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Vascular Access in Children 49
Venous Cutdown theless, foreign bodies. Catheters should therefore be retained only for as
A cutdown may be necessary to establish a rapid vascular access, for long as necessary. Feeding and drugs should be changed to the oral route
example, when all visible superficial veins may have been used or the as soon as possible. After 2–3 days, signs of inflammation may appear
patient comes in shock. The long saphenous vein, either near the ankle at the site of cannulation. These include pain, redness, and swelling. If
or at the groin, the femoral vein at the groin, and the basilic vein at the the redness appears other than along the site of cannulation, cellulitis
elbow or the cephalic vein at the delto-pectoral grove are all suitable is setting in, and the site of cannulation will need to be changed. If the
sites. The area around the chosen vein is cleaned and draped aseptically, catheter is being used for parenteral nutrition, intravenous antibiotics
then infiltrated with a suitable local anaesthetic. A transverse incision is may be given in an attempt to salvage the line. If the catheter is planned
made only in the skin over the vein. A haemostat is then used to widely for long-time use, it may be advisable to give regular antibiotics through
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open the subcutaneous tissues. The vein is usually then visible. The the vein from the beginning. The presence of infection elsewhere,
distal end of the vein is ligated. A small needle is passed transversely prolonged hospital stay, immunosuppression, and poor catheter care all
across the vein, and the part of the vein superficial to the needle is tran- contribute to catheter-related sepsis.
sected. A suitable catheter is then inserted and anchored with stitches. Thrombosis/thrombophlebitis
The transverse skin incision is closed with one or two stitches. The Thrombosis can occur in a catheter, and the thrombus can dislodge
catheter is anchored to skin with both stitches and plaster.
to distant parts with grave consequences to the patient. Early signs of
Intraosseous Infusion thrombosis are inadequate flow in the infusion fluid and extravasa-
The bone marrow space is a rich, noncollapsible venous network. tion. Use of silicone catheters, parenteral nutrition, and diabetes may
Intraosseous infusion is a quick method of resuscitating children in predispose the patient to thrombosis. Aortic thrombosis can complicate
shock when immediate intravenous access fails. Crystalloids, colloids, umbilical artery cannulation, which may lead to leg or bowel gangrene.
drugs (including anaesthetic drugs), and blood can be given rapidly If persistent blanching of skin of the leg occurs, the catheter may need to
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through this route. The flat, anteromedial, subcutaneous, upper aspect be removed. Regular flushing with normal saline, heparin, or urokinase
of the tibia 1–3 cm below the tibia tuberosity is usually used (Figure may serve as a preventive. After the catheter has been removed, the
9.3). Other sites that could be used are: vein may become a painful, fibrotic, noncompressible “cord”. This is
• the midline of the distal femur 3 cm proximal to the femoral thrombophlebitis. Only painkillers are necessary, as the condition usu-
condyles; ally settles with time.
• distal tibia proximal to the medial malleolus; Extravasation/skin necrosis
When a new catheter is inserted in a vein, sterile water or saline should
• anterior superior iliac spine;
be injected first and must be seen to flow freely before the injection of
• lateral malleolus; or drugs. If this is not done, drugs containing calcium, bicarbonate, or thio-
pentone, and drugs for chemotherapy can extravasate into subcutaneous
• proximal humerus distal to deltoid insertion.
tissues, causing necrosis. The dorsum of the hand and foot are common
sites. If a toxic drug is given accidentally, application of ice packs to
the area, subcutaneous irrigation with water or saline, and injection of
hyaluronidase or steroid may reduce the amount of tissue damage. If
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frank skin necrosis occurs, debridement, sometimes with delayed skin
grafting, may be necessary.
Cannula dislodgement/fracture/embolisation
Catheters need to be anchored properly with plaster, and cutdowns
should be secured with stitches. Brisk bleeding can occur when an arte-
rial catheter inadvertently dislodges. Pressure for a couple of minutes
will usually stop the bleeding. Appropriate splints are necessary in
restless children. If frequent intravenous injections are necessary in a
restless or shocked patient, or if a patient is receiving rapid intravenous
infusions, a second line should be considered. Fracture of a cannula with
embolism at distant sites has been reported.
Complications
Figure 9.3: Technique of intraosseous infusion. Complications of peripheral cannulation include:

• haemorrhage/failed cannulation;
The chosen site is cleaned and draped, and a little local anaesthetic
is given. A Jamshidi needle (which has a trochar), or bone marrow • air embolus during catheter insertion, tube change, or tube removal;
needle, or any size 13–18 butterfly needle can be used. The needle is • infection/cellulitis;
introduced perpendicular to the skin, then angled away from the growth • thrombosis/thrombophlebitis;
plate until a “give” is felt. The trochar is then removed. Blood should be
aspirated to confirm that the needle is in the marrow. The infusion fluid • extravasation/ skin necrosis;
can then be connected. Sterile gauze and plaster are used to secure the • cannula dislodgement/fracture/embolisation;
needle. The intraosseous route is for emergency only, and should not be
used for more than 2–3 hours. As soon as possible, it should be replaced • injury to surrounding structures (artery, nerve, solid organs);
by a suitable intravenous site. • compartment syndrome/osteomyelitis; and
Complications of Peripheral Vascular Access
• ugly scars from subcutaneous extravasation, when debridement and
Infection/cellulitis skin grafting have been done.
Although our bodies do not normally react to catheters, they are, never-