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Key Points

  1. Prevention of central line associated bloodstream infections (CLABSI) begins with prevention of the need for central lines. Excellence with placement of peripheral intravenous lines is foundational to prevention of such infections.

  2. The intraosseous (IO) route provides rapid vascular access in a crisis. This route may be used effectively in older patients (adolescents and young adults) and in different locations (femur, humerus, radius, both malleoli, and even sternum) than had been traditionally thought to be ideal for this approach.

  3. Although the pediatric surgeon commonly performs central venous catheterization, an understanding of the spectrum of approaches and anatomic options will help with the most difficult cases of vascular access.

  4. When placing a central venous catheter (CVC), the use of central line insertion checklists and bundles can minimize the risk of CLABSI.

  5. Children with long-term indwelling catheters who develop CLABSI present a challenging problem. A systematic approach to this problem will prioritize the health of the child and still preserve vascular access sites.

  6. Whether using the guidance of anatomic landmarks or ultrasound imaging, meticulous technique and knowledge of anatomy are imperative for achieving safe central venous access. Ultrasound guidance can be particularly helpful with catheterization of the internal jugular vein.

Vascular access is a key that unlocks the door of acute pediatric care. Although the access itself is not therapy, it enables therapy in nearly every realm of pediatric care. Contemporary neonatology, oncology, critical care, infectious disease, anesthesia, and trauma care depend heavily on reliable vascular access for diagnosis, monitoring, and treatment.

Pediatric vascular access can challenge the person on both ends of the catheter. For so many children, “the needle” creates more anxiety than any other component of acute health care. Children at varying developmental levels do not understand their need for vascular access. Even children who do understand will typically subjugate an emotional response in order to cooperate. The family and the care provider do well to ensure appropriate comfort, environment, and analgesia to the child who needs vascular access. The care provider confronts additional challenges when pursuing vascular access in the pediatric patient and must consider the following: the acuity of the situation, the size of the child, the nature of the access needed, the anatomy of the child, and the duration of need for vascular access. The skill of vascular access is much more than the technique.

The pediatric surgeon is the provider of vascular access sometimes as first choice and sometimes as last resort. Because of the breadth of application and the challenges of these procedures in children, the pediatric surgeon is often asked to help these children. In many child healthcare institutions, vascular access procedures comprise the most common pediatric surgical intervention, and children stand to benefit greatly from a surgeon who is skilled in these procedures.

Peripheral Intravenous Access

The peripheral intravenous catheter (PIV) is the most ubiquitous form ...

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