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  • Need for acute resuscitation.
    • Trauma.
    • Critical care monitoring.
  • Need for long-term central venous access.
    • Total parenteral nutrition.
    • Chemotherapy.
    • Hemodialysis.
    • Long-term antibiotic therapy.
    • Limited peripheral access in ill child.

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Absolute

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  • None.

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Relative

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  • Coagulopathy.
  • Severe thrombocytopenia.

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Expected Benefits

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  • Stable vascular access in infants and children to aid a variety of therapeutic interventions.

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Potential Risks

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  • Bleeding.
  • Pneumothorax.
  • Hemothorax.
  • Catheter infection.
  • Line sepsis.
  • Catheter malfunction or thrombosis.
  • Venous thrombosis.

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  • Cutdown central venous lines in premature infants and neonates require very fine vascular pickups and small right-angle clamps. It is best to assemble a sterile neonatal cutdown tray to have available at all times.
  • A portable ultrasound machine is helpful for internal jugular venous punctures.
  • All lines inserted in the operating room should be placed using live fluoroscopy on an appropriate radiolucent table.
  • A wide range of catheter types and sizes should be available at all times.
    • For both acute and long-term hemodialysis catheters, it is best to develop a weight-based catheter size chart in conjunction with pediatric nephrologists to ensure that the catheter placed has the capacity to provide adequate flow for dialysis or hemofiltration.

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  • Preoperative blood work should include hematocrit, platelet count, and coagulation studies.
  • If the child has had previous central lines, a duplex Doppler vascular ultrasound of the neck and upper extremity vessels should be performed to identify potential preoperative thromboses.
    • If multiple thromboses are seen, a magnetic resonance venogram is useful for preoperative planning.

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  • The patient is most often positioned supine with a shoulder roll in place.
  • If a saphenous vein cutdown or femoral vein catheterization is planned, the leg should be straight and abducted away from the midline.

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  • Figure 47–1: Saphenous vein cutdown.
    • This procedure is used most often for premature infants and neonates and can be performed at the bedside.
    • The location of the femoral artery is identified by palpation.
    • After infiltration of the area with local anesthesia, a short transverse incision is made 1 cm below the groin crease and medial to the femoral artery.
    • The saphenous vein is identified, ligated distally, and encircled proximally.
    • A 5-mm stab wound is made on the medial thigh just above the knee.
    • A Broviac catheter is tunneled from the distal incision to the venous cutdown site until the Dacron cuff is midway between the two incisions.
    • The catheter is measured to lie in the subdiaphragmatic superior vena cava (SVC) and is cut on a very acute angle to the appropriate length.
    • Using a No. 11 blade, an anterior venotomy is performed and the catheter placed bevel down into the vein.
    • Once in place, the catheter is secured in the vein with the previously placed suture.
    • The catheter is then checked to ensure that blood can be withdrawn and the catheter flushes easily.
    • The catheter is secured ...

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