This document provides a comprehensive overview of various vascular access methods in pediatric care, emphasizing their significance for critically ill newborns. It details different catheter types, including peripheral and central venous catheters, their indications, insertion techniques, complications, and specific applications such as umbilical access and intraosseous access. The text highlights both the advantages and drawbacks of each method, underscoring the importance of proper planning and execution in pediatric vascular access.

1. Vascular access in pediatrics
Dr Shambhavi Sharma
M.Ch Pediatric surgery
1St
year Resident

2. Introduction
• Vascular Access as a Vital Tool
– Crucial role in neonatal care
– Provide ongoing therapy and invasive monitoring for critically ill
newborns
• Therapeutic Advantages of Catheters and Cannulae
– Fluids, electrolytes, blood products, drugs, and specialized nutritional formulas
to newborns
• Monitoring Benefits
– Blood samples for analysis, measuring arterial and venous pressures

3. Types of Catheters
• Depending on the site of insertion:
– Peripheral Catheters (Percutaneous Peripheral catheters)
– Central venous catheters (CVCs)
• Peripherally Inserted Central Catheters (PICC)
• Implantable Vascular-Access Devices
• Tunneled CVC
• Non tunneled CVC
– Umbilical Vascular Access
– Intraosseous catheters
– Peripheral venous cutdown catheters

5. Peripheral Venous Access
• Most commonly used venous access in
infants and children
• For short-term needs
• Minimal complications and mainly used
for intravenous fluids and medications
– Dorsal veins of the hands and feet
– The superficial scalp veins
– The long saphenous vein
– The external jugular vein

7. Peripheral Venous Access
• Techniques for Vein Cannulation:
– Warming the extrimity
– Transillumination
– Epidermal vasodilatations
• Ultrasound (US) Guidance
• Near-Infrared Imaging Devices
• Non-Contact Near-Infrared
Imaging

8. Peripheral Venous Access
• Complications
– Phlebitis
– Thrombosis
– Extravasation
– Blockage

9. Central venous access
• Preoperative assessment and planning
– Proposed insertion and exit site
– Potential access and difficulty
– Consent
– Blood investigations
• Anaesthesia

10. Peripherally Introduced Central Catheter
• provide reliable central venous access in neonates and older children
without the need for directly accessing the central veins
• Suitable for infusion of fluids, medications, TPN, and blood products for
a period of weeks
• Small single or dual lumen catheters
• Outer diameter 0.6-1mm
• Maximum flow rate : 6ml/min
• Blood sampling possible but shortens lifespan of catheter

12. • Tip of the PICC should be placed at the superior
vena cava (SVC)/RA junction or the IVC/RA
junction
Advantage :
• Safe insertion
Disadvantage
• Infections, occlusion, and dislodgement of the catheter.

13. Central Venous Catheters
• Nontunneled : short- and medium-term (<10days)
• Tunneled CVCs: medium- and long-term
• Sites:
– Bilateral internal jugular veins
– Subclavian veins
– Femoral veins

14. Non tunneled CVC
eg : temporary hemodialysis catheter
Short (15-30cm), relatively stiff with multiple lumen
Advantage :
Safe insertion
Disadvantage :
High infection rate

15. Tunneled CVC
Types :
Hickman catheter :
2.7-12Fr ,single or multiple lumen
Tissue in growth cuff of dacron intended to reduce infection and inadventant removal
Hemodialysis catheter
two lumens with offset opening at the tip to prevent recirculation of blood during
hemodialysis

16. • CVCs lines can be used to give:
– Large volumes of fluids over a
short period of time
– Blood and blood products
– Hypertonic solutions
– Total parenteral nutrition
– Antibiotics
– Chemotheraputics

19. Totally Implanted Central Venous Catheters
• Implantable vascular-access (ports) are
used for patients who require long-term
venous access
• No external catheter
• Subcutaneous reservoirs attached to CVCs.
• Access the port, a special needle (a Huber
needle) is used to puncture the
diaphragm.

20. • Preferred sites for port placement include
– pectoral area
– parasternal area (above and medial to the areola)
– subclavicular area (medial to the anterior axillary
fold)

21. • Advantages
– A lower rate of infection when compared with other devices
– No restriction of daily activities
– No need for frequent dressing changes
• Malignancies, coagulopathies, hemolytic syndromes, and renal failure
• Disadvantage:
• require general anesthesia for surgical insertion and removal
• Less appropriate for those who cannot tolerate regular needle access and who
require continuous access

22. Umbilical Vein and Artery Access
• Neonates, 2 umbilicle artery, 1 umbilicle vein
• Indications:
– Monitoring central venous or arterial pressure.
– Blood sampling.
– Fluid resuscitation.
– Medication administration.
– TPN.
• Require dissection of the umbilical cord stump within a few hours of
birth
• UAC – 5 days, UVC-upto 2 weeks

24. • Require dissection of the umbilical
cord stump within a few hours of birth
• A small vertical skin incision is made
above or below the umbilical stump to
access the umbilical vein or artery,
respectively
• Once the fascia is incised, the
appropriate vessel is identified,
isolated, and cannulated

25. • UVC Positioning
– tip of the UVC should be precisely
positioned at the junction of the
inferior vena cava (IVC) and the
right atrium (RA).
• Radiographic Confirmation
– tip of the UVC is at or above the
level of the diaphragm.
– tip of the UAC is best positioned
between the sixth and tenth
thoracic vertebrae.

26. Complications
• UVC:
– tip migration
– sepsis and vessel thrombosis
– perforation of the IVC
– extravasation of infusate into the peritoneal cavity, and portal vein thrombosis
• UAC:
– aortic injuries
– thromboembolism of the aortic branches, aneurysms of the iliac artery and/or the
aorta
– paraplegia
– gluteal ischemia with possible necrosis

27. Intraosseous Access
• Rarely used except in emergency situations where other venous access
methods are not accessible.
• Proximal tibia 1-2 cm below the tibial tuberosity.
• Other sites include: – The distal tibia – The distal femur: 3 cm above the
superior aspect of the patella – The distal radius – The ulna – The iliac
crest – The sternum – The calcanium.
• Removed within 12–24 h of their insertion.

28. Technique
• A large-bore (16- or 18-gauge) bone-
aspiration needle, a styletted needle
used for bone marrow aspiration, or a
large spinal needle can be used.
• The insertion is made 1–3 cm below
and just medial to the tibial tuberosity
by advancing through bone into the
marrow space.
• Correct placement of the needle is
confirmed with the aspiration of
marrow and easy infusion of fluid.

29. Complication
• Most common - osteomyelitis
• Fracture
• Compartment syndrome
• Leakage at the insertion site
• Failure of infusion due to bending of the needle
• Occlusion of the needle with bone marrow
• Necrosis of the epiphyseal plate

30. Venous Cutdown
• Rarely used nowadays.
• The vessel of choice is the long saphenous vein near the medial
malleolus.
• A transverse incision is made anterior and cephalad to the medial
malleolus.
• The vein is readily identified by dissecting through the thin
subcutaneous tissue and is stabilized by placing proximal and distal stay
ligatures.
• The vein is then directly cannulated using a venous catheter of
appropriate size relative to the vein, and the catheter is anchored to the
adjacent skin.

32. Arterial Catheter
• Continuous hemodynamic monitoring
and blood sampling.
• Radial artery, dorsalis pedis, posterial
tibial, femoral.
• Digital ischemia
• Thromboembolism
• Local infections
• Pseudoaneurysm

33. References
• Holcomd and Ashcraft’s pediatric surgery.
• Coran paediatric surgery.
• Atlas of paediatric surgery.
• Newborn surgery.

34. Thank you