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 in a child during a life-threatening illness is difficult and often consumes precious time. An organized approach to vascular access can minimize this potentially life-threatening delay in treatment. This chapter discusses the priorities in vascular access during emergent, urgent, and stable situations. It also reviews various techniques for achieving vascular access and covers the relative indications and potential complications.
PRIORITIES OF VASCULAR ACCESS
Time is critical when attaining vascular access in life-threatening emergencies such as cardiopulmonary arrest or shock. Of course, any pre-existing 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 this and peripheral venous access simultaneously. Time should not be wasted waiting for attempts at peripheral venous catheterization before attempting intraosseous access, which can be attained more rapidly and more reliably. 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 vascular access.
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 access.
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 100-1).
TABLE 100-1VASCULAR ACCESS TECHNIQUES |Favorite Table|Download (.pdf) TABLE 100-1VASCULAR ACCESS TECHNIQUES
|Route ||Indications ||Benefits ||Risks and Disadvantages |
|Peripheral ||Short-term infusion of fluids or medications ||Minimal training required ||Local |
|Minimal risk ||Hematoma, infiltrations, infections |
|Time-consuming (especially if vascular collapse) |
|Intraosseous ||Emergent vascular access ||Attained rapidly and reliably ||Adverse effects rare |
|Cardiac arrest ||Osteomyelitis |