Pediatric emergency medicine trisk 1084

FIGURE 130.6 Percutaneous injury jugular vein catheterization SCALP VEIN CATHETERIZATION Indications To achieve IV access for delivering fluid and/or medication in an infant, usually younger than year of age, when peripheral extremity veins are unavailable Complications Inadvertent arterial puncture Ecchymoses and hematoma of the scalp Infection Equipment Butterfly scalp vein needle no 23, 25, or 27, or an over-the-needle catheter, 22 or 24 gauge; rubber band with tape; flush solution; 3-mL syringe; tincture of benzoin; tape; razor blade; povidone-iodine or chlorhexidine antiseptic solution; sterile gauze Procedure The infant younger than year of age has several easily accessible scalp veins These include the frontal, supraorbital, posterior facial, superficial temporal, and posterior auricular veins and their tributaries Restrain the patient in a supine position and have an assistant stabilize the infant’s head After assessment for the most accessible veins, shave an area large enough to expose not only the desired veins, but also an area of surrounding scalp for adequate taping of the infusion needle or catheter In this area, select a vein with a straight segment that is as long as the part of the needle or catheter that is to be inserted Verify the chosen vessel is a vein by palpating it to ensure it does not pulsate Place a rubber band around the infant’s head after attaching a small piece of tape to the rubber band to make it easier to lift and cut the rubber band after successful venipuncture Prepare the skin by cleansing with antiseptic solution and allowing it to dry Grasp a butterfly scalp vein needle by the plastic tabs or “wings” or the over-theneedle catheter at the base Keep the needle and syringe unattached initially to facilitate evaluation of free blood return Insert the needle in the direction of blood flow and pierce the skin approximately 0.5 cm proximal to the actual site where entry into the vein is anticipated ( Fig 130.7 ) While applying mild traction on the skin of the scalp, slowly advance the needle through the skin toward the vein Blood will enter the clear plastic tubing of the butterfly or the plastic tubing of the catheter with entry into the lumen of the vein Carefully cut the rubber band tourniquet, attach the syringe filled with saline flush solution, and slowly inject 0.5 mL of flush If the needle is satisfactorily inserted into the lumen of the vein, the solution will flow easily For catheterization, thread the catheter over the needle further into the vein continuing to assess for flow Appearance of a skin wheal when flushing the catheter indicates that the vein has not been satisfactorily cannulated, and another attempt must be made After successful catheterization, carefully tape the scalp vein needle or catheter as shown in the diagram To prevent accidental removal or infiltration of the vein, look for ways to position the infant safely UMBILICAL ARTERY CATHETERIZATION Indications Respiratory failure or cardiovascular collapse in the newborn infant for whom percutaneous attempts for vascular access have failed Used for resuscitation, arterial blood gas measurements, and continuous blood pressure monitoring Arterial catheterization is possible until approximately week of age Complications Embolization or thrombosis—inferior mesenteric, renal, or iliac arteries Infection Ischemia/infarction from vasospasm Hemorrhage—from dislodgment of catheter or perforation of the vessel wall Arrhythmias—from direct cardiac stimulation if the catheter enters the heart Air embolism FIGURE 130.7 Scalp vein catheterization Equipment 3-0 or 4-0 silk suture on straight or curved needle; antiseptic solution (povidoneiodine); sterile gauze pads; drapes and gloves; hemostats (four pairs), curved nontoothed iris forceps (4 in) or metal dilator and iris scissors; needle holder, sterile scalpel and no 11 or 15 blade; 22-gauge needle; 10-mL syringe filled with normal saline; T-connector (optional); three-way stopcock; nonthrombogenic umbilical catheter, 3.5, Fr (premature babies) or, 5Fr (fullterm); infusion solution, often normal saline, containing heparin (1 U/mL) Procedure During the catheterization, monitor heart rate and pulse oximetry, and keep the infant under a radiant warmer to maintain normothermia Figure 130.8A shows the pertinent anatomy Historically, there has been debate regarding optimal catheter tip location to prevent complications, but emerging evidence suggests that placement of the catheter in the “high” (T6–T9) rather than “low” (L3–L4) position may be preferred Place the infant supine in the frog-leg position and restrain him/her as necessary Gauze pads may be wrapped around the ankles and wrists and either pinned or taped securely to the bed/sheet Wearing mask, gown, and gloves, hold the sterile umbilical catheter over the infant to measure the vertical distance from the lateral aspect of the clavicle to the umbilicus The catheter will be advanced into the artery 60% of this distance, beginning at the skin surface, so its tip will reach the bifurcation of the aorta, the subdiaphragmatic (i.e., “low”) position For catheters to be placed in the “high” position, use the nomogram ( Fig 130.8A ) to establish the appropriate insertion length Recommended insertion lengths not account for the length of catheter that is within the umbilical stump from the abdominal wall Mark the catheter appropriately and attach it to the T-connector, stopcock, and syringe Flush it, leaving it full of fluid While lifting the umbilical cord with gauze in one hand, scrub the lower umbilical cord and abdomen from the xiphoid process to the symphysis pubis with povidone-iodine solution Drape the infant on both sides by folding two drapes into triangles or use an aperture drape; cover the area below the umbilicus with a third square drape At the base of the umbilical stump, suture a 3-0 or 4-0 silk tie around the cord to make a purse string, but leave the knot untied While holding the gauze on the nonsterile distal umbilicus, sever the cord 1.5 to cm above the abdominal wall with the scalpel as shown in Figure 130.8B , part A Remove the cut umbilicus and gauze from the sterile area Bleeding is usually minimal, stopping with gentle pressure or wiping; rarely, the purse string must be tightened Locate the umbilical vessels, usually two thick, white-walled arteries on one side, and a larger, thinner-walled vein on the other If the arteries in the stump are tortuous, cut it closer to the abdominal wall to facilitate cannulation Attach two clamps on opposite sides of the umbilicus, being careful to grasp a fibrous portion of the cord and not just Wharton jelly or an artery Evert the clamps to immobilize and expose the cord, and use the small curved forceps, as in Figure 130.8B , part B, to enter and then stretch the lumen of the artery Gentle,