Vascular Access
o A 2-month-old girl arrives at the
Emergency Department in cardiac
arrest. Other providers promptly
begin ventilation and perform chest
compression. You need to establish
vascular access to administer fluids
and medications
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MD
o What is the optimal site for
immediate vascular access for this
infant?
o If resuscitative efforts are
successful, what is the optimal site
for vascular access during the post
resuscitation period?
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MD
Objectives
o Prioritize sites of vascular access for
different clinical circumstances
o Describe the risks and benefits of
peripheral venous, central venous, and
intraosseous vascular access
o Describe the IO access technique
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MD
Selection of site and priorities of vascular
access 1
For CPR and treatment of
decompensated shock the one that is
o most readily accessible
o not require interruption
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MD
Selection of site and priorities of vascular
access 2
o Compensated shock… large bore
peripheral IV catheter
o Post resuscitation phase… central
venous catheter
o Intracardiac administration of drugs
during closed chest compression
o Arterial cannulation
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Priorities of Vascular Access
o During pediatric CPR or treatment of
decompensated shock.. IO access
o One practical approach: IO or
peripheral or central access
simultaneously
o During attempted resuscitation..
Transtracheal …LEAN
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Intraosseous Access
o Provides access to a noncollapsible marrow
venous plexus which serves as a rapid ,
safe and reliable route of administration
o Often can be achieved in 30-60 seconds by
using a rigid needle(specially designed or
Jamshidi-type)
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Intraosseous Access
o A rapid, safe, & effective route
for the administration of
medications & fluids, & may be
used for obtaining an initial blood
sample for type & crossmatch &
for chemical & blood gas analysis
even during resuscitation (Class
IIa; LOE 3).
o Acid-base analysis is inaccurate
after sodium bicarbonate
administration via the IO cannula.
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Intraosseous Access
o Epinephrine, adenosine, fluids, blood
products, & catecholamines can safely be
administered.
o Onset of action & drug levels achieved are
comparable to venous administration.
o Use manual pressure or an infusion pump to
administer viscous drugs or rapid fluid
boluses, & follow each medication with a
saline flush to promote entry into the
central circulation.
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Intraosseous Access
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Intraosseous Access
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Intraosseous Access
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Intraosseous Access
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Complications
o
o
o
o
o
Complications reported in fewer than 1%
Fracture of Tibia
Lower extremity compartment syndrome
Osteomyelitis
Extravasation of Drugs
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MD
Central V/S Peripheral
Venous Access
o More secure long-term access
o Not higher drug levels or a substantially
more rapid response
o Administration of drugs could injure
tissues(vasopressors ,calcium ,sodium
bicarbonate)
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Complications of central venous cannulation
o Local and systemic infection,venous or
arterial bleeding, arterial cannulation,
Thrombosis,plebitis, pulmonary
thromboembolism,hydro pneumo hemo
chylo thorax, cardiac tamponade,
arrhythmias, air embolism, catheter
fragment embolism
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Peripheral Venous Access Devices
o Over-the-needle catheters
o Catheter-over-wire devices
o Catheter-through-introducing sheath
devices
o Butterfly needles
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Peripheral Venous Access
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Peripheral Venous Access
A tourniquet is
placed around the
infant's head & the
needle inserted 0.5
cm from the
intended puncture
site in the direction
of blood flow.
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Peripheral Venous Access
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peripheral Venous Access
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Peripheral Venous Access
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Peripheral Venous Access
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Central Venous Access
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External Jugular cannulation
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Subclavian approach to central
vein
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Central Venous Access
Approach to Femoral Vein
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Venous Cutdown
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Venous Cutdown
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Venous Cutdown
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Venous Cutdown
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Mini-cutdown
oThe vessel is
elevated with a
hemostat & occluded
with gentle traction
from a distal tie.
oThe needle is
inserted & the sheath
is advanced into the
vessel.
oThe vessel should
not be tied off with
this technique.
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Arterial Lines
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Arterial Lines
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Summary points
o Intravascular or intraosseous
access is the preferred route for
medication and drug delivery in
cardiopulmonary emergencies.
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2
o Immediate intraosseous access is
recommended in cases of
decompensated shock and
cardiopulmonary arrest, particularly if
the provider lacks experience in
pediatric central venous access
techniques
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3
o Central venous catheterization
can be used in children in
emergencies. But it requires
significant expertise. Many
complications and delays may
occur in expert hands
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QUESTIONS???
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MD