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Pediatrics
Vascular AccessPART ONE: Central Venous Catheterization
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Objectives
•By the end of this workshop, the learner will be able to:
‐Recall at least 3 indications and 3 contraindications for central venous catheterization (CVC)
‐Describe the anatomic landmarks used to guide CVC at specified sites of insertion
‐Name at least 5 complications associated with CVC
‐Choose an appropriate sized central venous catheter according to indication for placement and/or the patient’s size
‐Distinguish between properly positioned and malpositioned central venous catheters on radiographic images
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Indications
•Peripheral access unobtainable
•Medication/fluid administration
•Emergency resuscitation
•Monitoring of CVP and ScvO2
•Parenteral nutrition
•Frequent blood sampling
•Hemodialysis/hemofiltration/Apheresis
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Contraindications
•Coagulopathy
•Thrombosis
•Skin infection at site of needle puncture
•Trauma
•Distorted anatomy
•Clavicular/proximal rib fractures
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Three common sites
•Internal jugular
•Femoral
•Subclavian
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•Anatomy
•Surface Landmarks
•Positioning
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•Anatomy
•Surface Landmarks
•Positioning
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Three common sites
•Internal jugular
‐Anterior
‐Middle
‐Posterior
•Subclavian
•Femoral
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IJ Anatomy
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Surface Landmarks
•Upper portion: medial to SCM
•Mid portion: posterior to SCM in the triangle of SCM heads and clavicle
•Lower portion: behind clavicular head of SCM where it descends to join SC just above medial end of clavicle
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Positioning
•Supine with a roll under the shoulders
•Head slightly turned AWAY from puncture site
•Slight trendelenburg (15-30 degrees)
•Puncture @ apex of triangle aimed at ipsilateral nipple
•Attempt to puncture during exhalation in spont breathing
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Three common sites
•Internal jugular
‐Anterior
‐Middle
‐Posterior
•Subclavian
•Femoral
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Subclavian Anatomy
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Surface Landmarks
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Positioning•Supine and in trendelenburg (30 degrees)
•Head/neck positioning:‐Extension of neck with rolled towel along axis of T-spine
‐Head in neutral position
‐Slight flexion and turned towards puncture site
•Attempt to puncture during exhalation in spont breathing
‐Expiratory hold if on mechanical ventilation
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Three common sites
•Internal jugular
‐Anterior
‐Middle
‐Posterior
•Subclavian
•Femoral
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Femoral Anatomy
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Femoral Anatomy
NAVEL
mpty space
ymphatics
Roger’s Textbook of Pediatric Intensive Care, 4th ed.
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Surface Landmarks/Positioning
•Positioning‐ “Frog-leg appearance”: Slight external rotation at the hip and flexion at the knee
‐ABduction of leg with external rotation at the hip
‐External rotation at the hip
•Rolled towel under the buttock
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Complications
•*Infection (F)
•Thrombosis (F)
•Arterial puncture
•*Bladder puncture (F)
•Hemorrhage
•Phlebitis
•Hemo/Pneumothorax (I/S)
•Tracheal puncture (I/S)
•Catheter fragment/ guidewire embolism
•Cardiac dysrhythmias
•Air embolism
•Erosion/perforation
•Pericardial tamponade
•Uncooperative patient
•Lack of experience/supervision
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Complications
•Complication rates ‐Adults: 0.5-15%, up to 35% for inexperienced
‐Pediatrics: 0.3%-34% (lowest for femoral)
•Risk increases exponentially with increasing number of attempts
‐Likelihood of failed cannulation correlates with repeated attempts
Kumar et al. Ultrasound guided vascular access: efficacy and safety. Best Practice & Research Clinical Anaesthesiology 2009; 23: 299–311 Rey et al. Mechanical complications during central venous cannulations in pediatric patients. Intensive Care Med 2009; 35: 1438–1443.
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Catheter-Associated Bloodstream Infection (CABSI)
•Most common complication of CVC
•Significant cause of morbidity, mortality and healthcare costs
•Substantially reduced by using a “bundle” of practices
•Lower risk of infection with subclavian venous access in adults
•Regardless of site, strict attention insertion technique can reduce infections
Miller et al. Decreasing PICU Catheter-Associated Bloodstream Infections: NACHRI's Quality Transformation Efforts. Pediatrics 2010; 125: 206-213
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ED CVL Insertion Bundle
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ED/PICU CVL Insertion Bundle
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ED CVL Insertion Bundle
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PICU Insertion Bundle
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Bundles of joy….
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Choosing a Catheter
•Size?
•Length?
•Number of lumens?
•Patient
‐Weight/size
‐Size of vessel
‐Indications
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Choosing a Catheter Size/Length
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Sequence of Events
•Inform/Consent parents
•Perform a “Time Out”
•Position**
•Insertion Checklist (“Bundle”)
•Perform Procedure/Apply sterile dressing
•Confirm Placement
•Document
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Sequence of Events
•Inform/Consent parents
•Perform a “Time Out”
•Position**
•Insertion Checklist (“Bundle”)
•Perform Procedure/Apply sterile dressing
•Confirm Placement
•Document
Pediatrics
???????????????????????????
Correct position or
Malpositioned???????????????????????????
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Sequence of Events
•Inform/Consent parents
•Perform a “Time Out”
•Position**
•Insertion Checklist (“Bundle”)
•Perform Procedure/Apply sterile dressing
•Confirm Placement
•Document
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Despite what Kiyetta is about to tell you…
Landmarks are still IMPORTANT!!!