Vascular Vascular AccessAccess

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oA 2-month-old girl arrives at the Emergency Department in cardiac arrest. Other providers promptly begin ventilation and perform chest compression. You need to establish vascular access to administer fluids and medications

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oWhat is the optimal site for immediate vascular access for this infant?

o If resuscitative efforts are successful, what is the optimal site for vascular access during the post resuscitation period?

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Objectives

o Prioritize sites of vascular access for different clinical circumstances

o Describe the risks and benefits of peripheral venous, central venous, and intraosseous vascular access

o Describe the IO access technique

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Selection of site and priorities of vascular access 1

For CPR and treatment of decompensated shock the one that is

o most readily accessibleo not require interruption

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Selection of site and priorities of vascular access 2

oCompensated shock… large bore peripheral IV catheter

oPost resuscitation phase… central venous catheter

o Intracardiac administration of drugs during closed chest compression

oArterial cannulation

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Priorities of Vascular Access

oDuring pediatric CPR or treatment of decompensated shock.. IO access

oOne practical approach: IO or peripheral or central access simultaneously

oDuring attempted resuscitation.. Transtracheal …LEAN

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Intraosseous Access

o Provides access to a noncollapsible marrow venous plexus which serves as a rapid , safe and reliable route of administration

o Often can be achieved in 30-60 seconds by using a rigid needle(specially designed or Jamshidi-type)

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Intraosseous Access

o A rapid, safe, & effective route for the administration of medications & fluids, & may be used for obtaining an initial blood sample for type & crossmatch & for chemical & blood gas analysis even during resuscitation (Class IIa; LOE 3).

o Acid-base analysis is inaccurate after sodium bicarbonate administration via the IO cannula.

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Intraosseous Access

o Epinephrine, adenosine, fluids, blood products, & catecholamines can safely be administered.

o Onset of action & drug levels achieved are comparable to venous administration.

o Use manual pressure or an infusion pump to administer viscous drugs or rapid fluid boluses, & follow each medication with a saline flush to promote entry into the central circulation.

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Intraosseous Access

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Intraosseous Access

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Intraosseous Access

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Intraosseous Access

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Complications

o Complications reported in fewer than 1%o Fracture of Tibiao Lower extremity compartment syndrome o Osteomyelitiso Extravasation of Drugs

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Central V/S Peripheral Venous Access

o More secure long-term accesso Not higher drug levels or a substantially

more rapid responseo Administration of drugs could injure

tissues(vasopressors ,calcium ,sodium bicarbonate)

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Complications of central venous cannulation

o Local and systemic infection,venous or arterial bleeding, arterial cannulation, Thrombosis,plebitis, pulmonary thromboembolism,hydro pneumo hemo chylo thorax, cardiac tamponade, arrhythmias, air embolism, catheter fragment embolism

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Peripheral Venous Access Devices

o Over-the-needle catheterso Catheter-over-wire deviceso Catheter-through-introducing sheath

deviceso Butterfly needles

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Peripheral Venous Access

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Peripheral Venous Access

A tourniquet is placed around

the infant's head & the needle

inserted 0.5 cm from the intended

puncture site in the direction of

blood flow.

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Peripheral Venous Access

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peripheral Venous Access

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Peripheral Venous Access

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Peripheral Venous Access

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Central Venous Access

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External Jugular cannulation

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Subclavian approach to central vein

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Central Venous AccessApproach to Femoral Vein

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Venous Cutdown

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Venous Cutdown

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Venous Cutdown

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Venous Cutdown

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Mini-cutdown

oThe vessel is elevated with a hemostat & occluded with gentle traction from a distal tie. oThe needle is inserted & the sheath is advanced into the vessel. oThe vessel should not be tied off with this technique.

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Arterial Lines

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Arterial Lines

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Summary points

oIntravascular or intraosseous access is the preferred route for medication and drug delivery in cardiopulmonary emergencies.

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2

o Immediate intraosseous access is recommended in cases of decompensated shock and cardiopulmonary arrest, particularly if the provider lacks experience in pediatric central venous access techniques

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3

oCentral venous catheterization can be used in children in emergencies. But it requires significant expertise. Many complications and delays may occur in expert hands

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QUESTIONS???