Vascular Access In Children

Scalp Vein Access

Scalp veins are easily accessible in children less than 1 year of age and provide a good route for maintenance fluid and drug administration ( Fig 17-11). The superficial temporal, posterior auricular, and supratrochlear veins are the most easily catheterized scalp veins. In all cases, the vein must be differentiated from its respective artery. Arteries are generally more tortuous; they pulsate, and they fill from below, whereas veins fill from above.

FIG. 17-11. A tourniquet is placed around the infant's head and the needle inserted 0.5 cm from the intended puncture site in the direction of blood flow.

The operator begins by shaving and prepping an area large enough to secure butterfly needle wings. A rubber-band tourniquet is placed around the head proximal to the venipuncture site and a butterfly needle—usually 23 to 27 gauge—is advanced into the vein. The needle is then taped at the skin entry point and at the butterfly with cotton support under the wings. A cover (medicine cup) may be used to protect the area. Complications from this procedure include infection, bleeding, extravasation of fluid or medications, and inadvertent arterial puncture.

Umbilical Vein Access

In the first 1 to 2 weeks after birth, the umbilical vessels offer easy central venous access. Even a severely dehydrated umbilical stump may yield good vessels with adequate preparation. In a normal infant, there are two small umbilical arteries and a single larger vein. The arteries arise from the internal iliac artery while the vein is continuous with the portal vein.

The operator begins by cleansing the cord. A transverse cut is made 1 cm above the junction of skin and cord, at which point a purse-string suture is placed. The single large vein and two smaller arteries are identified. A 3.5- to 5.0-Fr catheter is inserted into the vein and advanced to 4 to 5 cm in a term infant; further advancement may cause liver damage. The catheter should be filled with saline solution and flushed properly prior to placement to ensure an air-free system.

The most common complications relate to vascular insufficiency induced by the catheter. Evidence of ischemia—such necrotic enterocolitis, liver necrosis, poor peripheral circulation, or abdominal distention—is an indication for immediate removal of the catheter. The potential for infectious complications is equivalent to that for other indwelling catheters.

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