- Need for acute resuscitation.
- Critical care monitoring.
- Need for long-term central venous access.
- Total parenteral nutrition.
- Long-term antibiotic therapy.
- Limited peripheral access in ill child.
- Severe thrombocytopenia.
- Stable vascular access in infants and children to aid a variety of therapeutic interventions.
- Catheter infection.
- Line sepsis.
- Catheter malfunction or thrombosis.
- Venous thrombosis.
- 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.
- 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.
- 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.
- 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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