Rapid establishment of vascular access is necessary for aggressive
fluid resuscitation and administration of medications such as catecholamines, antibiotics,
narcotics, and sedatives during emergencies. However, attaining vascular
access during a life-threatening illness in a child is difficult
and often consumes precious time. An organized approach to vascular
access can minimize this potentially life-threatening delay in treatment.
This section discusses the priorities in vascular access during emergent,
urgent, and stable situations. This chapter reviews various techniques
for achieving vascular access and covers the relative indications
and potential complications.
Time is critical when attaining vascular access in life-threatening
emergencies such as cardiopulmonary arrest or shock. Of course,
any preexisting intravenous catheter should be utilized in the initial
resuscitation efforts, regardless of how small such a catheter might
be. If such access is not available during a life-threatening emergency,
intraosseous access should be attained as rapidly as possible, especially
in children under 6 years old. A practical approach is to pursue
intraosseous and peripheral venous access simultaneously. However,
time should not be wasted waiting for attempts at peripheral venous
catheterization before attempting intraosseous access, because intraosseous
access can be attained more rapidly and more reliably.1 Similarly,
skilled clinicians may attempt placing central venous catheters
during life-threatening emergencies, but such attempts should not
preclude simultaneous attempts at intraosseous access. After attaining
intraosseous access for initial fluid resuscitation and infusion
of emergency medications, peripheral or central venous catheterization
is the next priority in order to ensure a more reliable, long-lasting
For urgent situations, such as fluid resuscitation of a child
with compensated shock or dehydration, the risk-benefit ratio shifts.
Generally, it is most appropriate to initially insert a peripheral
venous over-the-needle catheter. If multiple attempts are unsuccessful,
or if the child requires fluids or medications that cannot be given
safely in a peripheral vein, central venous catheterization should
be attempted by a qualified individual. Of course, if the child’s clinical
condition deteriorates prior to achieving vascular access, priorities
should be reassessed and it may be necessary to attain intraosseous
Relatively stable children may need vascular access for maintenance
fluids or intravenous medications. Generally, peripheral venous
cannulation with an over-the-needle catheter is adequate. If vascular
access is necessary for more than 2 to 3 weeks, or if solutions
to be infused can cause serious tissue injury if extravasated, a
central venous catheter may be necessary. However, central venous
catheterization entails added risks, and its inherent risks and
benefits deserve consideration (Table 107-1).
Table 107-1. Vascular
Access Techniques |Favorite Table|Download (.pdf)
Table 107-1. Vascular
|Indications||Benefits||Risks and Disadvantages|
|Peripheral||Short-term infusion of fluids or medications||Minimal training required||Local|
|Hematoma, infiltrations, infections|
|Time-consuming (especially if vascular collapse)|
|Intraosseous||Emergent vascular access||Attained rapidly and reliably||Adverse effects rare|
|Decompensated shock||Compartment syndrome|
|Central Venous—Acute||Emergent vascular ...|
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