Pediatric Vascular Access PDF

# Pediatric Vascular Access ## Pediatric Considerations - **Thoroughly assess veins** using ultrasound to determine vessel health and patency, catheter to vein ratio, and then select appropriate size catheter based on assessment - **Alternative vein selection:** - The jugular vein may be the p...

# Pediatric Vascular Access ## Pediatric Considerations - **Thoroughly assess veins** using ultrasound to determine vessel health and patency, catheter to vein ratio, and then select appropriate size catheter based on assessment - **Alternative vein selection:** - The jugular vein may be the preferred point of insertion in very young children to avoid a pneumothorax. - The femoral vein is commonly used in pediatric critical care units due to ease of insertion in young patients and decrease the risk of infection compared to jugular vein placement. - Scalp, popliteal, greater and lesser saphenous, and femoral veins. - Tip location for lower extremity insertion sites optimally between levels 19-111, in patients less than one year of age. - The addition of Heparin to the infusate may decrease catheter occlusion (determine infusate compatibility with Heparin). ## Non-Acute Care Considerations - Due to the difficulty of catheter stabilization as well as the increased risk of air embolism in an ambulatory patient, the use of non-tunneled CVADs in jugular and femoral veins is discouraged outside of the acute care setting: PICC lines or tunneled CVADs are preferred. ## G. Tunneled Central Venous Catheter ### Indications/Contraindications - **Indications:** - Infusions that are projected to continue for months or years. - Hemodialysis/Apheresis. - Medication administration. - Total or partial parenteral nutrition (TPN or PPN). - Chemotherapeutic agents. - Blood and blood components. - Infusion of medications considered irritants or vesicants. - Difficult intravenous access patients. - **Contraindications:** - Presence of a bloodstream infection. - Severe coagulopathy. - Cellulitis (affecting intended insertion site). ### Site and Vessel Selection - Axillary vein - Subclavian veins ### Insertion Procedures and Supplies #### General Considerations - Follow all manufacturer’s instructions for use. - Insertion may be scheduled as an operative procedure or Interventional Radiology procedure. - Insertion may be performed at the bedside with tip location technologies. - Anesthesia or procedural sedation may be given. - Catheter exit site may be located in the chest, upper back, thigh (out of pelvic area), or lower torso. - Some catheters are manufactured with a cuff attached to the proximal end of catheter. This cuff is inserted in the tissue track to secure the catheter. #### Tunneled Catheters with Cuffs: - The exit site will heal within two to three weeks. Once the cuff has developed tissue attachment and exit site is healed, it may be maintained without a dressing per hospital policy or protocol. - Confirm tip location by ECG or ECG/Doppler technology, radiograph, or fluoroscopy prior to any infusion. - Obtain a free-flowing blood return prior to any infusion. - **Do not hub catheter**. Most catheters are numerically marked. The zero, dot or dash at the most proximal area of the catheter is the farthest the catheter should be advance. The remaining area is intended for the proper application of an antimicrobial disc and securement. #### Supplies - Tunneled central venous catheter - Sterile insertion tray - Ultrasound and manufactured probe/cord cover for vein visualization and access - Surgical equipment required for placement - Transparent antimicrobial dressing - Normal saline #### Optimal Tip Location - CAJ/Upper RA - Inferior vena cava (IVC) above the level of the diaphragm, if inserted via the femoral vein #### Pediatric Considerations - Assess/verify catheter tip location as the child grows to maintain optimal tip location. - In patients less than 12 months of age, the optimal tip location for lower extremity insertion sites is between level 19-111. - The addition of Heparin to the infusate may decrease catheter occlusion (determine compatibility with Heparin). ## H. Implanted Venous Port (Peripheral or Torso Location) ### Indications/Contraindications - **Indications:** - Infusions that are projected to continue for months to years. - Long term intermittent therapy. - **Contraindications:** - Severe coagulopathy - Severe, uncontrolled sepsis - Burns or cellulitis (affecting the intended insertion site) - Patient who is cachectic, below ideal body weight, or lacking subcutaneous tissue for port implantation ### Site and Vessel Selection - **Peripheral:** Basilic or cephalic vein - **Central:** - Axillary vein - Subclavian vein - Jugular vein - Femoral vein ### Considerations for Access - **Comfort related to the location of the implanted venous port:** Depth of the implanted port must be shallow enough for the clinician to palpate and insert a non-coring access needle safely to maintain access into the port septum. - **Care should be taken to select a site that allows a dressing to be securely applied and maintained while accessed.** ### Insertion Procedures and Supplies - **General considerations:** - Follow all manufacturer’s instructions for use - Insertion is scheduled as an operative procedure or Interventional Radiology procedure - Anesthesia or procedural sedation given - Port implantation site may be arm, upper chest or lower abdominal area depending upon the vein accessed - Port is sutured into fascia of subcutaneous pocket under the skin. - Numerous designs, shapes, and types of ports are available. - Confirm catheter tip location via fluoroscopy, ENG, EKG/Doppler or radiograph - Accessing an implanted venous port is a sterile procedure - Follow institution or organization policy and procedures for non-coring access needle rotation - Select appropriate non-coring needle length to allow the needle to clear the septum internally and reach the back of the port body without excess protrusion of the external portion of the needle/infusion set. - Obtain a free-flowing blood return prior to any infusion. ### Supplies for Placement of a Port - Implanted venous port - Sterile insertion tray - Ultrasound for vein visualization - Fluoroscopy or tip location technology - Surgical equipment required for placement - Normal Saline flush - Heparin, if indicated ### Supplies for Accessing an Implanted Port - Non-coring needle - Sterile access supply kit - Needleless connector - Normal saline flushes - Heparin, if indicated - Transparent and/or antimicrobial Dressing ### Optimal Tip Location - CAJ/Upper RA - Inferior vena cava (IVC) above the level of the diaphragm, if inserted via the femoral vein ### Pediatric Considerations - Catheter tip position: Assess/verify internal catheter tip location as the child grows, to maintain tip position in the SVC. ### Non-Acute Care Considerations - Educate patient as to the appropriate needle size for their port so they may share this information with the accessing clinicians in future encounters. - Education should include the caveat that the needle length initially determined to be appropriate is not absolute and may need to be adjusted in the future (i.e., due to changes in body habitus). ## I. Power/Pressure Injectable Vascular Access Devices - All types of vascular access devices may be power/pressure injectable. Power/pressure injectable catheters should be clearly marked and identified prior to use for power/pressure injection. - Power/pressure injectable catheters are made of polyurethane and engineered to withstand high pressure >300 pounds per square inch (PSI). - Used for power injection of IV contrast media for a computerized tomography (CT) or magnetic resonance imaging (MRI) scan.