In a pediatric patient requiring PICC placement, the tip should be positioned at which anatomical location?
- Mid-subclavian vein
- Superior vena cava–right atrial junction (Correct answer)
- Axillary vein
- Innominate vein
Correct answer: Superior vena cava–right atrial junction
The ideal PICC tip position is at the cavoatrial junction (SVC–right atrial junction) to ensure adequate hemodilution of infusates and reduce thrombosis risk.
Question 2: Which of the following fluids requires a central venous access device rather than a peripheral IV in pediatric patients?
- Normal saline
- Lactated Ringer's solution
- Total parenteral nutrition with >10% dextrose (Correct answer)
- 5% dextrose in water
Correct answer: Total parenteral nutrition with >10% dextrose
Solutions with osmolarity >900 mOsm/L, such as TPN with high dextrose concentrations, must be administered via central venous access to prevent severe phlebitis.
Question 3: A 10-year-old child with cancer requires long-term intermittent IV chemotherapy over the next 12 months. Which vascular access device is most appropriate?
- Peripheral IV catheter
- PICC line
- Implanted port (Correct answer)
- Non-tunneled central venous catheter
Correct answer: Implanted port
An implanted port is ideal for long-term intermittent access, offering reduced infection risk, preserved body image, and minimal maintenance between cycles.
Question 4: When using the basilic vein for PICC insertion in a pediatric patient, which position of the arm optimizes vessel diameter?
- Arm adducted across the chest
- Arm abducted 45–90 degrees from the body (Correct answer)
- Arm fully extended overhead
- Arm placed in dependent position below heart level
Correct answer: Arm abducted 45–90 degrees from the body
Abducting the arm 45–90 degrees increases basilic vein diameter and straightens the venous pathway, improving cannulation success.
Question 5: Which complication is MOST commonly associated with PICC lines in neonates compared to older pediatric patients?
- Air embolism
- Cardiac tamponade from tip migration (Correct answer)
- Arterial cannulation
- Hematoma at insertion site
Correct answer: Cardiac tamponade from tip migration
Cardiac tamponade from catheter tip migration into the pericardial space is a rare but disproportionately reported complication in neonates due to their small size and catheter mobility.
Question 6: Which topical anesthetic agent is contraindicated in infants under 3 months of age due to the risk of methemoglobinemia?
- LMX-4 (lidocaine 4%)
- EMLA cream (prilocaine/lidocaine) (Correct answer)
- Vapocoolant spray
- Buffered lidocaine injection
Correct answer: EMLA cream (prilocaine/lidocaine)
EMLA cream contains prilocaine, which can cause methemoglobinemia in infants under 3 months due to immature enzyme systems for reducing methemoglobin.
Question 7: What is the recommended flushing volume for a central venous catheter in a 4 kg neonate?
- 10 mL normal saline
- 5 mL normal saline
- 2× the internal volume of the catheter plus dead space (typically 1–2 mL) (Correct answer)
- The same volume as adult protocol (20 mL)
Correct answer: 2× the internal volume of the catheter plus dead space (typically 1–2 mL)
In neonates, flush volume should be proportional to catheter dead space (2× internal volume), typically 1–2 mL, to avoid fluid overload.
VABC Pediatric Access 3
In a pediatric patient requiring PICC placement, the tip should be positioned at which anatomical location?