Pediatric emergency medicine trisk 1086

FIGURE 130.8 A Anatomy for umbilical vessel catheterization B Umbilical artery catheterization C Umbilical vein catheterization Gently grasp the umbilical vein catheter about cm from the tip with either a small clamp or your gloved fingers ( Fig 130.8C ) Introduce the catheter tip into the umbilical vein Apply gentle pressure and advance the catheter through the venous lumen The catheter is inserted until blood flows freely This generally occurs when the catheter tip is just beyond the junction of the umbilicus and the abdominal wall Advance the catheter to the previously estimated depth Tighten the umbilical tape or the purse string suture Tape the catheter in place to further secure it It is important to confirm location of the catheter tip with an x-ray The umbilical vein catheter is usually withdrawn at the end of resuscitation to minimize the danger of infection or portal vein thrombosis; therefore, it is generally not necessary to suture this line in place INTRAOSSEOUS INFUSION Indications Emergency vascular access Favored if intravenous access cannot be rapidly obtained in life-threatening situations Complications Extravasation of fluids or medications into subcutaneous tissue Subcutaneous abscess, osteomyelitis, and bacteremia Physeal injury or fracture Fat embolus Equipment Povidone-iodine or chlorhexidine antiseptic solution; sterile gauze; gloves; drapes; 1% lidocaine; 3- to 5-mL syringe; 18- or 20-gauge intraosseous infusion needle; or commercially available IO device (EZ-IO [Arrow/Teleflex] or bone injection gun [Waismed/PerSys Medical]); saline flush solution; IV fluids and tubing Alternatives: bone marrow aspiration needle; 20-gauge lumbar puncture (LP) spinal needle Procedure Preferred locations are the proximal tibia or distal femur for ease of access and safety Prepare the selected site by cleansing with antiseptic solution In the awake patient, infiltrate from the skin to the periosteum with 1% lidocaine for anesthesia The desired site for placement in the proximal tibia is the flat, medial surface to cm below the tibial tuberosity ( Fig 130.9A ) Alternatively, the lower third of the femur in the midline approximately cm above the lateral condyle ( Fig 130.9B ) or the distal tibia to cm proximal to the medial malleolus ( Fig 130.9C ) can be used In the absence of an intraosseous needle, a bone marrow sampling needle or a spinal needle with bevel can be used After penetrating the skin with the needle, direct it at a slight angle 10 to 15 degrees from vertical and away from the growth plate of the long bone (caudad for proximal tibia insertion; cephalad for distal femur insertion) Apply downward pressure with a “to-and-fro” rotary motion to advance the needle When the needle passes through the cortex of the bone into the marrow cavity, resistance will suddenly decrease (a “trap door effect”) The needle should stand firmly without support Remove the stylet and connect a 5-mL syringe to the needle Attempt to aspirate marrow to confirm placement of the needle tip in the marrow space If marrow cannot be aspirated, gently attempt to flush with saline and assess for signs of infiltration If the line can be flushed easily without signs of infiltration, placement is good Flush the needle with heparinized saline and connect it to conventional IV infusion tubing Observe the site for extravasation of fluid, which is an indication that either the placement is too superficial or the bone has been pierced through both sides Restrain the leg and maintain a clean infusion site while the needle is in place Use of the EZ-IO for placement involves the same preparatory steps to sterilize the site Use the 15-gauge, 15-mm needle for patients under 39 kg and the 15gauge, 25-mm needle for those over 39 kg There is also a 15-gauge, 45-mm needle available for use when excessive soft tissue overlies the desired insertion site Load the needle onto the magnetic tip of the drill Insert the needle through the skin and soft tissue making contact with the anterior surface of the bone prior to actuating the drill The EZ-IO needles have markings on the needle shaft to indicate depth Once the drill is actuated, the needle will pass easily into the bone with application of minimal pressure A slight decrease in resistance may be felt as the marrow space is entered, but this is not as easily appreciated as with manual insertion Once the needle is firmly seated in the bone, unscrew and remove the inner trocar and attach the tubing that comes in the box with the needle Attempt to aspirate marrow to confirm placement of the needle tip in the marrow space If marrow cannot be aspirated, gently attempt to flush with saline and assess for signs of infiltration If the line can be flushed easily without signs of infiltration, placement is good Detach the tubing, apply the EZ-IO stabilizer, and reattach the tubing If marrow cannot be aspirated and the needle cannot be flushed but the needle is firmly seated, the needle tip either remains in the anterior cortex, in which case slight advancement by reattaching the drill is indicated, or it is in the posterior cortex in which case it needs to be removed, and a new site in a different bone identified ACCESSING CENTRAL VENOUS CATHETERS Types There are multiple brands of tunneled central venous catheter (CVC) Access to the central circulation is via cephalic, external jugular, internal jugular, brachiocephalic, subclavian, or saphenous veins Implanted venous access catheters (i.e., ports) are surgically inserted under the skin in the upper chest or arm The catheter is placed into a vein (usually the jugular, subclavian, or superior vena cava [SVC]) The catheter tip resides in the SVC outside of the right atrium Peripherally inserted central catheters (PICCs) are devices inserted for long- or short-term medication or intravenous fluid administration PICCs are often placed in the basilic or cephalic veins by either physicians or nurses The catheter tip resides in the distal portion of the SVC or at the SVC and right atrial junction FIGURE 130.9 Intraosseous access sites