Vascular Access In Pediatrics

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

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