Chapter 47. Pediatric Vascular Access

• 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.

Absolute

• None.

Relative

• Coagulopathy.
• Severe thrombocytopenia.

Expected Benefits

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

Potential Risks

• Bleeding.
• Pneumothorax.
• Hemothorax.
• 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.
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