VASCULAR ACCESS IN PEDIATRICS
Last Updated : 1/12/2012
Sunita Goel
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Types of vascular access
- Peripheral
- Central

Peripheral

vascular access


- Venous
- Arterial
- Intraosseous
- Venous cutdown

Equipment for peripheral vascular access


- Butterfly needles
- Over- the- needle catheters
- Through-the needle catheter

Indications for peripheral vascular access


- Fluid replacement
- Administration of blood products
- Administration of medications
- Parenteral nutrition
- Blood sampling

Contraindications of peripheral venous access


- Skin infection in the site
- Proximal vein injury
- Proximal unstable fractures
- Uncorrected coagulopathies (deep punctures, cutdowns)

Complications of vascular access


Localized
- Phlebitis, inflammation
- Site infection
- Infiltration
- Tissue necrosis
- Hematoma and bleeding
- Peripheral nerve palsy
- Positional deformities

Systemic
- Thrombosis
- Pulmonary thromboembolism
- Air embolism
- Catheter fragment embolism
- Fluid overload
- Electrolyte imbalance

Arterial Catheterization

Indications for arterial catheterization


- Continuous monitoring of systemic blood pressure
- Arterial blood sampling
- Continuous arteriovenous hemofiltration (CAVH)

Placement of arterial catheter


- Percutaneous insertion
- Arteriotomy
- Umbilical artery catheterization

Sites for arterial catheterization


- Radial and ulnar
- Posterior tibial
- Dorsalis pedis
- Femoral
- Axillary
- Brachial
- Temporal

Contraindications of arterial catheterization


- Likelihood of abnormal perfusion distal to the cannulation site (do Allen test)
- Skin infection at the site of entrance
- Thrombus formation
- Ischemia distal to the insertion
- Embolization
- Loss of distal structures (fingers, toes, feet, hands, etc.)
- Infection (very infrequent)
- Arteriovenous fistulas
- Exsanguinations

Intraosseous infusion
- Establishes vascular access in critically ill infants and toddlers.
- Absorption of fluids and most drugs infused into the marrow is rapid and complete.
- Not too useful in children above 5 years old

Indications for intraosseous infusion


- Cardiopulmonary arrest
- Shock
- Burns
- Life threatening status epilepticus

Sites for intraosseous infusion


- Proximal tibia
- Distal femur
- Distal tibia
- Anterior superior iliac spine

Technique for intraosseous infusion


- Prepare all the equipment
- Restrain the extremity
- Identify the insertion area (1-3 cm below the tibial tuberosity on the medial flat surface of the anterior tibia)
- Clean the skin with iodine
- Infiltrate the area with local anesthesia
- Advance the needle using firm pressure (away from the growth plate)
- Use a screwing motion and a 60 to 90 degree angle
- Remove the stylet; attach a syringe to the needle.
- Confirmation of successful needle placement
- The needle stands upright without support
- Able to aspirate marrow (not always)
- Lack of resistance of infusion
- Radiographic confirmation

Contra-indications to intraosseous infusion


- Ipsilateral fractured extremity
- Osteoporosis
- Osteogenesis imperfecta
- Skin infection
- Complications of intraosseous infusion
- Extravasation of fluid
- Skin necrosis
- Compartment Syndrome
- Osteomyelitis
- Fracture

Central venous access

Types (by access site):


- Central venous catheters
- Peripherally inserted central venous catheters (PICVC)
- Umbilical catheters: UAC, UVC

Types (by time in use):


- Temporary
- Long term
- Implanted

Long term central venous catheters:


- Broviac (various sizes)
- Hickman (one size only)
- Groshong (anti-reflux mechanism with a one way occlusion valve)

Implantable subcutaneous ports:


- Port-a-cath
- Infuse-a-port
- Mediport
- P.A.S. port
Preferred for older children and adolescents. Placed completely under the skin. Special non-coring needle is used only. Lasts 1000-2000 punctures

Indications for central venous access


- Central venous pressure (CVP) measurement
- Delivery of drugs
- Administration of high concentration parenteral alimentation
- Rapid infusion of large volumes of fluids or blood products
- Exchange transfusion
- Chemotherapy
- Blood sampling
- Administration of vasoconstrictors inotropes
- Hemodialysis or hemofiltration
- Plasmapheresis

Contra-indications for central venous access (relative)


- Infected skin site
- Hypercoagulable states (thrombosis)
- Increased intracranial pressure (for bilateral jugular veins)
- Bacteremia (colonization of catheter)
- Bleeding diathesis

Complications of central venous access


- Bleeding
- Pneumothorax
- Catheter thrombosis
- Infection
- Perforation
- Arrhythmias
- Embolism (air, catheter)
- Endocarditis
- Cardiac tamponade
- SVC syndrome
- Catheter fracture, malposition, migration

Central venous catheter sizes in pediatrics

Weight (kg)
Age (years)
Size (French)
<5
0 - 0.5
3,4
>5
0.5 - 1.5
5,7
>15
5 - adult
5 - 11


Sites for central venous catheters


- Internal jugular
- External jugular
- Antecubital
- Subclavian
- Femoral

The Seldinger technique


- Localize the desired vessel
- Introduce a thin wall needle
- Introduce a guidewire through the needle into the vessel
- Make a skin incision and dilate
- Insert the catheter over the wire

Positioning of the central catheter tip
- Obtain a chest x-ray
- The tip should not intrude against a venous wall or the right atrium

Ideal position of central venous catheter tip


- Just above the superior vena cava-right atrium junction
- Just below the junction of the right atrium and inferior vena cava
- Below the origin of renal veins (low femoral)

Umbilical Vein and Arterial Catheterization and Venous Cutdown Sites

Umbilical vein catheterization (UVC):


- Used in newborn infants < 7 days old
- Used for exchange transfusion, administration of drugs, CVP monitoring, administration of high glucose concentrations

Two methods: Direct placement, cutdown

Complications of UAC
- Thrombosis
- Bleeding
- Bacteremia
- Sepsis
- Cellulitis
- Renal failure
- Necrotizing enterocolitis
- CHF
- Embolization
- Infectious arthritis
- Ischemia
- Vascular perforation
- Exsanguinations

Sites for venous cutdown:
- Saphenous
- Basilic
- Distal cephalic
- Proximal cephalic
- External jugular
- Facial

Technique for venous cutdown
- Immobilize the extremity
- Identify the site
- Cleanse the skin with iodine
- Infiltrate the skin (lidocaine)
- Make an incision and dissect
- Identify the vein (over hemostat)
- Pass a loop of 3-0 silk under the vein and cut the loop
- Ligate the vein distally
- Make a venotomy
- Advance the catheter into the vessel 5 to 6 cm.
- Flush the catheter with saline
- Tie the proximal suture
- Close the wound with 4-0 silk and secure the catheter



Contributor Information and Disclosures

Sunita Goel
Lecturer in Anaesthesiology, BJ Wadia Childrens hospital, Mumbai, India


First Created : 1/10/2001

References

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