Vascular access

Typical scenarios (who needs a line?)

• Oncology patients• Short bowel/TPN dependent patients• Pulmonary hypertension patients• Patients requiring extended antibiotic

treatment (e.g. osteomyelitis)• Patients requiring intermittent treatment (e.g.

sickle cell, metabolic disorder, etc.)

Oncology patients

• Oncology patients are in general the only children who require multiple-lumen implanted vascular access devices

• These devices should only be ordered by NPs, pediatric oncology fellows, or attendings, as device selection is critically dependent on tumor type, disease stage, and treatment protocol

TPN-dependent patients• Long-term requirement + high incidence of

infections exposes these patients to the risks of multiple procedures (insertions and removals)

• Insertion requests require accurate, up-to-date knowledge of vascular anatomy

• Removal requests should prompt consideration of reinsertion timing

• Multiple-lumen implanted devices place these patients at higher risk of infection and thrombosis, and are therefore essentially never appropriate

TPN-dependent patient scenario

• 5 yo with short bowel syndrome after NEC as neonate; has had 6 prior Broviacs placed

• Patient presents with fever and (+) blood cultures for yeast

• What is the appropriate action?

TPN-dependent patient scenario• 5 yo with short bowel syndrome after NEC as

neonate; has had 6 prior Broviacs placed• Patient presents with fever and (+) blood cultures

for yeast• What is the appropriate action?– The admitting pediatric attending calls the pediatric

surgical attending of the week, and requests an urgent line removal

– After this conversation, an Urgent Line Request form is submitted to provide information to the surgical and anesthesia care teams

TPN-dependent patient scenario

• What happens next?– The patient is made NPO, placed on the add-on

schedule, and the line is removed ASAP

• The patient has very difficult peripheral access.– Best option: peripheral IV treatment for as long as

possible, with bare minimum of 24 hours

TPN-dependent patient scenario

• In planning for the patient’s line replacement, the history is reviewed, and it is noted that on the last MRV 2 years ago both subclavians and the left internal jugular vein were occluded. Since that time, the patient has had 3 right IJ lines, and the last insertion was difficult.– A repeat MRV is the best option, as ultrasounds

do not clearly visualize the SVC– This type of patient should not go to the OR

without a map of the vasculature

Pulmonary hypertension patients

• Long-term requirement exposes these patients to the risks of multiple procedures (insertions and removals)

• Insertion requests require accurate, up-to-date knowledge of cardiac status and vascular anatomy

• Removal requests should prompt consideration of reinsertion timing

• Only pulmonary hypertension staff may request

Extended antibiotic therapy

• PICC line may be an alternative• Insertion requests require clear knowledge of

proposed length of treatment• Pediatric R3s may request AFTER discussion

with Pediatric attending

Intermittent access

• Portacath (implanted reservoir device) is appropriate for patients who don’t need frequent or daily infusions

• Insertion requests require clear knowledge of proposed type of treatment

• Some conditions place patients at excess risk for anesthesia and thrombosis (e.g. sickle cell disease, some metabolic disorders)

• Vascular access should be requested by heme-onc fellows or relevant attendings

Who receives the vascular access requests?

• The vascular access requests are received by pediatric surgical office staff, and scheduled as elective procedures

• Questions about scheduling should be directed to Maireni Franco in the office (2-8586)

Who reviews the vascular access requests?

• Accuracy of vascular access requests are the responsibility of the submitter

• Most requests are reviewed by pediatric surgery attendings

• For these reasons, it is critical that those submitting a request know the patient well and have reviewed all relevant studies/history

• If you submit a request, you are attesting to the accuracy of the data

When in doubt, ask• Complex or unusual patients are best

managed by attending-to-attending discussion—resist the temptation to “just submit a request”– Example: Patient with epidermolysis bullosa

• The pediatric surgical attending of the week can always be found by clicking the link at http://pedsurgery.columbia.edu