Vascular access in neonates small children dr. rasha helmy

1. Presented by:
Rasha Helmy
Lecturer of pediatrics & pediatric nephrology,
Cairo University

2. Introduction:
 Generally peritoneal dialysis is considered the
preferred method for dialysis in neonates and small
children.
Why vascular
access?

3. Not feasible
• Recent abdominal
surgery.
• Omphalocele &
gastroschisis.
• Peritoneal
adhesions.
• Obliterated
peritoneal cavity.
• Peritoneal
membrane failure.
Not effective
• Inborn error of
metabolism (e.g
urea cycle defect &
MSUD).
• Poisoning.

4. The ideal vascular access delivers an adequate flow rate
for the dialysis prescription, has a long use-life, and
has a low rate of complications (e.g. infection, stenosis,
thrombosis, aneurysm, and limb ischemia)”.
 The arteriovenous fistula (AVF) best approximates this
definition

5. The ideal vascular access delivers an adequate flow rate
for the dialysis prescription, has a long use-life, and
has a low rate of complications (e.g. infection, stenosis,
thrombosis, aneurysm, and limb ischemia)”.
 The arteriovenous fistula (AVF) best approximates this
definition, however
- Not useful in acute cases
- Not feasible in neonates and small children
Despite some efforts at microsurgical approaches for
smaller children

6. Also we need vascular access in
situations other than HD
Failure of peripheral vascular access.
Prolonged hospital stay.
Hyperosmolar infusions.
TPN.
Exchange transfusion.
Plasmapheresis.
ECMO.

7. Venous access in small children

8. Venous access in small children
Why difficult?
CONSEQUENCES OF SIZE DIFFERENCE:
 Vessels are small-sized.
 Technically more difficult to approach
 More risk of injury.
 Small patients require small catheters.
 Difficulty in maintaining access
 Shorter life, repeat access, site exhaustion, …

9. Venous access in small children
Why difficult?
•Radiographic tools may be utilized to plan
and guide vascular access
•Needs general anaesthesia

10. Venous access in small children
 Peripheral lines  short duration & limited flow

11. Venous access in small children
 Peripheral lines  short duration & limited flow
 Adequate duration
 Multilumen access? 
 Flow/ size 
 Tip position 
Determine approach
& type of access

12. Types of central vascular access
-Central venous catheters:
Uncuffed ‘intermediate term’ usu. Polyurethane
catheters
Cuffed tunneled ‘long-term’ usu. Silicone catheters
Access via
Internal jugular vein.
Subclavian vein.
Femoral vein.
 Others.

13. Types of central vascular access
-Central venous catheters.
-Umbilical venous catheter.
-Peripherally inserted central catheter.

14. Central venous catheters
Types:
Short term (non cuffed)
Long term (cuffed)
Sites:
Internal jugular vein
Subclavian vein
Femoral vein

15. Sizes:
When selecting a catheter for central venous access,
one should recognize that the flow rate through a
catheter is
- Directly proportional to its internal diameter .
- Inversely proportional to its length.

16. Various catheters sizes according to weight of the
child:
Size of the child Catheter size
Neonate 5 Fr
3-6 kg 7 Fr
6-12 kg 8 Fr

17. Pros Cons
 Easily placed.
 Can be used immediately
 Painless to the patient
 Requires little planning prior
to placement
 Easily removed if used as
“transitional” access for future
PD or transplant patients
 Decrease risk of high-output
cardiac failure.
 No vascular steal Possible
 Infection rate is high.
 Failure rates and replacement
rates high.
 Permanent damage to central
venous system (stenosis/
thrombosis) may occur.
 Blood flow rates are variable,
leading to potentially poor
clearance.
 Damage to central vessels can
prohibit future AVF/AVG
placement in ipsilateral
extremity.
 Arrhythmia.

18. General principles in central venous
catheter insertion
 Decide if the line is really necessary
 Know your anatomy
 Be familiar with the equipment
 Obtain patient positioning
 Take your time
 Use sterile technique
 Always have a hand on your guide wire
 Always aspirate as you advance as you withdraw the
needle slowly

19. Internal jugular vein catheter
 Central venous access via the IJV is safe, relatively easy
and very commonly used in infants and children.
 The right IJV is the preferred vein for central venous
access as it offers straight access to the superior vena
cava.
 The rate of complications are lower compared to the
femoral and the subclavian access.

20. Technique
 A shoulder roll provides an appropriate degree of neck
extension with a slight contralateral head rotation .
The carotid artery is palpated with one hand, then the
skin is usually punctured at the level of the cricoid ring
just lateral to the carotid artery. The needle is
advanced at a 30-40° angle to the skin towards the
ipsilateral nipple.

21.  Ultrasound can be used to visualize the diameter and
position of the IJV in relation to the carotid artery. In
particular in patients with expected difficulties or with
previous central lines in that position an ultrasound
improves the likelihood of a successful puncture. In
addition obstruction of the vein can be excluded.

22. Difficulties and complications
during insertion
 Injury to the carotid artery.
 Very rarely, a haematoma causing tracheal
compression can occur.
 The risk of pneumothorax or hemothorax (lower than
that in subclavian access).
 Malpositioning occurs more often when the left IJV is
used. The guidewire may form a bow and end up in the
right IJV.

24. Subclavian vein catheter
 The subclavian approach remains the most commonly
used blind approach for subclavian vein cannulation.
 The physician’s experience and comfort level with the
procedure, however, are the main determinants as to
the success of the line placement in cases with no
other patient-related factors that may increase the
incidence of complications.

25. Technique
 The child is placed in the Trendelenburg position with
a rolled towel underneath the shoulders between the
scapulae to slightly hyperextend the back. The neck
should not be overextended.
 The puncture site should be at the junction of the
medial and middle thirds of the clavicle near the
depression created by the deltoid and the pectoralis
major muscles.

26.  The introducer needle is inserted through the
puncture site. It is held parallel to the frontal plane
and directed toward the posterior aspect of the sternal
notch.
 The needle should be advanced along the inferior
surface of the clavicle (parallel to the anterior chest
wall as possible) to decrease the risk of puncturing the
pleura.

27. Contraindications to subclavian venous
catheter insertion:
Absolute:
Trauma to the ipsilateral clavicle, anterior proximal
rib, or subclavian vessels .
Coagulopathy (direct pressure to stop bleeding cannot
be applied to the subclavian vein or artery, because of
their location beneath the clavicle).
Relative:
Chest wall deformity.
Future AV access planned in ipsilateral arm

28. Femoral vein catheter
 The femoral vein is not often used as the primary site for
central venous access.
 The rare occasions for using the femoral site include the
following :
 Placement of a temporary hemodialysis or pheresis
catheter .
 Inaccessibility of other primary central veins as a
consequence of thrombosis or stenosis.
 During cardiopulmonary resuscitation (CPR), in that this
approach does not interfere with chest compressions or
defibrillation

29. Technique
 The leg is restrained with the hip abducted and in
slight external rotation.
 The pelvis is elevated slightly by placing a towel under
the hips to improve exposure of the vein.
 The femoral artery is palpated with one hand, then the
skin is usually punctured 0.3-1 cm medially.

30.  The needle is advanced at a 30-40° angle to the skin
towards the umbilicus.
 Ultrasound guidance should be used for this
procedure when equipment and operator expertise is
available.

31. Complications
 Injury to the femoral artery.
 Hematoma formation.
 Thrombosis.
 Infection.

32. Location Advantage Disadvantage
Internal jugular vein •Bleeding can be
recognized & controlled
•Malposition is rare
•Less risk of
pneumothorax
•Risk of carotid artery
puncture
•Pneumothorax is
possible
Subclavian vein •Most comfortable for
conscious patients
•High risk of bleeding
•Bleeding is difficult to be
controlled
•High risk of
pneumothorax
Femoral vein •Technically easier
•No risk of pneumothorax
•Preferred site for
emergencies
•Highest risk of infection
•Risk of DVT
•Not good in ambulatory
patients

33. Umbilical venous catheter
 An umbilical venous catheter (UVC) is placed into the
cardiovascular system through the remaining “tail” of a
cut umbilical cord.

35. Umbilical venous catheter
• Simple & relatively rapid.
• Sedation is not required.
• Can be used in emergency.Pros
• Only inserted in 1st few days of life.
• Injury to adjacent anatomic structures.
• Infection.
• Portal vein thrombosis
Cons

36. PICC
 PICC lines have been used with great success in
neonatal intensive care units (NICUs) and are
considered a mainstay of vascular access in this
setting.
 PICC are inserted peripherally, usually in the cephalic
vein in the upper extremity or the saphenous vein in
the lower extremity, the distal tip is placed in a large
central vein.

38. PICC
• Simple & relatively rapid.
• May not require sedation.
• Vessel is not ligated.
• Decrease potential for infection.
Pros
• A blind technique beyond the initial
insertion.
• Small caliber catheter.
• Injury to adjacent anatomic structures.
Cons

39. Take home message
 Generally PD is the preferred method of dialysis in
neonates & small children but sometimes may not be
feasible or not effective.
 Vascular access in the neonates & small children
patient is a challenging, but sometimes necessary.
 Choosing the best vascular access option for pediatric
HD patients remains challenging.

40.  For the complications of CVC, it remains a suboptimal
choice for HD vascular access and should be
considered as a bridge to a more permanent,
optimized, vascular access.
 Ultrasound guidance should be used for placing
central venous catheters whenever the equipment and
operator experience is available.