Procedures for Vascular Access

Procedures for Vascular Access SAMUEL H. WALD, JULIANNE MENDOZA, FREDERICK G. MIHM, AND CHARLES J. COTÉ

Arterial Cannulation Umbilical Artery Radial Artery Axillary Artery Temporal Artery Femoral Artery Dorsalis Pedis and Posterior Tibial Artery

Venous Cannulation Peripheral Intravenous Cannulation Central Venous Pressure Measurement Establishing a Large Intravenous Catheter in Small Patients Central Venous Catheterization Intraosseous Infusion Umbilical Vein Catheterization

VASCULAR CANNULATION IS AN IMPORTANT PROCEDURE in the anesthetic and perioperative management of children. Its routine use was introduced in the 1950s.1 The indications are to provide routes to administer fluids, drugs, and blood products, monitor cardiopulmonary function, and access blood for laboratory testing. Although establishing vascular access may be extremely difficult at times, especially in the very young or small child, no child should be denied an indicated procedure because of an operator’s inability to access the vascular system; appropriate consultation should be sought as necessary. Regardless of the procedure or the person in whom the procedure is attempted, gloves should be worn to maintain clean or sterile technique and to protect health care professionals from exposure to blood and sharps.2–6 An update from the Pediatric Perioperative Cardiac Arrest Registry suggests that lack of good vascular access may contribute to an underestimation of the fluid requirement or blood loss and inadequate replacement of fluid or blood in anesthetized children, thus underscoring the importance of appropriate and adequate vascular access and monitoring.7,8

Venous Cannulation PERIPHERAL INTRAVENOUS CANNULATION Indications Percutaneous intravenous (IV) access should be present in almost all anesthetized children for the following reasons9,10: ■ To provide a route for postoperative pain management. ■ To administer drugs, fluids and electrolytes, glucose, and blood products, including resuscitation medications. ■ To measure central venous pressure; the accuracy of this measurement does not vary according to the location of the catheter11 but does depend on ensuring direct continuity between the central and peripheral circulation.9,12 This can be assessed by providing a large, sustained inspiration or occluding the venous return of the extremity, which both cause an increase in the peripheral pressure.11,13,14 Hypothermia may impair the accuracy of such measurements.15 Equipment ■ Alcohol pads or chlorhexidine swabs ■ Gloves

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■ Tourniquet ■ Gauze ■

Clear plastic dressing (Tegaderm, 3M Medical-Surgical Division, St. Paul, MN, or OpSite, Smith & Nephew, Inc., Largo, FL) ■ Tape ■ Arm board Consider the possible need for latex-free equipment. In cases of difficult access, the availability of a transillumination light source (Karl Storz, 485 B Type, Tuttlingen, Germany) may improve the success rate of catheter placement.16 Ultrasonography also may be used to obtain peripheral venous access at the basilic, cephalic, or brachial veins.17–19 Finally, new near-infrared and infrared technology is available to aid in the identification of peripheral veins (AccuVein, AccuVein, Inc., Huntington, NY; VeinViewer, Christie Digital Systems, Cypress, CA).20 Practical Suggestions 1. Awake IV line placement can be facilitated by any combination of good patient rapport, eutectic mixture of local anesthetics (EMLA) cream (lidocaine 2.5% and prilocaine 2.5%), lidocaine and tetracaine patch, lidocaine by iontophoresis, lidocaine by topical cream, topical tetracaine (Ametop), ethyl chloride spray, and/or premedication.21–30 2. Prefilling the cannula with saline solution may reduce menisci tension and allow a more rapid blood flashback. 3. A butterfly needle can be inserted for induction, followed by an appropriate-sized catheter after anesthesia. 4. A T-connector (Abbott, Inc., Chicago, IL) may be used to minimize the fluids necessary to flush drugs administered through the IV line; this is particularly important for infants.31 5. A calibrated burette should be used to limit the total infusion and provide a means to titrate fluids accurately in infants and young children. 6. A flow-limiting infusion pump may be used for preterm and full-term neonates. 7. Flow rates may be significantly changed by catheter brand, tubing type, and addition of extensions and stopcocks (see also E-Figs. 52.1 and 52.2).32 8. One-way valves in the IV tubing to prevent backflow of drugs or infusions.

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9. Air filters also may be useful for children at risk for paradoxical gas embolization. Complications Hematoma from a failed vascular cannulation is usually of no serious consequence. Infection or thrombosis may be limited by aseptic technique.33–35 One study of 642 Teflon catheters in 525 patients showed that the risk of catheter complications in children was extremely small and would not be reduced significantly by routine replacement of the catheters.36 Catheter life span is unrelated to the insertion site, cannula size, or brand in infants younger than 12 months of age.37,38 Skin sloughing is usually caused by subcutaneous infiltration of calcium, potassium, or hypertonic solutions; it may be avoided by frequent inspection of the IV line for swelling in the subcutaneous tissues before injecting medications.39 The risk of subcutaneous infiltration increases with the administration of medications versus no medications and with parenteral nutrition solutions compared with 5% or 10% dextrose solutions, but the risk of infiltration is no different with solutions that contain potassium (≤20 mEq/L vs. >20 mEq/L). In addition, there is no difference between gravity-controlled versus infusion delivery devices.40 There are insufficient data to support the routine use of heparin to prolong the patency of peripheral IV catheters in neonates and children.41 The severity of extravasation injuries depends on many factors, including pH, osmolarity, the diluent, vasoactive properties, and cytotoxic properties. The treatment of extravasation injuries varies with the extent of the injury from simple cessation of the IV solution and removal of the IV catheter while aspirating as much infiltrate as possible, to limb elevation, application of heat or cold packs, saline washout, topical treatments or injections (topical lidocaine, prilocaine, nitroglycerine, antimicrobials, subcutaneous or intradermal hyaluronidase, phentolamine, sodium thiosulfate or dexamethasone), assessment of compartment pressures, escharotomy, and in some cases, skin grafting.42–46

CENTRAL VENOUS PRESSURE MEASUREMENT Some studies in children and adults describe a reasonable correlation between the venous pressure transduced in peripheral IV catheters and central venous catheters, even in critically ill children. Hypothermia (peripheral vasoconstriction) decreases the accuracy of such measurements, but it is useful to understand that transducing the pressure of a peripheral vein may provide valuable information regarding right-sided cardiac filling pressures.9,10,15,47–49

ESTABLISHING A LARGE INTRAVENOUS CATHETER IN SMALL PATIENTS Indications The following procedure is used for any child in whom there is the potential for massive, rapid hemorrhage: 1. Prepare and drape the appropriate area using standard sterile techniques. 2. Perform a standard IV cannulation of an antecubital, saphenous, or external jugular vein with a small IV catheter (e.g., 22-gauge). 3. Pass a small, flexible guidewire (e.g., 0.018 inch) through the IV catheter, remove the catheter, and with a No. 11 blade, make a small incision at the entry point of the wire at the skin. 4. Pass the next larger size IV catheter over the wire to dilate the vein and leave in place; stiff IV catheters are more effective. An alternative is to use a small dilator from a pulmonary artery catheter introducer and leave the sheath in place. The wire is

removed, and the next larger size wire is inserted (0.025 inch). The catheter (or sheath) is removed, leaving this larger wire within the vein. This process may be repeated with larger catheters and wires until the desired size cannula or sheath is reached. An alternative is to leave progressively larger pulmonary artery introducer sheaths in the vein; both techniques provide a reasonably rapid method of establishing a large-bore IV infusion site. Rapid Infusion Catheters and Introducer Sheaths Special rapid volume catheters (6F and larger; Arrow International, Reading, PA) allow venipuncture with a needle or small IV catheter, passage of a guidewire, and then introduction of a dilator and sheath, with fewer steps required. Intravenous Cutdown Indications ■ Percutaneous cannulation is unsuccessful. ■ Percutaneous cannulation is tenuous. ■ The catheter in place is inadequate for the planned surgical procedure. The most common sites for insertion are the saphenous vein at the medial malleolus and the brachiocephalic vein at the antecubital fossa. This procedure may require considerable time to perform and has limited utility for emergent access.50 Complications IV cutdown has a high incidence of infection and therefore should be used only on a short-term basis. Saphenous Vein Cannulation The saphenous vein is often a reliable point for IV access in infants and children that may be directly visualized or cannulated with a “blind” technique (Fig. 49.1). It is consistently found lateral to the medial malleolus of the ankle one-half to one finger breadth over the anterior quadrant. 1. Cleanse the area in the standard fashion after a tourniquet is applied to the lower extremity below the knee. 2. The saphenous vein may or may not be palpated, and visualization may not be possible. 3. Enter the skin at a 30-degree angle at the expected site of the saphenous vein at the level of the medial malleolus, with the tip of the needle directed toward the upper twothirds of the calf. If no evidence of venipuncture is seen on insertion, slowly withdraw the needle because the flash of blood often occurs while exiting the vein. 4. If unsuccessful on the first attempt, fan medially and then laterally from the same insertion point, slowly advancing and withdrawing the catheter until blood return is obtained. 5. Once a flashback is seen, gently advance the entire unit 2 to 3 mm into the lumen before twisting and advancing the catheter off the needle. Safety Intravenous Catheters In the United States, federal law requires that retractable or sheathed needles designed to reduce the potential for needlestick injury are available for use by health care personnel (Table 49.1).51 A study that compared traditional IV catheters with safety devices found that a larger proportion of children younger than 3 years of age required more than one safety catheter to successfully gain IV access. The retractable IV catheter was associated with an almost fourfold greater incidence of splattering and spilling of

Procedures for Vascular Access

blood compared with traditional catheters.52 The excess splatter occurs when the powerful spring-loaded mechanism rapidly retracts the needle into the housing of the safety device; therefore sheathed catheters are regarded as inherently safer because they require no action on the part of the operator to protect the needle tip. Note that U.S. federal legislation requires that these devices be available, but the ultimate decision to use them rests with the physician operator. Therefore, the type of catheter should not be dictated by the hospital but rather by the individuals who place the catheters.

CENTRAL VENOUS CATHETERIZATION Indications ■ To provide a secure means to administer fluids and blood when major shifts in intravascular volume are anticipated (e.g., multiple trauma, intestinal obstruction, burns). ■ To monitor cardiac filling pressures.

Saphenous vein Medial malleolus

FIGURE 49.1  Long saphenous vein cannulation.

To infuse drugs and fluids that are sclerosing to peripheral veins (e.g., antibiotics, vasoactive drugs, or hyperalimentation fluids). ■ To access blood for laboratory sampling. ■ To measure mixed venous acid-base balance, to estimate cardiac output (Fick principle) or measure cardiac output (dye dilution). ■ To aspirate air emboli from the heart. The common sites for central venous cannulation are the external and internal jugular veins, the subclavian and brachiocephalic veins, the femoral vein in infants and children, and the umbilical vein in neonates. Approaches such as the internal jugular and subclavian veins should be used with extreme caution in the presence of a bleeding diathesis as stopping bleeding may be difficult. The percutaneous approach to central venous cannulation is most successful using a modified Seldinger technique (Fig. 49.2).53,54 The advantages of this technique are that it avoids the need for a cutdown, only one venipuncture is made with a thinwalled, small-gauge needle, a guidewire directs the catheter within the blood vessel, introducing a large catheter through the small venipuncture site minimizes the chances of significant hematoma formation even after systemic heparinization, and the procedure often can be accomplished when access is required emergently. Whenever a central line is inserted into the heart from above, care must be taken to ensure that the catheter tip is positioned at the junction of the superior vena cava and the right atrium, because other positions have been associated with perforation of large vessels and the myocardium (Fig. 49.3) and with triggering of ventricular arrhythmias.55 Ultrasound guidance, pressure waveform analysis, or electrocardiographic guidance may help prevent complications related to central catheter placement.56,57 Ultrasound-guided access assists successful cannulation of the internal jugular vein,56 the infraclavicular axillary vein,57 and the subclavian vein.58,59 In a meta-analysis of 18 trials with 1646 infants, children, and adults, two-dimensional ultrasound guidance yielded better outcomes than the landmark method.60 In contrast, a review of 5434 landmark-guided approaches by fully trained anesthesiologists collected over 22 years ( 1 3 < 1 year of age) at 1 institution, 95% of which were internal jugular, reported a 99.5% success rate. Success also depended on experience and the child’s age: the success rate was less in junior faculty and smaller children.61 The greatest benefit with ultrasound was to cannulate the internal jugular vein rather than the subclavian or femoral veins.60 See Chapter 43 and Videos 49.1 and 49.2 for ultrasound-guided techniques.

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■

TABLE 49.1

Comparison of Intravenous Safety Mechanisms

Safety Mechanism

Operator Activation Required

Syringe Attachment

Rapid Flash

Bulky

Advantages

Disadvantages

Devices (Manufacturers)

Retractable needle

Yes

No

Yes

Yes

Unobstructed and rapid blood flash Similarity in use to non-safety devices

Angiocath Autoguard (Becton Dickinson Medical, Franklin Lakes, NJ) Secure IV (Span America Medical Systems, Inc., Greenville, SC)

Blunted needle

No

Yes

No

No

Passive action requiring no operator activation Syringe attachment possible

Bulky Requires operator activation No syringe attachment Slow blood flash if needle has been partially withdrawn

Introcan Safety IV Protectiv and Acuvance (Smiths Medical, Kent, UK)

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A

B

C

D

FIGURE 49.2  A, Seldinger technique for catheter placement. The needle is inserted into the target vessel, and the flexible end of the guidewire is passed freely into the vessel. B, The needle is then removed, leaving the guidewire in place. C, The catheter is advanced with a twisting motion into the vessel. D, The wire is removed, and the catheter is connected to an appropriate infusion or monitoring device. (Redrawn with permission from Schwartz AJ, Coté CJ, Jobes DR, et al. Central venous catheterization in pediatrics. Scientific exhibit, American Society of Anesthesiologists, New Orleans, 1977.)

Complications Pneumothorax, arrhythmia, hematoma, bleeding, infection, thrombosis, inadvertent arterial puncture, cardiac tamponade, air embolus, thoracic duct injury, and malposition are all possible complications associated with central venous cannulation. Data in adults suggest that the smallest catheter and placement from

the left subclavian approach may have the least complication rate; similar studies have not been conducted in children.62 The infection rate reported after 1056 central venous catheters were inserted into 289 children with burn injury varied from 2.0% to 7.3% for catheters in place for less than 11 days, but that rate increased dramatically to 15.8% to 37.5% for catheters left in

Procedures for Vascular Access

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Jugular veins Innominate veins

Thoracic duct

49

Left subclavian vein

Right subclavian vein Right atrium

A

A

Right ventricle

A

A

V

C

V

D

A

A

E

V

B

V

V

F

FIGURE 49.3  Proper and improper central venous pressure catheter placement. A, Normal vascular anatomy. B, Proper location for right internal jugular catheter (i.e., high right atrium or superior vena cava). C, Ventricular location of any catheter is dangerous and contraindicated. D, A short left-sided internal jugular catheter may erode through the innominate vein (arrow). E, A left-sided internal jugular catheter striking the lateral wall of the superior vena cava (arrow) may erode through it and must be partially withdrawn or advanced. F, A short right subclavian catheter may strike the lateral wall of the innominate vein (arrow) and erode through it; this catheter should be advanced or withdrawn. Continued

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A

A

G

V

V

H

FIGURE 49.3, cont’d  G, Proper location for a right subclavian line. H, A short left subclavian line may erode through the superior vena cava (arrow); this catheter should be advanced or withdrawn. A, atrium; V, ventricle.

place for 12 to 14 days.63 A randomized study that compared the success rate of insertion of the internal jugular versus subclavian approach in 280 pediatric cardiac surgical patients found a similar success rate with the two approaches, although the incidence of positive catheter tip culture results (22% vs. 3.4%) and bloodstream infection (6.9% vs. 0%) were greater with the internal jugular approach.64 The first attempt success rates were similar with the two approaches (64% vs. 69%). However, the rate of arterial puncture was greater in the internal jugular group (8% vs. 2%) but success rate overall (91% vs. 82%) was greater in the subclavian group. The frequency of catheter malpositions was greater with the subclavian route (17% vs. 1%). In a separate study, catheterassociated bloodborne infections diminished dramatically after initiation of a rigorous hand hygiene program.65 Aseptic Technique Contamination of catheters during insertion may result in catheter colonization or bacterial infection. Evidence suggests that the use of maximum barrier precautions during placement, including the use of sterile gloves, long-sleeved gowns, full-size drapes, and a nonsterile mask and cap, decrease the risk of catheter-related infection.33,35,66,67 The efficacy of chlorhexidine versus povidoneiodine for preventing bacteremia remains unclear, and the safety of chlorhexidine in infants and children has not been fully established.68 For older infants and children, chlorhexidine may be safe and effective, but it can cause severe local contact dermatitis in low-birth-weight infants69,70; its use in older children has been shown to reduce the incidence of catheter-associated infection compared with povidone-iodine.71,72 In a case-controlled, prospective, active surveillance study in a pediatric intensive care unit (ICU), independent risk factors for central line–associated bloodstream infection were the duration of central venous catheterization in the ICU, nonoperative cardiovascular disease, gastrostomy tube, parenteral nutrition, central line placement in the ICU, and red blood cell transfusion.73 External Jugular Vein Catheterization 1. Place the child in the Trendelenburg position with the head turned 45 degrees away from the side of cannulation.

2. Place a pillow or rolled sheet under the shoulders to extend the head and allow complete access to the neck. 3. Under aseptic conditions, venipuncture and catheter insertion are completed according to the techniques shown in Fig. 49.2. A J-wire is usually more useful to circumvent the plexus of veins at the clavicle.74,75 4. Suture or tape appropriately and cover with an occlusive dressing. Many catheters will not pass beyond the clavicle or will pass into the axillary vein; success is generally more often attained on the right side.76,77 If a shorter catheter is used, infusion and pressure monitoring are very dependent on the position of the head.78 Continuous free-flowing infusion is best maintained when the head is turned away from the side of catheter insertion. This vein is particularly valuable in children with difficult peripheral venous access and in an emergent situation that suddenly develops intraoperatively that requires establishment of additional IV access. Internal Jugular Vein Catheterization Numerous approaches and techniques are used for internal jugular vein cannulation.79–82 A high approach using the apex of a triangle formed by the two bellies of the sternocleidomastoid muscle and the clavicle may be used as a landmark for insertion (Fig. 49.4). With the use of the Seldinger technique, the success rate, even in neonates, approaches 75% on the first attempt and 90% to 95% on the second attempt.53 Cannulation of the right side virtually ensures a central location because the internal jugular vein, the superior vena cava, and the right atrium are in a straight line (see Fig. 49.4). Left-sided cannulation risks injury to the thoracic duct and possible pneumothorax because the apex of the lung is more cephalad on the left. In addition, if the catheter inserted on the left is too short, it is not unusual for the tip to rest against the wall of the superior vena cava, be position dependent, and possibly erode through the wall of the vessel. Fig. 49.3 illustrates desirable and less desirable sites for catheter tips that may avoid or result in perforation. The principal advantage of the high approach is that the most common complication (arterial puncture, approximately 10%) is easily recognized and usually treated uneventfully.

Procedures for Vascular Access

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Left internal jugular vein Right internal jugular vein

Left common carotid artery

Right common carotid artery

Thoracic duct

Right subclavian artery

Sternocleidomastoid

Left subclavian artery

1

Sternal head Clavicular head

Clavicle

Left subclavian vein

Right subclavian vein Innominate veins

2

Aortic arch

1st rib

Superior vena cava

Sternum

Right atrium Right ventricle

A

B

Nipple

C

M

L Midpoint

SCM

C

FIGURE 49.4  A, The anatomic relationships of major chest and neck structures. Note how the internal jugular vein is in close proximity to the carotid artery. Also, note that a nearly straight line is formed by the internal jugular vein, innominate vein, superior vena cava, and right atrium (yellow dashed line); thus it is rare for a right internal jugular catheter to migrate anywhere but to the right atrium. B, The relationship of external anatomic landmarks to the anatomy illustrated in A. Note the triangle formed by the two bellies of the sternocleidomastoid muscle and the clavicle. 1, The preferred point of needle insertion at the apex of this triangle for internal jugular vein puncture. 2, The point of needle insertion for subclavian vein puncture. C, The anatomic landmarks as they would appear to an anesthesiologist. The needle is introduced at the apex of the triangle outlined in C and is directed at an angle of 30 degrees to the skin toward the ipsilateral nipple. This point of entry is generally half the distance between the mastoid process and the sternal notch. C, clavicle; M and L, medial and lateral bellies of the sternocleidomastoid muscle (SCM).

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In one study, the effects of a simulated Valsalva maneuver (positive inspiratory pressure of 25 mm Hg for 10 seconds), liver compression, and Trendelenburg position individually or in combination on the cross-sectional area of the right internal jugular vein were studied. The mean increase in cross-sectional area of the right internal jugular vein was maximized at 17.4% ± 16.1% from baseline when all three maneuvers were combined.83 The magnitude of this maneuver varied with the age of the child: the effect was greatest in children 1 to 6 years of age and clinically negligible in infants younger than 12 months of age. The effect on ease of catheter placement was not investigated, but a larger-sized vessel should improve the success rate.83 For neonates, a study using skin traction in infants weighing less than 5 kg showed that a technique using tape for skin traction combined with ultrasound guidance increased internal jugular cross-sectional area and decreased the time to place the catheter.84–86 Technique 1. Position the child as for external jugular vein cannulation but with a rolled towel under the center of the back to allow the head to be slightly extended (see Fig. 49.3 and Videos 49.1 and 49.2 for positioning and the use of ultrasound to guide insertion). The head is turned slightly away from the side of insertion; turning the head too far to the side may compress the vein and move the vein in closer proximity to the carotid artery. 2. Locate the apex of a triangle formed by the two bellies of the sternocleidomastoid muscle. This point is usually where the external jugular vein crosses the sternocleidomastoid muscle or the midpoint between the mastoid process and the sternal notch. 3. Palpate the carotid artery. Introduce the needle just lateral to this artery at an angle of 30 degrees to the skin surface. If the internal jugular vein is superficial, a less acute angle may be indicated. While continuously aspirating, advance the needle toward the ipsilateral nipple a distance of no more than 2.5 cm. If no blood is freely obtained, slowly withdraw the needle while maintaining aspiration. The needle can compress the vessel on entry, and it straightens during withdrawal, allowing free aspiration of blood. 4. Once venipuncture is accomplished, carefully remove the syringe and occlude the end of the needle (to prevent entraining air if the child is breathing spontaneously) until a flexible guidewire is inserted (see Fig. 49.2).54 The wire should advance easily. However, if the wire cannot be advanced, the needle has passed out of the vessel lumen or its tip rests against the vessel wall. In this situation, the wire and needle should be withdrawn simultaneously to avoid shearing the wire. If the wire passes without difficulty, then cannulation proceeds as demonstrated in Figs. 49.2 and 49.4. The location of the catheter tip should be confirmed with a radiologic study and optimally repositioned as necessary (see Fig. 49.3). 5. Suture the catheter in place, and protect the area with an occlusive dressing. Contraindications ■ A bleeding diathesis (relative contraindication); in lifethreatening emergencies, the benefit may outweigh the risk. ■ Contralateral pneumothorax. ■ Increased intracranial pressure (Trendelenburg position and venous occlusion by the catheter may increase intracranial

pressure); this is a relative contraindication and ultrasoundguided insertion may provide a great advantage because Trendelenburg position may not be required. ■ Aberrant vessels (e.g., cervical aortic arch). Subclavian Vein Catheterization The subclavian vein is a site frequently used for central vein cannulation.87,88 Success rates greater than 80% have been reported even in neonates.89–91 The advantages include fixed landmarks, ease of securing the line to children for long-term management, and patient comfort. Disadvantages include pneumothorax and hemothorax.92,93 If this site is chosen, we suggest obtaining a chest radiograph after the catheter is inserted and before surgery begins to preclude an unrecognized intraoperative tension pneumothorax. The use of the Seldinger technique (our preference) may reduce the incidence of damage to intrathoracic structures compared with other techniques. As with left-sided internal jugular vein cannulation, if a left subclavian catheter tip rests against the wall of the superior vena cava, it can erode through, resulting in hemothorax or hydrothorax (see Fig. 49.3H). In a comparison of neutral versus lowered shoulder position in 361 adult patients, neutral position significantly reduced the incidence of misplacement of the catheter tip (ipsilateral internal jugular or brachiocephalic vein) with no difference in the rate of arterial puncture or pneumothorax.94 This maneuver remains to be tested in children. As described earlier, the jugular approach was associated with a greater incidence of positive catheter tip culture results (22% vs. 3.4%) and bloodstream infection (6.9% vs. 0%) compared with the subclavian approach.64 Importantly, although there was no significant difference in firstattempt success (64% vs. 69%), the frequency of arterial punctures was significantly greater with the internal jugular vein approach (8% vs. 2 %), but catheter malposition was greater with the subclavian approach (17% vs. 1%). A Cochrane review of 13 studies with 2360 procedures compared ultrasound cannulation of femoral or subclavian access with landmark techniques and found no difference in complications or success rate, although the experience of the clinicians was not examined.95 Technique 1. Prepare and position the child as previously described for external jugular vein puncture. 2. Insert a needle immediately inferior to the clavicle at a point one-half to two-thirds its length from the sternoclavicular junction; while “hugging” the undersurface of the clavicle, the needle is directed toward the suprasternal notch while continuously aspirating. 3. As soon as free blood flow is obtained, proceed as in Fig. 49.2. If the Seldinger technique is not used, then first locating the subclavian vein with a small-gauge finder needle is recommended. 4. Suture the catheter in place, and apply an occlusive dressing. If the child’s ventilation is controlled, the risk of pneumothorax may be decreased by momentarily ceasing ventilation so that the apex of the lung is away from the needle tip while probing for the subclavian vein. Once successful venipuncture has been achieved, maintaining positive end-expiratory pressure reduces the possibility of air embolism. Optimal depths for right subclavian catheterization have been studied in infants 2 to 5 kg using transesophageal echocardiography and were found to be 40 to 55 mm for catheter tip placement at the junction of the superior vena cava and the right atrium.96 Contraindications are the same

Procedures for Vascular Access

as for internal jugular vein catheterization (see Video 49.1 for illustration of technique).

to be safe in infants weighing less than 1000 g with the caution of careful catheter advancement to avoid cardiac perforation.110

Brachiocephalic Vein Catheterization The brachiocephalic vein offers the advantage of being far removed from the intrathoracic structures.97 The main disadvantage is that a significant number of catheters introduced at this site do not pass centrally—that is, they are caught in the axilla or pass up the jugular vein (internal or external).98–100 Other disadvantages include significant catheter migration with movement of the arm and possibly an increased incidence of infection. This approach is commonly used by radiologists and pediatric nurses for placement of peripherally inserted central catheters (PICCs), which can be used on a long-term basis.101–103 These catheters often markedly improve patient care and the quality of life for the child because of the reduced need for peripheral venous access and the reduced number of venipunctures for blood testing. One study examined an ultrasound supraclavicular approach in infants weighing 0.7 to 10 kg; they had a 98.9% success rate with more punctures needed on the right than the left.104 The routine use of heparin to prevent catheter thrombosis and occlusion is not supported by published studies, but the data are inadequate to reach a conclusion one way or the other.105

Technique 1. Prepare and drape the groin using an aseptic technique with the legs at 90-degree angles (“frog-leg position”) (see Fig. 49.5B). Place a roll under the hips, thereby slightly elevating the hip, to provide optimal conditions 2. Palpate the femoral artery at a point midway between the pubic tubercle and the anterior superior iliac spine (see Fig. 49.5, A). Using the Seldinger technique, enter the vein at a point just medial to the femoral artery and 1 to 2 cm below the inguinal ligament. Insert a catheter as in Fig. 49.2. As for the brachiocephalic vein, special long catheters and wires are needed to achieve a central location (see Video 49.2). As with many vascular access methods, ultrasound guidance can be quite useful.107,111–113 3. Protect the catheter insertion site as previously described (see discussion of internal jugular vein catheterization). If an alternative technique is used (e.g., catheter through the needle), maintain compression of the cannulation site until hemostasis is ensured. The saphenous vein may be cannulated by direct venous cutdown at its junction with the femoral vein if percutaneous techniques are unsuccessful.

Technique 1. Prepare and drape the arm with aseptic technique. 2. Cannulate the brachiocephalic vein either by using the modified Seldinger technique (special long catheters and wires for this purpose) or by passing a catheter through a needle (Intracath CVC Catheter, Argon Medical, Plano, Texas). If the catheter cannot be threaded once the vein is entered, initiating rapid IV fluid administration, cephalad positioning of the arm, and anterior displacement of the shoulder may assist advancement. If percutaneous techniques are not possible, direct venous cutdown may be performed. Femoral Vein Catheterization The femoral vein may also be used for access to the central circulation.106 When trainees placed such lines, the ultrasound approach was superior to the palpation/landmark approach,107 although in more experienced hands, ultrasound did not improve the success rate.95 The catheter must pass into the thorax to provide accurate measurements of the cardiac filling pressures. Nonetheless, there is a reasonable correlation with central filling pressures even when the catheter tip rests within the abdomen.108 Occasionally, the catheter is inadvertently advanced into a vertebral vein; this can be confirmed with a lateral radiograph. One advantage of this route is that the vein is large and presents easy access distant from the vital intrathoracic structures (Fig. 49.5). Disadvantages include difficulty in securing the catheter to the child, kinking of the catheter with leg flexion, and problems in maintaining insertion site sterility. Short-term catheterization can provide large-bore venous access for the duration of a procedure with expected large and rapid blood loss if other veins are not accessible. Surprisingly, this site is not associated with a greater incidence of catheter-related sepsis compared with other insertion sites.63,109 This site is not appropriate if disruption of inferior vena cava blood flow is possible (e.g., Wilms tumor resection with invasion of the inferior vena cava, abdominal trauma). The tip of the catheter should be located either low in the atrium or inferior to the level of the diaphragm but superior to the level of the renal veins to reduce the potential for renal vein thrombosis. Use of this technique also has been reported

INTRAOSSEOUS INFUSION The administration of IV fluid into the medullary cavity of long bones is a proven method for volume resuscitation in a hypovolemic child and even in teenagers.114–121 This method can effectively deliver drugs to the central circulation as quickly as using peripheral IV infusion sites.122 It is a particularly valuable emergency route of drug administration, even in the hands of emergency medical technicians123–125 and as part of emergency department resuscitation of pediatric trauma patients.118,126 Complications such as cellulitis, abscess, fractures, and osteomyelitis have been reported in less than 1% of cases, and this technique does not appear to affect later growth of the tibia with proper insertion technique,127–129 but the time required for bone healing is unknown.130 Compartment syndrome may occur if the needle is misplaced. These complications relate in part to duration of infusion, underlying medical conditions, and aseptic technique. The major difficulties with this technique are due to failure to adhere to proper landmarks131 and bending and clotting of the needle. This technique is used in an emergency situation if several attempts at peripheral or central venous cannulation have failed (suggested “if you cannot achieve reliable access quickly,” which generally means after three attempts or 90 seconds).132,133 Sites for insertion include the upper medial tibia just below the tibial tuberosity, the lower medial tibia just superior to the medial malleolus (to avoid growth plates), the lower femur, and the anterior iliac crest. Intraosseous infusions are discontinued once an alternative IV infusion site has been secured. This technique has been successfully used for resuscitation of burn victims.134,135 Intraosseous devices should not be used in a fractured leg. For the most recent, complete information, please refer to a review directed to the anesthesiologist caring for pediatric patients.136 Technique 1. Palpate the tibial tuberosity. 2. Locate a point on the medial surface of the tibia at least 1 to 2 cm below and medial to the tibial tuberosity for the

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A Practice of Anesthesia for Infants and Children Iliacus muscle Anterior superior iliac spine

Pubic tubercle N

A V

Pubic symphysis

N

Pectineus muscle

A V

Adductor longus muscle Sartorius muscle

Inguinal ligament

A

B

FIGURE 49.5  Insertion of a central venous catheter from the femoral approach. A, The easiest method to remember the anatomy is the mnemonic NAVEL (nerve, artery, vein, empty space, leg or lymph node) such that the vein is always located medial to the artery, and the femoral nerve is located lateral to the artery. B, The femoral artery is palpated just below the inguinal ligament, and a needle is passed just medial to the arterial pulsations. C, The Seldinger technique is used (see Fig. 49.2) and the catheter tip is advanced to the desired location (into the low right atrium or below the level of the diaphragm but above the level of the renal veins).

C

Procedures for Vascular Access

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49 A

B

C

D FIGURE 49.6  A, The intraosseous needle may be inserted in either of two locations: at a point 1 to 2 cm below and medial to the tibial tuberosity or at the medial malleolus (arrows). B and C, The leg is prepared, and the intraosseous needle punctures the skin (note the X mark (arrow) connecting the tibial tuberosity with the point of needle insertion); the needle is advanced with a twisting motion in a caudal direction. D, The stylet is removed, and the selected solution is infused.

site of needle puncture, because the mantle of the tibia is thin at this location (Fig. 49.6A). 3. Use a special short needle with a stylet to puncture the mantle of the tibia at a 75-degree angle directed toward the feet to avoid the epiphyseal plate (see Fig. 49.6B and C). A styleted spinal needle also may be used. 4. The appropriate position is readily achieved with the loss of resistance; take care to avoid advancing the needle too far (i.e., out the opposite side or against the opposite mantle of the tibia). The needle is usually quite stable if properly positioned. 5. Attach standard IV infusion equipment. Fluid should flow freely without extravasation (see Fig. 49.6D). A mechanical handheld, battery-powered intraosseous needle insertion device that works much like an electric drill (Fig. 49.7) is the EZ-IO (Teleflex Medical Inc., Research Triangle Park, NC). Several sizes of intraosseous needles (depth of insertion) are available to limit the depth of insertion (determined by patient weight); we recommend that this device be immediately available in all operating rooms137 and prenatal ICUs because this is the simplest and easiest means for establishing emergent intraosseous access (even in out of hospital venues).138–143 The specially designed IV fluid low-profile adapter (already primed with IV fluid) is then attached to the sheath, providing clear access for drugs, fluid, or blood administration.

UMBILICAL VEIN CATHETERIZATION Indications The umbilical vein provides convenient access to the central circulation of a neonate to restore blood volume and to administer glucose and drugs. This procedure is often carried out blindly with later radiographic confirmation of correct position. A large fraction of catheters are initially malpositioned, which if unrecognized, can lead to life-threatening complications.144–148 Monitoring changes in the ECG may be helpful (see further). A change in the configuration of the electrocardiogram (ECG) suggests that a small QRS complex reflects catheter position below the diaphragm; a normal-sized QRS complex with a small P wave was associated with location within the inferior vena cava at the thoracic level; and the appearance of a tall P wave indicated positioning within the right atrium.144 Umbilical vein catheterization also provides a route for the procedure of exchange transfusion and for measuring central venous pressure. Equipment Umbilical artery catheter sizes 3.5F and 5F ■ Scalpel and blade ■ Fine-curved forceps ■ Mosquito hemostats ■ Umbilical tape ■ Scissors ■ Sutures with needle (3-0 silk) ■

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A

B

C

D

E FIGURE 49.7  A, The EZ-IO (Teleflex Medical Inc., Research Triangle Park, NC) is a battery-powered intraosseous needle insertion device that works much like an electric drill. B, After appropriate preparation of the skin, at a point 1 to 2 cm below and medial to the tibial tuberosity, the intraosseous needle is directed down and away from the epiphyseal plate. C, After successful insertion of the needle and its sheath, the needle is removed, leaving the tip of the metal sheath lodged within the bone marrow cavity. D, The intraosseous system is ready for connection and use. E, The specially designed intravenous fluid adapter (already primed with intravenous fluid) is then attached to the sheath, providing clear access for drugs, fluid, or blood administration. (Courtesy Charles J. Coté, MD.)

■ ■ ■ ■ ■ ■

Antiseptic solutions (e.g., povidone-iodine and alcohol) Three-way stopcocks 10-mL syringe Sterile drapes Infusion solution of 10% dextrose in water, with 1 to 2 units of heparin per milliliter at 1 mL/hour Calibrated transducer/monitoring system if used for central venous pressure measurement

Technique 1. Prepare and drape the umbilicus with sterile technique; cut the cord approximately 1 cm above the umbilicus. The umbilical vein orifice is more patulous and thin walled than the two umbilical arteries (Fig. 49.8). 2. Holding the catheter filled with heparinized solution 2 cm from the tip, gently introduce it into the vein. In some situations, forceps can aid in directing the catheter. Traction of the umbilical stump caudad may help to advance the catheter (see Fig. 49.8). The catheter is passed a distance

that approximates the length between the umbilical stump and the right atrium. Blood should freely aspirate into a syringe. Inability to withdraw blood may occur if the tip of the catheter is resting against a vessel wall or if a clot is present within the catheter lumen. It is important that the tip of the catheter be placed in the proper position—that is, at the junction of the inferior vena cava and right atrium. A radiograph confirms proper catheter position. Monitoring changes in the configuration of the ECG during insertion may allow for a more accurate placement within the right atrium but is limited to neonates with a normal tracing.144 At times, the catheter may fail to traverse the ductus venosus and become wedged in the liver. This position is potentially dangerous because portal necrosis and subsequent cirrhosis may result should hyperosmolar or sclerosing solutions be injected (calcium, sodium bicarbonate, 25%–50% glucose).148–150 A low position might be acceptable for short-term use if it is not possible to pass the catheter centrally, but the distance of insertion should

Procedures for Vascular Access

Equipment The materials used for cannulation are identical to those described for umbilical venous catheterization. Equipment is required for continuous monitoring of blood pressure. End-hole rather than side-hole catheters may have a smaller incidence of thrombosis or associated ischemic events.164

Portal sinus

RV

RA

Diaphragm Catheter in umbilical vein Liver Ductus venosus IVC Portal vein

FIGURE 49.8  Umbilical vein catheterization. The umbilical vein is thin walled and patulous, whereas umbilical arteries are thicker walled and of smaller diameter. Caudal traction on the umbilical stump may facilitate catheter advancement. The catheter should be advanced through the liver into the central circulation within the low right atrium (RA) before administration of any medications. IVC, Inferior vena cava; RV, right ventricle.

be no more than 3 to 4 cm or just until blood is freely aspirated. 3. Suture the catheter in place, cover the insertion site with antibiotic ointment, and tape it to the abdominal wall. The catheter is then connected to a constant-infusion system and should be removed as soon as the indications for its insertion have passed. Complications appear to relate in part to the duration of insertion.146,148,151 Complications 148,152 ■ Thrombosis of portal or mesenteric veins 146 ■ Infection (septicemia) ■ Endocarditis ■ Pulmonary infarction (misplacement of the catheter into the pulmonary vein through a patent foramen ovale) 153–156 ■ Portal cirrhosis and esophageal varices later in life 157 ■ Cardiac tamponade 145,158 ■ Liver abscess and subcapsular hematoma

Arterial Cannulation UMBILICAL ARTERY The umbilical artery in a neonate is a convenient site for monitoring arterial blood pressure, blood gases, and pH. It provides emergency access to an infant’s circulation for restoration of blood volume and administration of glucose and drugs.159–162 Continuous monitoring of arterial O2 saturation is also possible.163

Technique 1. Prepare and drape the area with sterile technique; cut the umbilical cord approximately 1 cm above the umbilicus. The two umbilical arteries are identified (Fig. 49.9). The cut vessel ends have thicker walls, are smaller than the vein, and are usually in spasm. The artery is entered in the manner described for umbilical vein catheterization, except that cephalad traction is applied to the umbilical stump (see Fig. 49.9A) to encourage caudal direction of the catheter. The catheter should course through the umbilical artery into the iliohypogastric artery and then into the descending aorta. Proper positioning of the catheter tip is crucial. If the catheter is advanced too far up the aorta, it may pass through the ductus arteriosus and into the pulmonary artery. If this situation is not recognized, blood pressure and blood gas measurements may be misleading. Care should be taken to ensure the placement of the catheter tip in the descending aorta (at T7 to T9). Early reports suggested that a cephalad position, at or above the level of the diaphragm, is easier to maintain but predisposes infants to increased risk of embolization to renal or mesenteric vessels (see Fig. 49.9B).165–168 However, positioning just above the bifurcation of the descending aorta—that is, at L3 to L5 (see Fig. 49.9A) (below the origin of the renal arteries and visceral branches of the aorta) has not been supported by a Cochrane review; a cephalad position is recommended.169 The caudad position is difficult to maintain, and the catheter tip may slip into one of the iliac arteries, resulting in tissue ischemia (see Fig. 49.9C). 2. Confirm the position radiographically. Once the catheter is properly positioned, the system is connected to a constantinfusion pump and heparinized fluids (10% dextrose in water or normal saline solution) are infused. Suture and tape the catheter and apply antibiotic ointment as for umbilical vein catheters. A Cochrane review of the use of heparin suggested that low-dose heparinization of the infusate (0.25 unit/mL) reduces the likelihood of catheter occlusion compared with intermittent flushing with heparinized solutions.170 Complications Using the umbilical artery as a source for blood pressure monitoring and blood gas analysis only and reserving alternative sites for glucose and drug administration may minimize complications. Changes in cerebral blood flow are associated with intraventricular hemorrhage and have been documented to occur with umbilical artery blood sampling; fewer changes in cerebral blood flow occur with low-positioned catheters.171 The incidence of documented intraventricular hemorrhage appears to have a stronger relation with age than with catheter position and is not associated with the use of low-dose heparin.170,172 The use of an alternate site for monitoring may reduce complications.173 Other complications are as follows: ■ Accidental disconnection of stopcocks and catheters or vessel perforation can lead to potentially dangerous exsanguination.174

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A Practice of Anesthesia for Infants and Children Acceptable catheter tip location

Aorta

T-7,8,9

Diaphragm

Aorta Aorta Diaphragm

Acceptable catheter tip location L-3-4 Common Common iliac artery

Common iliac artery Catheter in umbilical artery

Hypogastric artery

A

Catheter in umbilical artery

Hypogastric artery

B

C FIGURE 49.9  Umbilical artery catheterization. Cephalad traction on the umbilical stump may facilitate catheter advancement. A, The catheter tip at L3-4 just above the aortic bifurcation and below the renal arteries is one acceptable location (arrow to yellow line). B, An alternative acceptable location is in the descending aorta between T7 and T9 (arrow to yellow line). C, An area of necrosis in the left buttock that resulted from a catheter migrating into the internal iliac vessel, occluding one of its branches.

■

Blood clots may embolize retrograde or, more likely, distally, leading to ischemia or infarction of the infant’s gut, kidneys, or lower limbs (see Fig. 49.9C).175 ■ Vascular spasm is usually transitory and may be resolved by withdrawal of the catheter. Several cases of flaccid paraplegia have been reported resulting from spasm or embolic phenomena.176 ■ The infant is always at risk for sepsis; therefore clear indications for the insertion of this catheter are mandatory. The catheter should be removed at the earliest possible time. A Cochrane review failed to establish a role for prophylactic antibiotics in reducing catheter-related infections.177

■

Hypertension as a result of renal artery emboli may cause ischemia and infarction of the kidney.168,178 179 ■ Aortic thrombosis may occur.

RADIAL ARTERY Radial artery cannulation is a reasonable alternative to umbilical artery cannulation in a neonate and is the primary site of arterial cannulation in infants and children in most pediatric institutions. Percutaneous radial artery cannulation is widely practiced, with minimal morbidity.146,180–185 The use of ultrasound may improve success rate.186 Failure to cannulate the artery percutaneously may be followed successfully by direct arterial cutdown. Children with

Procedures for Vascular Access

Down syndrome (trisomy 21) have abnormal radial vessels (both size and location, 16% to 19%), which can make arterial cannulation particularly difficult; some children with Down syndrome have a single median artery.187,188 The ulnar artery also has been used as an alternative site for arterial catheterization when attempts at insertion in other locations have been unsuccessful; to ensure adequate perfusion of the hand, this site should not be used if previous attempts at cannulation of the ipsilateral radial artery had been attempted.189 Indications Indications for radial artery cannulation include monitoring of arterial blood pressure, arterial blood gases, and pH. The right radial artery is preferred in neonates because it is representative of preductal blood flow. Technique (Video 49.3) 1. Confirm the adequacy of ulnar artery collateral flow by the modified Allen test (Fig. 49.10A). The color of the hand is noted. The hand is passively clenched, and the radial and ulnar arteries are simultaneously compressed at the wrist (see Fig. 49.10B). The ulnar artery is then released, and flushing (reperfusion) of the blanched hand is noted (see Fig. 49.10C). If the entire hand is well perfused while the radial artery remains occluded, indicating adequate collateral flow, catheterization of the radial artery is performed. Note that the sensitivity of the Allen test is approximately 73%, with a specificity of 97%.190–192 Many have abandoned the Allen test because of its poor sensitivity as a predictor of ischemia of the hand if the test failed and they simply avoid cannulating the ulnar artery. 2. Secure the hand using an arm board with slight extension of the wrist to avoid excessive median nerve stretching. The fingertips should be left exposed when the hand is taped down so that any peripheral ischemic changes from spasm, clot, or air can be observed. 3. Observe the course of the radial artery in a neonate with the aid of a fiberoptic light source directed toward the lateral side or dorsal aspect of the wrist. Use of a Doppler device or visualization via ultrasound186 may also be of great value.193,194 4. Use a 20-gauge needle to make a small skin puncture over the maximal pulsation of the radial artery, usually at the second proximal wrist crease. This step eases passage of the cannula by reducing resistance offered by the skin and prevents a burr from forming on the catheter tip as it passes through the dermis. A method to avoid accidental puncture of the artery is to pull the overlying skin laterally to make the skin nick. 5. Perform cannulation with a 24- or 22-gauge catheter either on direct entry of the artery at an angle of 15 to 20 degrees or on withdrawing the cannula after transfixion of the artery (Fig. 49.11A to C). A wire (0.018 inch) may be used as an aid to advance 22-gauge and nontapered 24-gauge catheters. 6. Attach the catheter firmly to a T-connector to permit continuous infusion of isotonic saline solution (1 unit/mL) at the rate of 1 to 2 mL/hour via a constant-infusion pump (see Fig. 49.11D). The catheter is securely taped in place. A pressure transducer is connected to allow continuous arterial pressure monitoring. To ensure accurate blood pressure measurement, it is essential that the transducer is calibrated to the neonate’s or child’s heart level, that all

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49 A

B

C FIGURE 49.10  Modified Allen test. A, Color and perfusion of the hand are noted. B, The hand is first passively clenched, and then both radial and ulnar vessels are occluded. C, The ulnar artery is released while the radial artery remains occluded. If flow through the ulnar artery and collateral arch in the hand is adequate, the color and perfusion should rapidly return. If not adequate, then simply do not cannulate the radial artery.

air bubbles are removed from the system, and that no more than 3 feet of tubing is used between the neonate or child and the transducer to minimize artifacts caused by the monitoring tubing.195 7. Obtain blood samples by clamping off the distal end of the T-connector, cleaning the injection port of the T-connector with povidone-iodine, introducing a 22-gauge needle, and withdrawing 1 mL of blood. A sample of blood is obtained by heparinized syringe, with minimal blood

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A

B

C

D FIGURE 49.11  A, After adequate collateral circulation has been ensured, the radial artery is palpated and the appropriate catheter is advanced into the vessel. B, After blood return is noted, the catheter is threaded over the needle and into the artery. C, Pulsatile backbleeding confirms intraarterial position. D, A T-connector with appropriate flush solution is connected; the catheter is aspirated to clear air bubbles and then gently flushed. Antibiotic ointment and benzoin are applied. The injection port should be clearly marked as “arterial” to minimize accidental drug administration into the artery. A Luer-Lok connection is preferred to prevent accidental disconnection.

loss and minimal manipulation of the system.180,196 An alternative is the use of a 3-mL syringe on a three-way stopcock: aspirate 2 to 3 mL, clamp the system, and then take the sample of blood from the T-connector as just described. After sampling, the clamp is released, the aspirated blood is readministered, and continuous infusion is resumed or flush is run into the 3-mL syringe and then the system is gently manually flushed intermittently with the syringe but the flush syringe is changed just once per 24 hours. This method of sampling maintains a closed system with reduced potential for sources of infection. Bolus flushes should be very brief or a slow infusion because prolonged flushing in neonates and infants may flush a crystalloid solution retrograde to the brain and cause a stroke. Disastrous results may occur if an air bubble or blood clot should accompany a bolus flush.197–201 All arterial lines must be clearly identified (red tape) to avoid accidental infusion of hypertonic solutions and sclerosing medications. Complications ■ Infection at the site of the catheter insertion, with possible septicemia. ■ Arterial thrombus formation. This depends on the size of catheter inserted, the material of which it is constructed, the technique of insertion, and the duration of cannulation.

■

Emboli. A blood clot or air may embolize to the digits, resulting in arteriolar spasm or more serious ischemic necrosis. ■ Disconnecting the catheter from the infusion system. Blood loss may be life-threatening, especially in an infant. ■ Ischemia. The radial artery cannula should be withdrawn if ischemic changes develop. ■ Vasospasm. Usually transient but requires careful observation. The method just described is the traditional percutaneous radial artery cannulation at the ventral aspect of the wrist. The radial artery on the dorsal aspect of the wrist within the anatomic snuff box may be used as an alternative site.202 Once an attempt at cannulation of the radial artery is made, the ipsilateral ulnar artery should not be instrumented to ensure adequate perfusion of the entire hand. Strict indications for inserting radial artery catheters are necessary, and their removal must be considered at the earliest possible time.165–168

AXILLARY ARTERY Even though axillary arterial cannulation is reported to be used in children as a site when radial or lower extremity access fails, there are few studies specifically related to the risks and benefits of axillary access. In a study of 96 arterial catheters in 56 adult surgical ICU patients, catheter-related infections were increased with prolonged insertion.203 The infection rate at axillary sites was greater than at the radial and femoral sites. There is only one

Procedures for Vascular Access

publication of axillary arterial monitoring in pediatric patients and it reported no major complications in 16 children.204 Seven of these patients were neonates with the duration of insertion from 5 to 15 days. There were no differences in systolic blood pressures in either arm after the line was removed or during the time the line was in place. In general, an ultrasound guided technique is highly recommended to minimize damage to surrounding structures (brachial plexus).

TEMPORAL ARTERY When the radial artery has been previously cannulated or is inaccessible, the temporal artery may be used.205 Cerebral infarction has been described as a complication of this technique. It appears to be related to retrograde embolization of air or a blood clot.206 An advantage of this sampling site is that it provides preductal blood gas values. However, in our experience, the tortuous course of the artery and the resultant apposition of the distal tip of the catheter and the arterial wall have caused difficulties in freely drawing blood samples.

FEMORAL ARTERY Femoral catheterization in infants and children includes a greater risk of vascular injury or thrombosis resulting in ischemia207 and is not recommended if other peripheral sites are available. In situations in which peripheral arterial cannulation is impossible (e.g., in burned patients, children with poor peripheral perfusion, children with congenital heart disease), the femoral artery should be used rather than not having any invasive arterial monitoring; the remote possibility of a complication must be balanced versus a greater likelihood of life-threatening complications owing to less than ideal monitoring.208 Technique 1. Locate the femoral artery by palpation at the groin; this can be confirmed with ultrasonic guidance. Anatomically, it is situated midway between the anterior superior iliac spine and the pubic tubercle (See also Fig. 49.5). 2. After sterile preparation of the skin, insert a catheter of appropriate size into the femoral artery using the Seldinger technique. The artery is entered at the point of maximal pulsation, approximately 1 cm below the line joining the anterior superior iliac spine and the pubic tubercle. 3. After cannulation, connect the catheter to a continuous-flow system and pressure transducer. The catheter is sutured in place, the insertion site is covered, and an occlusive dressing is applied. The possibility of fecal and urinary contamination makes this last step particularly important. Complications ■ Infection ■ Emboli of clot and air, leading to ischemic necrosis of the lower limb ■ Poor arterial puncture technique, leading to osteoarthritis of the hip joint; severe trauma to the femoral artery has resulted in gangrene of the lower limb, retroperitoneal hemorrhage, and arteriovenous fistula formation.209–211 Up

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to approximately 24% of children will have no resolution of thrombosis and approximately 1% may have partial arrest of bone growth, likely as a result of thrombus formation.212,213 ■ Vasospasm is usually transient but requires careful observation.

DORSALIS PEDIS AND POSTERIOR TIBIAL ARTERY The dorsalis pedis and posterior tibial arteries are additional sites for arterial cannulation in children when more desirable locations are inaccessible. Collateral circulation should always be checked. Ultrasound guidance may be helpful.214 If cannulation is attempted or performed in one artery in the foot, the ipsilateral artery should not be instrumented to ensure adequate collateral blood flow. Technique The artery is cannulated in the same manner as for the radial artery at a point of maximal pulsation. An understanding of the anatomy of the dorsalis pedis and posterior tibial arteries before attempting this procedure is important. If percutaneous cannulation is impossible, the cutdown technique may be performed. The complications are similar to other arterial line sites of insertion.

ANNOTATED REFERENCES Camkiran Firat A, Zeyneloglu P, Ozkan M, Pirat A. A randomized controlled comparison of the internal jugular vein and the subclavian vein as access sites for central venous catheterization in pediatric cardiac surgery. Pediatr Crit Care Med. 2016;17:e413-e419. This randomized, prospective study compared the success rate for placement of central venous catheters via the internal jugular route with subclavian routes in 280 children scheduled for cardiac surgery. There was no significant difference in the success rate at first attempt (64% vs. 69%), but the rate of arterial puncture was significantly higher in the internal jugular group (8% vs. 2%) and success rate overall was greater in the subclavian group (91% vs. 82%). However, catheter malposition was greater with the subclavian route (17% vs 1%). Overall, the risk of catheter-associated infection complications was greater with the internal jugular route (22% vs. 3.6%). Carter JH, Langley JM, Kuhle S, Kirkland S. Risk factors for central venous catheter-associated bloodstream infection in pediatric patients: a cohort study. Infect Control Hosp Epidemiol. 2016;37(8):939-945. This was a within-institution study reviewing their experience from 1995 to 2013 involving 5648 patients that revealed a central line–associated bloodstream infection rate of 3.87/1000 in-hospital line days. Over time there was an 84% reduction in these infections that was primarily related to a vigorous hand hygiene campaign. Siddik-Sayyid SM, Aouad MT, Ibrahim MH, et al. Femoral arterial cannulation performed by residents: a comparison between ultrasound-guided and palpation technique in infants and children undergoing cardiac surgery. Paediatr Anaesth. 2016;26(8):823-830. This was a randomized prospective study that compared ultrasound-guided with palpation-guided placement of femoral arterial lines in 106 pediatric patients. The number of successful cannulations of first attempt was greater in the ultrasound group (24/5 vs. 13/53), and the time to successful cannulation was also shorter (301 ± 234 seconds ± 420 ± 248 seconds). The ultrasoundguided technique when used by residents was superior to the palpation-guided technique. A complete reference list can be found online at ExpertConsult.com.

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161. Sherman NJ. Umbilical artery cutdown. J Pediatr Surg. 1977;12(5):723-724. 162. Coleman MM, Spear ML, Finkelstein M, et al. Short-term use of umbilical artery catheters may not be associated with increased risk for thrombosis. Pediatrics. 2004;113(4):770-774. 163. Cohen RS, Ramachandran P, Kim EH, Glasscock GF. Retrospective analysis of risks associated with an umbilical artery catheter system for continuous monitoring of arterial oxygen tension. J Perinatol. 1995;15(3):195-198. 164. Barrington KJ. Umbilical artery catheters in the newborn: effects of catheter design (end vs side hole). Cochrane Database Syst Rev. 2000;(2):Cd000508. 165. Adelman RD, Karlowicz MG. What is the appropriate workup and treatment for an infant with an umbilical artery catheter-related thrombosis? Semin Nephrol. 1998;18(3):362-364. 166. Fletcher MA, Brown DR, Landers S, Seguin J. Umbilical arterial catheter use: report of an audit conducted by the Study Group for Complications of Perinatal Care. Am J Perinatol. 1994;11(2):94-99. 167. Ford KT, Teplick SK, Clark RE. Renal artery embolism causing neonatal hypertension: a complication of umbilical artery catheterization. Radiology. 1974;113(1):169-170. 168. Plumer LB, Kaplan GW, Mendoza SA. Hypertension in infants–a complication of umbilical arterial catheterization. J Pediatr. 1976;89(5): 802-805. 169. Barrington KJ. Umbilical artery catheters in the newborn: effects of position of the catheter tip. Cochrane Database Syst Rev. 2000;(2):Cd000505. 170. Barrington KJ. Umbilical artery catheters in the newborn: effects of heparin. Cochrane Database Syst Rev. 2000;(2):Cd000507. 171. Lott JW, Conner GK, Phillips JB. Umbilical artery catheter blood sampling alters cerebral blood flow velocity in preterm infants. J Perinatol. 1996;16(5):341-345. 172. Relationship of intraventricular hemorrhage or death with the level of umbilical artery catheter placement: a multicenter randomized clinical trial. Umbilical Artery Catheter Trial Study Group. Pediatrics. 1992;90(6):881-887. 173. Shahid S, Dutta S, Symington A, et al. Standardizing umbilical catheter usage in preterm infants. Pediatrics. 2014;133(6):e1742e1752. 174. Puvabanditsin S, Zaldana F, Raviola J, et al. Vessel perforation and false tracking resulting from umbilical artery catheterization: a case report and literature review. Pediatr Dev Pathol. 2016;Mar 1. 175. Rudolph N, Wang HH, Dragutsky D. Gangrene of the buttock: a complication of umbilical artery catheterization. Pediatrics. 1974;53(1):106-109. 176. Munoz ME, Roche C, Escriba R, et al. Flaccid paraplegia as complication of umbilical artery catheterization. Pediatr Neurol. 1993;9(5):401-403. 177. Inglis GD, Davies MW. Prophylactic antibiotics to reduce morbidity and mortality in neonates with umbilical artery catheters. Cochrane Database Syst Rev. 2004;(3):Cd004697. 178. Bauer SB, Feldman SM, Gellis SS, Retik AB. Neonatal hypertension. A complication of umbilical-artery catheterization. N Engl J Med. 1975;293(20):1032-1033. 179. Bogovic M, Papes D, Mitar D, et al. Abdominal Aortic Thrombosis in a Healthy Neonate. Ann Vasc Surg. 2016;32:131 e137-131 e139. 180. Todres ID, Rogers MC, Shannon DC, et al. Percutaneous catheterization of the radial artery in the critically ill neonate. J Pediatr. 1975;87(2):273-275. 181. Cole FS, Todres ID, Shannon DC. Technique for percutaneous cannulation of the radial artery in the newborn infant. J Pediatr. 1978;92(1):105-107. 182. Ducharme FM, Gauthier M, Lacroix J, Lafleur L. Incidence of infection related to arterial catheterization in children: a prospective study. Crit Care Med. 1988;16(3):272-276. 183. Furfaro S, Gauthier M, Lacroix J, et al. Arterial catheter-related infections in children. A 1-year cohort analysis. Am J Dis Child. 1991;145(9):1037-1043.

Procedures for Vascular Access 184. Sellden H, Nilsson K, Larsson LE, Ekstrom-Jodal B. Radial arterial catheters in children and neonates: a prospective study. Crit Care Med. 1987;15(12):1106-1109. 185. Scheer B, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care. 2002;6(3):199-204. 186. Latham GJ, Veneracion ML, Joffe DC, et al. High-frequency microultrasound for vascular access in young children–a feasibility study by the High-frequency UltraSound in Kids studY (HUSKY) group. Paediatr Anaesth. 2013;23(6):529-535. 187. Lo NS, Leung PM, Lau KC, Yeung CY. Congenital cardiovascular malformations in Chinese children with Down’s syndrome. Chin Med J. 1989;102(5):382-386. 188. Lo RN, Leung MP, Lau KC, Yeung CY. Abnormal radial artery in Down’s syndrome. Arch Dis Child. 1986;61(9):885-890. 189. Kahler AC, Mirza F. Alternative arterial catheterization site using the ulnar artery in critically ill pediatric patients. Pediatr Crit Care Med. 2002;3(4):370-374. 190. Kohonen M, Teerenhovi O, Terho T, et al. Is the Allen test reliable enough? Eur J Cardiothorac Surg. 2007;32(6):902-905. 191. Bertrand OF, Carey PC, Gilchrist IC. Allen or no Allen: that is the question! J Am Coll Cardiol. 2014;63(18):1842-1844. 192. Valgimigli M, Campo G, Penzo C, et al. Transradial coronary catheterization and intervention across the whole spectrum of Allen test results. J Am Coll Cardiol. 2014;63(18):1833-1841. 193. Buakham C, Kim JM. Cannulation of a nonpalpable artery with the aid of a Doppler monitor. Anesth Analg. 1977;56(1):125-126. 194. Morray JP, Brandford HG, Barnes LF, et al. Doppler-assisted radial artery cannulation in infants and children. Anesth Analg. 1984;63(3):346-348. 195. Shinozaki T, Deane RS, Mazuzan JE. The dynamic responses of liquid-filled catheter systems for direct measurements of blood pressure. Anesthesiology. 1980;53(6):498-504. 196. Galvis AG, Donahoo JS, White JJ. An improved technique for prolonged arterial catheterization in infants and children. Crit Care Med. 1976;4(3):166-169. 197. Lowenstein E, Little JW 3rd, Lo HH. Prevention of cerebral embolization from flushing radial-artery cannulas. N Engl J Med. 1971;285(25):1414-1415. 198. Bedford RF. Radial arterial function following percutaneous cannulation with 18- and 20-gauge catheters. Anesthesiology. 1977;47(1):37-39.

199. Hager DL, Wilson JN. Gangrene of the hand following intra-arterial injection. Arch Surg. 1967;94(1):86-89. 200. Katz AM, Birnbaum M, Moylan J, Pellett J. Gangrene of the hand and forearm: a complication of radial artery cannulation. Crit Care Med. 1974;2(5):270-272. 201. Miyasaka K, Edmonds JF, Conn AW. Complications of radial artery lines in the paediatric patient. Can Anaesth Soc J. 1976;23(1):9-14. 202. Amato JJ, Solod E, Cleveland RJ. A “second” radial artery for monitoring the perioperative pediatric cardiac patient. J Pediatr Surg. 1977;12(5):715-717. 203. Norwood SH, Cormier B, McMahon NG, et al. Prospective study of catheter-related infection during prolonged arterial catheterization. Crit Care Med. 1988;16(9):836-839. 204. Lawless S, Orr R. Axillary arterial monitoring of pediatric patients. Pediatrics. 1989;84(2):273-275. 205. Gauderer M, Holgersen LO. Peripheral arterial line insertion in neonates and infants: a simplified method of temporal artery cannulation. J Pediatr Surg. 1974;9(6):875-877. 206. Prian GW, Wright GB, Rumack CM, O’Meara OP. Apparent cerebral embolization after temporal artery catheterization. J Pediatr. 1978;93(1):115-118. 207. Cilley RE. Arterial access in infants and children. Semin Pediatr Surg. 1992;1(3):174-180. 208. Park MK, Guntheroth WG. Direct blood pressure measurements in brachial and femoral arteries in children. Circulation. 1970;41(2):231-237. 209. Bogart DB, Bogart MA, Miller JT, et al. Femoral artery catheterization complications: a study of 503 consecutive patients. Cathet Cardiovasc Diagn. 1995;34(1):8-13. 210. Riker AI, Gamelli RL. Vascular complications after femoral artery catheterization in burn patients. J Trauma. 1996;41(5):904-905. 211. Taylor LM Jr, Troutman R, Feliciano P, et al. Late complications after femoral artery catheterization in children less than five years of age. J Vasc Surg. 1990;11(2):297-304, discussion 304-306. 212. Macnicol MF, Anagnostopoulos J. Arrest of the growth plate after arterial cannulation in infancy. J Bone Joint Surg Br. 2000;82(2):172175. 213. Rizzi M, Kroiss S, Kretschmar O, et al. Long-Term Outcome of Catheter-Related Arterial Thrombosis in Infants with Congenital Heart Disease. J Pediatr. 2016;170:181-187 e181. 214. Song IK, Choi JY, Lee JH, et al. Short-axis/out-of-plane or longaxis/in-plane ultrasound-guided arterial cannulation in children: a randomised controlled trial. Eur J Anaesthesiol. 2016;33(7):522-527.

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