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Venous Access. Matthew L. Paden, MD Emory University Children’s Healthcare of Atlanta at Egleston. Peripheral IV. Butterfly & angiocaths Short catheters generally placed in forearm, hand or scalp veins Short term therapy and unable to handle caustic chemicals (chemotherapy).

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venous access

Venous Access

Matthew L. Paden, MD

Emory University

Children’s Healthcare of Atlanta at Egleston

peripheral iv
Peripheral IV
  • Butterfly & angiocaths
    • Short catheters generally placed in forearm, hand or scalp veins
    • Short term therapy and unable to handle caustic chemicals (chemotherapy)
peripheral sites
Peripheral Sites
  • Veins of the Forearm
  • 1. Cephalic vein2. Median Cubital vein3. Accessory Cephalic vein4. Basilic vein5. Cephalic vein6. Median antebrachial vein
peripheral sites4
Peripheral Sites
  • Veins of the Hand
  • 1. Digital Dorsal veins2. Dorsal Metacarpal veins3. Dorsal venous network4. Cephalic vein5. Basilic vein
peripheral ivs
Peripheral IVs
  • Try to cannulate the most distal veins first
    • Drugs or fluids put through the cannula may extravasate at the upstream failed cannula site
  • Transillumination
  • Topical nitropaste
types of central vascular access devices
Types of Central Vascular Access Devices
  • Non-tunneling
  • Tunneling
  • Implanted
non tunneling
Non-Tunneling
  • Direct venipuncture through the skin into a selected vein.
    • Peripheral IV
    • Peripherally inserted central catheter
    • Percutaneous catheters
non tunneling picc
Non-Tunneling - PICC
  • Peripherally inserted central catheters (PICC)
    • Midline
  • Central venous catheter inserted at or above the antecubital space and then advanced until the distal tip of the catheter is positioned at the superior vena cava or superior vena cava and right atrial junction.
non tunneling picc14
Useful for patient receiving long term medication therapy, chemotherapy or TPN

Used for frequent blood sampling

Distal end positioned at the superior vena cava or junction of superior vena cava and right atrium

Non-tunneling - PICC
non tunneling picc15
Non-Tunneling - PICC
  • Peripherally inserted central catheters (PICC)
non tunneling midlines
Non-Tunneling - Midlines
  • Used for shorter term intravenous therapy (up to 4 weeks)
  • Used for frequent blood sampling
  • Distal end positioned at the proximal end of the upper extremity
non tunneling cvc
Non-Tunneling – CVC
  • Percutaneous catheters
  • Also known as: Central Venous Catheters (CVC)
    • Subclavian, femoral or internal jugular
    • Single, double or triple lumen
non tunneling cvc20
Tip advanced to superior vena cava or SVC and right atrium junction

As with PICC, appropriate for patients requiring long term chemotherapy or TPN

Non-tunneling - CVC
tunneling
Tunneling
  • Hickman®
  • Broviac®
  • Groshong®
tunneling23
Tunneling
  • Inserted into a central vein via percutaneous venipuncture or cut down
  • Catheter then tunneled under the skin in the subcutaneous tissue and exited in a convenient location
  • Dacron cuff hold the catheter in place
tunneling broviac
Tunneling - Broviac®
  • Similar to the Hickman catheter, but is of smaller size.
  • This catheter is mostly used for pediatric patients. 
tunneling groshong
Tunneling - Groshong®
  • Similar to Hickman®and Broviac®with closed ended patented 3-way valve.
implanted vads ports
Implanted VADs - Ports
  • Catheter attached to a self-sealing silicone septum surrounded by a titanium, stainless steal or plastic port
  • Port sutured under the skin
  • Some brand names:
    • Port-a-cath®
    • Infus-a-port®
    • Power Port ®
implanted vads ports28
Implanted VADs - Ports
  • Catheter runs from port to superior vena cava at the right atrium
  • No part of the device is exposed outside the body
  • Can deliver chemotherapy, TPN, antibiotics, blood products and blood sampling
insertion complications
Insertion Complications
  • Inadvertent Arterial Puncture
  • Hematoma Formation
  • Extravasation
  • Infection
  • Phlebitis
  • Pneumothorax
systemic complications
Systemic Complications
  • Infection
  • Deep Vein Thrombosis
  • Pulmonary Embolism
  • Superior Vena Cava Syndrome
mechanical complication
Mechanical Complication
  • Catheter tip migration
  • Broken or damaged catheter
  • Catheter occlusion
femoral vein
Femoral Vein
  • Adults –
    • DVT
    • Excess infection risk
    • “Potentially inaccurate CVP”
femoral vein35
Femoral Vein
  • Kids –
    • Better risk profile
    • Ease of insertion, compressible
    • No difference in DVT – ref 1-2
    • Same infection risk (maybe lower) – ref 3-5
    • Accurately reflects RAP if no increase in abdominal pressures – ref 6-8

1. Beck C, et al. J Ped 1998;133:237-41.

2. Jacobs B, et al. Crit Care Med 1999;27:A29

3. Casado-Flores J, et al. Ped Crit Care Med 2001;2:57-62.

4. Richards M, et al. NNIS Pediatrics 1999;103:103-9

5. Stenzel JP, et al. J Ped 1989;114:411-5.

6. Fernendez E, et al. Ped Crit Care Med 2004;5:14-18

7. Lloyd R, et al. Pediatrics 1992;89:506-8.

8. Ho K, et al. Crit Care Med 1998;26:461-4.

femoral anatomy
Femoral anatomy
  • Vein is medial to the artery
    • Froehlich’s theorem
  • Superficial distal to inguinal ligament, then dives deep
  • 0.5-2cm inferior to the inguinal ligament
quiz question
Quiz Question
  • What are the anatomic landmarks to determine where to stick for the femoral vein in a pulseless patient?
    • A. 1/3 of the distance from the anterior superior iliac spine to the pubic tubercle
    • B. ½ the distance between the pubic tubercle and the anterior superior iliac spine
    • C. 1/3 of the distance from the pubic tubercle and the anterior superior iliac spine
    • D. None of the above
quiz answer
Quiz answer
  • D. None of the above
  • The femoral ARTERY lies ½ the distance between the pubic tubercle and the anterior superior iliac spine.
  • The femoral vein is 0.5-1.5 cm medial to this depending on the size of the patient.
straight vs frog leg
Straight vs. Frog leg
  • “The optimal positioning of the leg can vary according to the preference of the operator.”
    • Discuss
procedure
Procedure
  • 30-45 degree angle to skin
  • 2 methods
    • Stick with negative pressure on syringe while entering and exiting
    • Insert needle, and only negative pressure on removal
      • Allows you to better stabilize the needle by resting your hand on the thigh
procedure42
Procedure
  • Blood flash - Insert wire
    • Wire not going smoothly
      • Needle no longer in vessel
      • False tracking in subcutaneous tissue
      • Thrombus
      • Advancing into lumbar veins
  • Small incision
    • Blade directed away from wire
procedure43
Procedure
  • Twisting motion of dilation
  • Remove dilator
  • Advance catheter
  • Remove wire
  • Aspirate and flush all ports
  • Secure line with sutures
  • Sterile dressing
procedure45
Procedure
  • Wheeler – “Confirmation of proper CVC position is required after placement of all CVC’s”
warnings
Warnings
  • If you hit the artery – pressure until hemostatic
  • Wire should float – should never have resistance
  • If can’t pull the wire through the needle – remove both wire and needle together so you don’t sheer off the wire
  • Never let go of the wire
  • Catheter tip “pointing too cephalad” – in lumbar veins
complications
Complications
  • 74 of 89 (83%) – no complications
  • Other 15 – minor bleeding/hematoma
  • 94.4% success rate
  • Median duration 5 days
    • 21% <3 days 26% 7-14 days
    • 43% 4-7 days 10% >14 days
  • Long term – 8 leg swelling, 11 BSI

Venkataraman, et al. Clin Ped 1997;36:311-9.

complications48
Complications
  • 45 months – 395 CVL – 162 femoral
  • No insertion complications
  • Mean duration 8.9 days
  • 9 noninfectious complications
    • 4 thrombosis, 1 perforation, 1 embolism, 2 bleeding
  • “The low incidence of complications in this study suggests that the femoral vein is the preferred site in most critically ill children when CVC is indicated.”

Stenzel JP, et al. J Ped 1989;114:411-5

subclavian vein
Subclavian Vein
  • When to use it
    • May be better for long term access
    • Obese – clavicle gives you a landmark
    • Shock – less likely to collapse
  • Relative contraindications
    • Trauma to the area
    • Coagulopathic
subclavian anatomy
Subclavian Anatomy
  • Begins as axillary vein, eventually joins the IJ to become the inominate or brachiocephalic
  • Anterior scalene separates the SCA from SCV
  • Most common is infraclavicular approach
positioning
Positioning
  • Head down 15-30 degrees
  • Rolled towel placed longitudinally between scapulae
  • Tilt head toward side of catheterization
    • Reduced catheter malposition in infants
quiz question57
Quiz Question
  • What is the anatomic landmark on the clavicle where you insert the needle?
    • A. 1 cm below the junction of the middle and lateral thirds of the clavicle
    • B. 1 cm below the junction of the middle and medial thirds of the clavicle
    • C. 1 cm below the middle third of the clavicle
    • D. 1 cm below the lateral third of the clavicle
quiz answer58
Quiz Answer
  • What is the anatomic landmark on the clavicle where you insert the needle?
    • B. 1 cm below the junction of the middle and medial thirds of the clavicle
procedure59
Procedure
  • Needle inserted 1 cm below junction of middle and medial thirds of the clavicle
  • Marched down clavicle and parallel to frontal plane
  • Bevel directed caudal
  • Blood flash during insertion or withdrawal
procedure60
Procedure
  • Regular Seldinger technique
  • Watch for dysrhythmias with wire insertion
confirmation
Confirmation
  • Position should be in the distal SVC
  • FDA – “the catheter tip should not be placed in or allowed to migrate into the heart”
  • 34% mortality rate with CVC related pericardial effusions in pediatrics
complications62
Complications
  • Inability to cannulate
  • SCA puncture/cannulation
  • Catheter misplacement
  • Pneumothorax
  • Hemothorax
  • Nerve injury
complications63
Complications
  • 100 patients - 1/3 of patients <1 year
  • 92% overall success rate
    • 89% in emergencies
  • Major complications
    • 4 pneumothorax, 2 BSI

Venkataraman, et al. J peds 1998;113:480-5.

internal jugular vein
Internal Jugular Vein
  • When to use it
    • High rate of success
    • Compressible if coagulopathic
    • Lung hyperinflation (less likely to get pneumothorax than subclavian)
    • Transvenous pacing via RIJ
  • Relative contraindications
    • Ongoing CPR – difficult to access
    • Cervical trauma/increased ICP
internal jugular anatomy
Internal Jugular Anatomy
  • Lateral to carotid artery in sheath
  • Beneath the triangle formed by the sternal and clavicular heads of the SCM and the clavicle
quiz question71
Quiz Question
  • All of the following are correct about a left internal jugular cannulation EXCEPT:
    • A. LIJ has a more acute angle at connection with subclavian
    • B. Lower pneumothorax risk compared to right because right pleural dome is higher
    • C. Lymphatic duct adjacent to junction of LIJ and innominate vein
    • D. Reduced risk of carotid puncture because of its caudo-cephalad structure
quiz answer72
Quiz answer
  • B is the correct answer to the question
  • Reasons to go right –
  • The left has :
    • More acute angle at connection with subclavian
    • Left pleural dome is higher (more pneumothorax risk)
    • Lymphatic duct adjacent to junction of LIJ and innominate
internal jugular positioning
Internal Jugular Positioning
  • Trendelenberg 15-30 degrees
  • Shoulder roll
  • Head turned away from side of insertion
procedure median approach
Procedure – Median approach
  • Needle insertion – approximately one half the distance between the mastoid and the sternal notch
  • 20-30 degree needle angle
  • Seldinger technique – watch for dysrhythmias
procedure77
Procedure
  • Finder needle techniques
    • Consider when:
      • Poor landmarks (obese)
      • Coagulopathic
      • Carotid artery disease in adults
  • Ultrasound
correct ij placement
Correct IJ placement

CXR provided by Jeremy P. Feldman, MDE-Bay Fellow in Pulmonary Vascular Disease

complications81
Complications
  • Arterial puncture more common than subclavian
  • Pneumo/hemo thorax very rare
  • Catheter malpositioning similar to subclavian
axillary vein
Axillary Vein
  • Find axillary artery
  • Get PIV just inferior to it in axillary vein
  • Wire it up
  • Appropriate size catheter?
  • 226 neonates done with 9 failures
  • 47 critically ill kids (14d-9y)
    • 79% cannulation rate
  • Rare complications – similar thrombosis rates to subclavian and internal jugular
temporary dialysis catheters
Temporary Dialysis Catheters
  • We have available :
    • 7 French Triple Lumen regular CVL
    • 7 French 10 cm Double Lumen Medcomp
    • 8 French 9cm Double Lumen Mahurkar
    • 12 French 13 cm Triple Lumen Mahurkar
    • 12 French 20 cm Triple Lumen Mahurkar
vascular access for pediatric crrt pros and cons of femoral site
Relatively larger vessel may allow for

larger catheter

higher flows

Ease of placement

No risk of pneumothorax

Preserve potential future vessels for chronic HD

Shorter femoral catheters with increased % recirculation

Poor performance in patients with ascites/increased abdominal pressure

Trauma to venous anastamosis site for future transplant

Vascular Access for Pediatric CRRT: Pros and Cons of Femoral Site

PROS

CONS

vascular access for pediatric crrt pros and cons of ij scv site
Tip placement in right atrium decreases recirculation

Not affected by ascites

Preserve potential vein needed for transplant

SCV stenosis (SCV)

Superior vena cava syndrome

Risk of pneumothorax in patients with high PEEP

Trauma to veins needed potentially for future HD access

Vascular Access for Pediatric CRRT: Pros and Cons of IJ/SCV Site

PROS

CONS

femoral versus ij catheter performance
Femoral versus IJ catheter performance
  • 26 femoral
    • 19 > 20 cm
    • 7 < 20cm
  • 13 IJ
  • Qb 250 ml/min (ultrasound dilution)
  • Recirculation measurement by ultrasound dilution method

Little et al: AJKD 36:1135-9, 2000

femoral versus ij catheter performance89
Femoral versus IJ catheter performance

* p<0.001

** p<0.007

Little et al: AJKD 36:1135-9, 2000

femoral versus ij catheter performance pediatrics
Femoral versus IJ catheter performance: Pediatrics

(Gardner et al, CRRT 1997Quinton 8 Fr; n = 20; 120 Treatments)

P value NS NS NS NS