|
Dr Sunita Goel
Lecturer in Anaesthesiology
BJ Wadia Childrens hospital
|
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
|
Indications for arterial catheterization |
- Continuous monitoring of systemic blood pressure
- Arterial blood sampling
- Continuous arteriovenous hemofiltration (CAVH)
Placement of arterial cathether
- 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
Contraindications 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 cathethers
- 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 (antireflux 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 noncoring needle is used only
Lasts 1000-2000 punctures
|
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
|
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
- Plasmapharesis
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
Contraindications for central venous access (relative)
- Infected skin site
- Hypercoagulable states (thrombosis)
- Increased intracranial pressure
(for bilateral jugular veins)
- Bacteremia (colonization of catheter)
- Bleeding diathesis
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)
Complications of central venous access
- Bleeding
- Pneumothorax
- Catheter thrombosis
- Infection
- Perforation
- Arrhythmias
- Embolism (air, catheter)
- Endocarditis
- Cardiac tamponade
- Svc syndrome
- Catheter fracture, malposition, migration
|
Umbilical vein catheterization |
- Used in newborn infants < 7 days old
- Used for
Exchange transfusion
Administration of drugs
CVP monitoring
Administration of high glucose concentrations
|
Umbilical arterial catheterization |
Two methods:
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
|
Last created on 07-09-2002
Last submitted on 01-07-2006
|
