VASCULAR ACCESS IN SICK CHILDREN
A reliable venous access is the crucial step in PALS and intensive care, though temporary intraosseous access (discussed later) may be used for emergency fluid and drug administration, if a reliable venous access cannot be achieved within three attempts or 90 seconds.
Two common approaches to venous access in sick children in PICU are—(a) peripheral venous cannulation, and(b) central venous cannulation, with procedural details provided in Ch 31.3. Intraosseous cannulation is another short-term option in emergency, while venesection is no longer used routinely.
Peripheral venous cannulation (PVC) is easier and preferred choice for venous access, though with higher risks of—(a) displacement, (b) local extravasation, thrombophlebitis, cellulitis or gangrene, (c) catheter- related infections, and rarely (d) air or catheter-fragment embolism. Potential risk of infections increases after 48-72 hours, requiring change of location even if no displacement.
Central venous cannulation (CVC) that reaches up to superior vena cava or right atrium is used in intensive care for—(a) hemodynamic (e.g. CVP) monitoring, (b) frequent blood collections, and (c) prolonged infusion
of irritating solutions, e.g. total parenteral nutrition. However, CVC carries higher risk of complications, e.g. infections, thromboembolism, traumatic bleeding and arrhythmia.
Intraosseous cannulation is a safe, simple and reliable method to administer drugs and fluids in emergency, when IV access is difficult and cannot be achieved within three attempts or 90 seconds. This access can be easily obtained in children lt; 6 years and any IV fluids or drugs may be infused via intraosseous route with comparable dose, onset of action and efficacy. However, rapid volume infusions or viscous drugs may need to be administered under pressure to overcome resistance of emissary veins (see Ch 32.3) Complications are rare (lt;1%) but tends to be more severe than PVC and hence, this procedure should be reserved only as a temporary measure till suitable venous access is obtained. Potential complications include—(a) tibial fracture, (b) local skin necrosis or compartment syndrome, (c) osteomyelitis and very rarely, (d) fat embolism.
27.4.4