Vascular Access In Pediatrics

Sunita Goel
Lecturer in Anaesthesiology, BJ Wadia Childrens hospital, Mumbai, India
First Created: 01/10/2001 

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)

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

Vascular Access in Pediatrics Vascular Access in Pediatrics 2001-01-10
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