1. Vascular access

2. Typical scenarios (who needs a line?) Oncology patients Short bowel/TPN dependent patients Pulmonary hypertension patients Patients requiring extended antibiotic treatment (e.g. osteomyelitis) Patients requiring intermittent treatment (e.g. sickle cell, metabolic disorder, etc.)

3. Oncology patients Oncology patients are in general the only children who require multiple-lumen implanted vascular access devices These devices should only be ordered by NPs, pediatric oncology fellows, or attendings, as device selection is critically dependent on tumor type, disease stage, and treatment protocol

4. TPN-dependent patients Long-term requirement + high incidence of infections exposes these patients to the risks of multiple procedures (insertions and removals) Insertion requests require accurate, up-to-date knowledge of vascular anatomy Removal requests should prompt consideration of reinsertion timing Multiple-lumen implanted devices place these patients at higher risk of infection and thrombosis, and are therefore essentially never appropriate

5. TPN-dependent patient scenario 5 yo with short bowel syndrome after NEC as neonate; has had 6 prior Broviacs placed Patient presents with fever and (+) blood cultures for yeast What is the appropriate action?

6. TPN-dependent patient scenario 5 yo with short bowel syndrome after NEC as neonate; has had 6 prior Broviacs placed Patient presents with fever and (+) blood cultures for yeast What is the appropriate action? – The admitting pediatric attending calls the pediatric surgical attending of the week, and requests an urgent line removal – After this conversation, an Urgent Line Request form is submitted to provide information to the surgical and anesthesia care teams

7. TPN-dependent patient scenario What happens next? – The patient is made NPO, placed on the add-on schedule, and the line is removed ASAP The patient has very difficult peripheral access. – Best option: peripheral IV treatment for as long as possible, with bare minimum of 24 hours

8. TPN-dependent patient scenario In planning for the patient’s line replacement, the history is reviewed, and it is noted that on the last MRV 2 years ago both subclavians and the left internal jugular vein were occluded. Since that time, the patient has had 3 right IJ lines, and the last insertion was difficult. – A repeat MRV is the best option, as ultrasounds do not clearly visualize the SVC – This type of patient should not go to the OR without a map of the vasculature

9. Pulmonary hypertension patients Long-term requirement exposes these patients to the risks of multiple procedures (insertions and removals) Insertion requests require accurate, up-to-date knowledge of cardiac status and vascular anatomy Removal requests should prompt consideration of reinsertion timing Only pulmonary hypertension staff may request

10. Extended antibiotic therapy PICC line may be an alternative Insertion requests require clear knowledge of proposed length of treatment Pediatric R3s may request AFTER discussion with Pediatric attending

11. Intermittent access Portacath (implanted reservoir device) is appropriate for patients who don’t need frequent or daily infusions Insertion requests require clear knowledge of proposed type of treatment Some conditions place patients at excess risk for anesthesia and thrombosis (e.g. sickle cell disease, some metabolic disorders) Vascular access should be requested by heme- onc fellows or relevant attendings

12. Who receives the vascular access requests? The vascular access requests are received by pediatric surgical office staff, and scheduled as elective procedures Questions about scheduling should be directed to Maireni Franco in the office (2-8586)

13. Who reviews the vascular access requests? Accuracy of vascular access requests are the responsibility of the submitter Most requests are reviewed by pediatric surgery attendings For these reasons, it is critical that those submitting a request know the patient well and have reviewed all relevant studies/history If you submit a request, you are attesting to the accuracy of the data

14. When in doubt, ask Complex or unusual patients are best managed by attending-to-attending discussion—resist the temptation to “just submit a request” – Example: Patient with epidermolysis bullosa The pediatric surgical attending of the week can always be found by clicking the link at http://pedsurgery.columbia.edu