Pediatric emergency medicine trisk 1087

Indications IV fluid administration Medication administration Blood product administration Blood draws Complications CVC-associated infection Thrombus Displaced/ruptured/broken catheter Occlusion Phlebitis Cardiac arrhythmias Infiltration Infusion of medications that interact with silicone (e.g., phenytoin or diazepam) Use caution to avoid infusion of incompatible medications Equipment Tunneled Central Venous Catheters Sterile gloves, mask, and eyewear Povidone-iodine, 70% isopropyl alcohol, or chlorhexidine gluconate per institutional protocol depending on if access is through the cap or directly into the line Sterile drapes Catheter clamp (never use a hemostat) Three needles (18, 19, or 20 gauge) 10-mL syringe with normal saline flush 5-mL syringe with heparin (100 U/mL) Two sterile 10-mL syringes (for phlebotomy) Fluids and/or medications to be administered 10 × gauze pads Implantable Venous Access Catheters Sterile gloves, mask, and eyewear Povidone-iodine or chlorhexidine per institutional protocol Sterile drapes Two Huber needles (19, 20, or 22 gauge) with 90-degree bend Extension tubing with clamp or stopcock 10-mL syringe with normal saline flush 5-mL syringe with heparin solution (100 U/mL) × gauze pads Silk tape 10 Protective barrier (e.g., Tegaderm) 11 Fluids and/or medications to be administered FIGURE 130.10 Accessing implantable central venous access catheters Peripherally Inserted Central Catheters Chlorhexidine 3-mL syringe with heparin 10 U/mL 5-mL normal saline flush Two 5-mL Luer-Lock syringes Procedure Tunneled Central Venous Catheters Maintain sterile technique when accessing a CVC Clamp the catheter with the catheter line clamp (do not use a hemostat) Hold the CVC tubing with a × in the nondominant hand and remove the cap Place a 10-mL syringe flushed with normal saline, unclamp, and flush with mL; then withdraw from the CVC to ensure patency Discard to mL of blood, and then clamp the catheter Administer medication or fluids as ordered once the syringe or IV tubing is securely attached to the catheter Set the medication/fluid rate and volume using an infusion pump, unclamp the catheter, and begin the infusion When not in use, the CVC should be clamped with the catheter line clamp When drawing a blood sample, first clean the catheter cap per institutional protocol Once the needleless access cap is cleaned, attach a Luer-Lock syringe, unclamp, and withdraw to mL of blood to discard Attach a second syringe and withdraw the necessary amount of blood Flush the catheter with mL normal saline and to mL of heparin (100 U/mL) In small infants, in patients with severe anemia, or when frequent sampling is required, consider reinfusing the initial blood sample to clear the line prior to the saline flush and heparin If difficulty occurs withdrawing blood from the catheter, this may be caused by catheter placement, clot, or malfunction Certain maneuvers that may aid in blood flow include placement of the patient in reverse Trendelenburg position, placing slight tension on the catheter, holding the patient’s arms over their head, or use of a Valsalva maneuver Withdrawing with force will only collapse the catheter tubing If the aforementioned maneuvers are not successful, gently flush the catheter with to mL of heparin solution (100 U/mL) If this attempt fails, alteplase may be used (see below) Implantable Venous Access Catheters Maintain sterile technique at all times ( Fig 130.10 ) Prepare the overlying skin with antiseptic solution as per institutional protocol If time allows, consider placement of topical anesthetic over the port site 30 to 40 minutes before access is planned Connect the Huber needle to extension tubing and flush the tubing and needle lumen with normal saline, then clamp Stabilize the circular reservoir with