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BACKGROUND

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Many pediatric patients will need some form of vascular access during their initial evaluation or hospitalization. The child’s severity of illness or injury, type of infusion needed, duration of therapy, and skill of the provider will often determine the type of line selected. Ultrasound-guided vascular access is an important advance in safety and efficacy and is discussed in a separate chapter. This chapter reviews the insertion and monitoring needed for peripheral intravenous access, central venous access, and peripherally-inserted central catheters (PICC lines).

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PERIPHERAL INTRAVENOUS ACCESS

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Even at hospitals with a team dedicated to placing intravenous lines, the hospitalist may be called upon to obtain peripheral intravenous (PIV) access, especially when others have been unsuccessful.

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INDICATIONS

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PIV access is obtained to administer medications, fluids, or blood products. It may also be used for frequent phlebotomy draws. A line may be placed at the same time as obtaining a blood sample “just in case” the lab results should require IV access.

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CONTRAINDICATIONS

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Avoid areas distal to a fracture, as there may be vascular disruption, and it may be difficult to assess for swelling associated with extravasated IV fluids or medications. When possible, avoid areas with edema, burns or cellulitis, or abnormal skin integrity. A vein that has been scarred from frequent use may be difficult to access.

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ANATOMY

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Common IV sites include veins in the dorsum of the hand, the forearm, and the antecubital fossa. The cephalic vein that courses over the distal radius is a reliable site that is often overlooked and is affixed firmly to the underlying fascia. If the upper extremity is being used, the nondominant hand is preferable. Figure 191-1 shows common sites for placement of an IV catheter in the upper extremity. In infants, the lower extremities (i.e. feet) or the scalp can be considered as sites for IV placement. The saphenous vein is predictably located anterior to the medial malleolus and so can be accessed blindly. In general, attempt access distally first, in case additional attempts are required in the proximal extremities. The external jugular access site may be difficult to obtain as well as secure, and should be done by experienced personnel only.

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FIGURE 191-1.

Venous anatomy of the upper extremity.

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EQUIPMENT

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Table 191-1 lists the equipment needed to place an IV line. It is important to have everything assembled and easily available before starting the procedure. In children, IV access often requires a second health care provider to help restrain the child properly. Most hospitals use over-the-needle catheters that include a safety, self-sheathing device. Use the largest bore and shortest catheter possible when rapid administration of medication, fluids, or blood is needed. A 24- or 22-gauge ...

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