Pediatric emergency medicine trisk 4667 4667

The procedure differs slightly when accessing a totally implanted CVC or port Because intact skin is penetrated, the use of a topical anesthetic cream before access should be considered when feasible After leaving the topical anesthetic on for the manufacturers’ recommended time, it should be wiped off and the skin should be cleansed with 2% chlorhexidine gluconate, alcohol, or povidone-iodine Povidone-iodine should not be cleaned off with alcohol Using a sterile technique, triangulate the port body with three fingers, and insert a Huber needle through the skin directly into the reservoir diaphragm when resistance is met at the back of the reservoir The needle should be secured in place and patency should be confirmed with aspiration and flushing After use, the totally implanted device must be flushed using to mL of heparin (10 units/mL) When the port is not being used, patency is maintained with to mL of 100 units/mL flush on a monthly basis Complications resulting from accessing CVCs include occlusion, air embolus, catheter breakage or displacement, and infection Although most of these complications can be avoided if care is taken to maintain aseptic technique, the clinician should be aware of their diagnosis and management Clinical Findings/Management Catheter Occlusion Difficulty drawing blood or infusing fluid through a CVC can be the result of catheter malposition or occlusion The catheter may be positioned against a vessel wall, or fibrin or blood may clot in the lumen In addition, various precipitates can occlude the lumen of the catheter Waxy precipitates can result when parenteral nutrition solutions contain combinations of fat, protein, and carbohydrate, and particulate precipitates can result from the poor solubility of calcium and phosphorus IV phenytoin (especially when administered in a glucose-containing solution) and diazepam can also precipitate Children who require IV medications or fluids at home may present for shortterm management of catheter occlusions Increasing the venous pressure gradient along the catheter can facilitate phlebotomy These maneuvers include having the patient hold his or her arms above the head, cough or perform Valsalva maneuver, and placing the patient in Trendelenburg position If blood still cannot be drawn, mL of saline should be used to gently irrigate the CVC Never flush against resistance as the pressure can force a clot into the bloodstream or rupture the catheter, particularly if the practitioner uses too much force or too small a syringe Care should be taken to observe the catheter for a balloon “aneurysm,” a sign of impending rupture