1. Vascular Access

2. I.S. MD oA 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

3. I.S. MD oWhat is the optimal site for immediate vascular access for this infant? oIf resuscitative efforts are successful, what is the optimal site for vascular access during the post resuscitation period?

4. I.S. MD Objectives oPrioritize sites of vascular access for different clinical circumstances oDescribe the risks and benefits of peripheral venous, central venous, and intraosseous vascular access oDescribe the IO access technique

5. I.S. 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

6. I.S. MD Selection of site and priorities of vascular access 2 oCompensated shock… large bore peripheral IV catheter oPost resuscitation phase… central venous catheter oIntracardiac administration of drugs during closed chest compression oArterial cannulation

7. I.S. MD Priorities of Vascular Access oDuring pediatric CPR or treatment of decompensated shock.. IO access oOne practical approach: IO or peripheral or central access simultaneously oDuring attempted resuscitation.. Transtracheal …LEAN

8. I.S. MD Intraosseous Access oProvides access to a noncollapsible marrow venous plexus which serves as a rapid, safe and reliable route of administration oOften can be achieved in 30-60 seconds by using a rigid needle(specially designed or Jamshidi-type)

9. I.S. MD Intraosseous Access oA 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). oAcid-base analysis is inaccurate after sodium bicarbonate administration via the IO cannula.

10. I.S. MD Intraosseous Access oEpinephrine, adenosine, fluids, blood products, & catecholamines can safely be administered. oOnset of action & drug levels achieved are comparable to venous administration. oUse 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.

11. I.S. MD Intraosseous Access

12. I.S. MD Intraosseous Access

13. I.S. MD Intraosseous Access

14. I.S. MD Intraosseous Access

15. I.S. MD Complications oComplications reported in fewer than 1% oFracture of Tibia oLower extremity compartment syndrome oOsteomyelitis oExtravasation of Drugs

16. I.S. MD Central V/S Peripheral Venous Access oMore secure long-term access oNot higher drug levels or a substantially more rapid response oAdministration of drugs could injure tissues(vasopressors,calcium,sodium bicarbonate)

17. I.S. MD Complications of central venous cannulation oLocal 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

18. I.S. MD Peripheral Venous Access Devices oOver-the-needle catheters oCatheter-over-wire devices oCatheter-through-introducing sheath devices oButterfly needles

19. I.S. MD Peripheral Venous Access

20. I.S. MD 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.

21. I.S. MD Peripheral Venous Access

22. I.S. MD peripheral Venous Access

23. I.S. MD Peripheral Venous Access

24. I.S. MD Peripheral Venous Access

25. I.S. MD Central Venous Access

26. I.S. MD External Jugular cannulation

27. I.S. MD Subclavian approach to central vein

28. I.S. MD Central Venous Access Approach to Femoral Vein

29. I.S. MD Venous Cutdown

30. I.S. MD Venous Cutdown

31. I.S. MD Venous Cutdown

32. I.S. MD Venous Cutdown

33. I.S. MD 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.

34. I.S. MD Arterial Lines

35. I.S. MD Arterial Lines

36. I.S. MD Summary points oIntravascular or intraosseous access is the preferred route for medication and drug delivery in cardiopulmonary emergencies.

37. I.S. MD 2 oImmediate intraosseous access is recommended in cases of decompensated shock and cardiopulmonary arrest, particularly if the provider lacks experience in pediatric central venous access techniques

38. I.S. MD 3 oCentral venous catheterization can be used in children in emergencies. But it requires significant expertise. Many complications and delays may occur in expert hands

39. I.S. MD QUESTIONS???