Chapter 8: Vascular Access

INTRODUCTION

Although it is always best to utilize the least invasive access, central venous access is often required in the PICU. This chapter addresses central venous access and arterial access first and then addresses peripheral venous access and interosseus access. Ultrasound considerations are incorporated throughout the chapter.

CENTRAL VENOUS ACCESS

Central versus peripheral access: Peripheral access should be used whenever possible, unless specific indications for central venous access are present.

INDICATIONS

• Unable to achieve peripheral access

• Large volume resuscitation

• Need for vesicant, irritant, or hyperosmolar or highly concentrated solutions (including total parenteral nutrition [TPN], electrolyte replacement, greater than 12.5% dextrose, pH <5 or >9, or osmolarity >600 mOsm/L)

• Need for vasoactive support

• Need for hemodynamic monitoring, including central venous pressure, pulmonary artery pressure, or mixed venous saturation monitoring

• Frequent blood draws

• Need for prolonged access (chemotherapy, prolonged antibiotic course)

CONTRAINDICATIONS

• Increased bleeding risk secondary to thrombocytopenia or coagulopathy.

• Predisposition to sclerosis or thrombosis. Contraindicated in a vessel with a known thrombus.

RISKS/POTENTIAL COMPLICATIONS

• Bleeding: Assessment for thrombocytopenia and coagulopathy should occur prior to line placement

• Infection: Use sterile technique with full barrier to minimize infection

• Embolization of intravascular thrombus, guidewire, or air

• Vessel perforation

PREPARATION

• Materials

  • Sterile gloves, gown, drapes

  • Surgical hat, mask

  • Catheter (see Table 8-1 for size and length considerations)

  • Caps for each catheter lumen

  • Introducer needle

  • Syringe (non-Luer Lock) to attach to introducer needle and two to three additional 3-mL syringes

  • Guidewire (at least double the length of the catheter; verify that guidewire passes through needle prior to starting procedure)

  • Scalpel

  • Tissue dilator

  • Suture

  • Kelly clamp

  • Additional syringes

• Medications

  • Lidocaine 1% for skin numbing (and appropriate needle for superficial injection)

  • Chlorhexidine (>2 months) or iodine (<2 months) for skin preparation

• Catheter selection

TECHNIQUE

• Preparation

  • Sterile procedure: Use cap/mask, gown, sterile gloves

  • Prepare the area with 2% chlorhexidine (>2 months) or 10% povidine-iodine (<2 months)

  • Catheter preparation

    • Flush all ports and caps with normal saline or heparinized saline

    • Clamp lumens after flushing

• Anesthesia

  • For use of systemic sedation or analgesia, ensure NPO status (6 hours for solids; 4 hours for clear liquids).

  • Inject local anesthetic (1% lidocaine) into the tissues at and below the venipuncture site. Withdraw prior to injection to avoid intravascular injection.

• Seldinger technique (Figure 8-1...