Neonatal and Pediatric Vessels Better Care, Better Outcomes

Cephalic vein

Cephalic vein

Basilic vein Median cubital basilic vein

Basilic vein Dorsal venous arch

Dorsal digital metacarpals

Cephalic vein

Cephalic vein

Neonatal and Pediatric Vessels AND PEDIATRIC VESSELS

NEONATAL

• The use of peripheral intravenous catheters should be considered for infants whouse require intravenous access for catheters no more than seven and in for whom access ♦ The of peripheral intravenous should be days considered infants who is attained within three attempts. require intravenous access for no more than 7 days and in whom access is attained three attempts. •within Utilize the smallest gauge and shortest length catheter that will accommodate ♦ Utilize the smallest gauge and shortest length catheter that will accommodate the the prescribed therapy. prescribed therapy.

Vessel Specifics

VESSEL SPECIFICS Forearm

• Basilic Vein FOREARM

• Cephalic Basilic Vein Vein

Hand

• Dorsal Digital Metacarpals HAND

Cephalic Vein Advantages

• DorsalDigital VenousMetacarpals Arch Dorsal Dorsal Venous Arch Disadvantages Advantages

Advantages - Readily visible ♦ Easily - Distalaccessible location ♦ Readily visiblefree - Keeps hands ♦ Distal location Disadvantages ♦ Keeps hands free

Advantages Disadvantages - Difficult to anchor on infant - Readily visible ♦- Distal ♦ Increased Easilylocation accessible nerveactivity endings - Interferes with child’s ♦- Bones ♦ Readily visible Difficult to anchor on infant act as natural splints ♦ Distal location ♦ Interferes with child's activity ♦ Bones act as natural splints

- Easily accessible

-D  ifficult to observe in chubby infants and toddlers

- Easily accessible

- Increased nerve endings

Disadvantages ♦ Difficult to observe in chubby infants and toddlers

Antecubital

• Basilic Vein • Cephalic Vein • Median Cubital Veins

ANTECUBITAL Advantages Basilic Vein - Large and readily visible Cephalic - EasilyVein palpable - Preferred sitesVeins in infants Median Cubital - P referred sites for PICC insertion Advantages

♦ ♦ ♦ ♦

Large and readily visible Disadvantages Easily palpable - Elbow joint must remain Preferred extendedsites in infants Preferred sites for - Limits activity PICC insertion - Limits phlebotomy

Disadvantages ♦ Elbow joint must remain extended ♦ Limits activity ♦ Limits phlebotomy

Cephalic v.

Cephalic v.

Basilic v. Median cubital basilic v.

Basilic v. Dorsal venous arch

Dorsal digital metacarpals

C ephalic v.

Cephalic v.

LEG LEG Leg

FemoralVein Vein Femoral • Femoral Vein Greater Saphenous Vein Greater Saphenous Vein • Greater Saphenous Vein PoplitealVein Vein Popliteal

Popliteal v. Popliteal v. Anterior tibial v. Anterior tibial v. Great saphenous v. Great saphenous v. Communicating v. Communicating v.

• Popliteal Vein

These veins should onlybebeused usedfor forcentral central These veins shouldonly only These veins should used line insertion central line insertion. linefor insertion Advantages Advantages APICC dvantages and CVCinsertion insertion ♦♦PICC - PICCand and CVC CVC insertion ♦ Keeps hands free ♦ Keeps - Keepshands handsfree free accommodatelarger larger catheter -Can Canaccommodate accommodate catheter ♦♦Can larger catheter

Dorsalis pedis v. Dorsalis pedis v. Lateral marginal v. Lateral marginal v. Femoral v. Femoral v.

Disadvantages Disadvantages Disadvantages -Possible Possible arterial puncture arterial puncture ♦♦Possible arterial puncture More difficult to access Moredifficult difficulttotoaccess access ♦♦More

FOOT ANKLE FOOT ANKLE Foot&& and Ankle

Popliteal v. Popliteal v.

Communicating v. Communicating v.

Lesser saphenous v. Lesser saphenous v.

Saphenous v. Saphenous v.

Posterior tibial v. Posterior tibial v.

Greater Saphenous Vein • Greater Saphenous Vein Greater Saphenous Vein Lesser Saphenous Vein • Lesser Saphenous Vein Lesser Saphenous Vein Dorsal Venous Arch • Dorsal Venous Arch Dorsal Venous Arch

Median marginal v. Median marginal v.

Commonly used in children Commonly usedininchildren childrengenerally generally Commonly used not yet walking. before walking. before walking. Disadvantages Advantages Advantages Disadvantages Advantages Disadvantages Decreases mobility Highly visible ♦Decreases Highlyvisible visible Decreases mobility ♦♦Highly ♦phlebitis mobility R  isk of in older patients Readily accessible ♦ ♦ Readily accessible Risk of phlebitis olderpatients patients ♦ Readily ♦ accessible Risk of phlebitis ininolder M  ore difficult to advance cannula - Keeps hands free Frees hands Moredifficult difficulttotoadvance advancecannula cannula ♦♦Frees ♦♦More - Easy hands to splint Easytotosplint splint ♦♦Easy

Superficial temporal v. Superficial temporal v.

Scalp

Supratrochlear v. Supratrochlear v.

SCALP • Superficial Temporal Vein SCALP

Superficial Temporal Vein • Posterior Temporal Auricular Vein Superficial Vein Posterior Auricular Vein • Supratrochlear VeinVein Posterior Auricular Supratrochlear Vein Supratrochlear Vein

Scalp veins can be used in children up to 18 months; after that, the in hairchildren follicles up to 18 Scalp veinscan canbebe used Scalp veins used intoughens children up to 18 mature and the epidermis months; after that, the hair follicles mature

months; after that, the hair follicles mature and theepidermis epidermistoughens. toughens. and the Advantages - Easily observed Advantages Advantages - Readily dilates Easilyobserved observed ♦♦Easily No valves present Readilydilates dilates ♦♦-Readily Allows use ofpresent extremities ♦ No valves ♦ No valves present Allowsuse useofofextremities extremities ♦♦Disadvantages Allows - Hair must be removed

Posterior auricular v. Posterior auricular v.

Disadvantages - Infiltrates easily Disadvantages ♦ Hairmust must removed Difficult to secure catheter ♦ -Hair beberemoved Greater family anxiety Infiltrateseasily easily ♦♦Infiltrates ♦ Difficult to securecatheter catheter ♦ Difficult to secure Greaterfamily familyanxiety anxiety ♦♦Greater

Key Points and Considerations • Neonates are at higher risk of infiltration injuries due to the use of infusion pumps, the need for resuscitation and their inability to communicate pain • Mean dwell times have been reported between 36 and 50 hours • IV site checks should be documented at a minimum of hourly

Vessel Location and Condition • Straight, soft, elastic veins are preferred • Prominent veins may not always be the best choice as they may be positioned in an unsuitable location • Accidental removal may be less likely if placed in the upper arm, however recognition of phlebitis may be difficult • The lower the gestational age, the less mature the skin will be; additionally, subcutaneous tissue around vessels is less obvious as gestational age decreases; therefore, vessels will be closer to the surface

Infusion Purpose and Characteristics • Medications and solutions with high osmolarities and high or low pH irritate the vein wall • Trauma to the vein is related to the composition of the infusate Solution Osmolality

Phlebitis Potential

600 mOsm/kg

High

• Commonly administered hyperosmolar solutions: - Parenteral dextrose concentrations > 10% - Parenteral nutrition - Ampicillin - Cefotaxime - Sodium bicarbonate - Phenobarbital • pH level 9 can lead to vein irritation • Increased irritation occurs with rapid administration and inadequate time for the blood to buffer the infusate

Therapy Duration • Preservation of the veins is essential if prolonged therapy is anticipated, therefore a PICC should be considered

Site Selection • Select the appropriate and most distal vein first. If the medication/solution has high potential for vein irritation, select the most appropriate and largest vessel to accommodate the infusion • Perform the venipuncture proximal to a previously cannulated site, injured vein, bruised area or site of a recent complication • Rotate access sites to the opposite extremity when possible

Catheter Material and Size • Softer materials are less irritating to the intimal lining of the vein • Select the smallest gauge appropriate to accommodate the prescribed therapy

Patient Activity • Arm boards/immobilization devices should be used to secure and protect vascular access sites in areas of flexion; regular site and circulatory checks should be performed, and removal of these devices may be indicated on occasion • Avoid the lower extremities in the walking pediatric patient if possible

Complications Catheter-Related Bloodstream Infection (CRBSI) • Inherent with the use of any vascular access device • Can be due to migration of skin flora from the insertion site along the catheter tract, with colonization of the catheter • Catheter colonization can also occur from contamination of the catheter hub, insertion site during placement, infusates or hematogenous seeding from a distant site • Premature infants are at higher risk due to deficiencies in their immune system and the number of invasive procedures they undergo

Phlebitis • Definition: inflammation of the vein. Causes can be mechanical, chemical or bacterial. • Signs and symptoms - Pain - Erythema or edema - Red streak over venous pathway - Palpable venous cord - Purulent drainage • INS Standards provide a phlebitis scale to quantify observations in documentation

Mechanical Phlebitis • Associated with movement of the catheter against the vein wall causing irritation to the intimal lining of the vein • Risk factors: - Rapid or traumatic insertion - Large catheter in relation to the size of the vein - Inadequately secured catheter - Extensive movement of the cannulated extremity - Inexperienced inserter

Chemical Phlebitis • Most commonly associated with peripheral devices • Erythema often within two (2) hours of infusing irritating medications or solutions

Catheter Occlusions • Can be partial, one-way or total • Caused by inadequate flushing, incompatible medications or lipid residue • Large catheters with insufficient venous flow increase the risk of thrombus formation

Indications for PICC Placement in Infants • Premature infants weighing 7 days • Require hyperosmolar or irritating solutions or medications • Infections requiring intravenous antimicrobial therapy • Gastrointestinal disorders

• Congenital cardiac disorders • Limb anomalies • Lack of adequate peripheral venous access • Require vasoactive medications • Medical provider’s or parent’s preference

References Alexander M, Corrigan A, Gorski L, et al. Infusion nursing: an evidence based approach. 3rd ed. St. Louis, MO: Saunders Elsevier; 2010:467-469. Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs. 2011;34(1S)S46. Pettit J, Wyckoff MM. Peripherally inserted central catheters: a guideline for practice. 2nd ed. Glenview, IL: National Association of Neonatal Nurses; 2007. Phillips LD. Manual of I.V. therapeutics: evidence-based infusion therapy. 5th ed. Philadelphia, PA: F.A. Davis Company; 2010:546-623. Weinstein SM. Plumer’s principles & practice of intravenous therapy. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

BD and BD Logo are trademarks of Becton, Dickinson and Company. © 2015 BD MSS0009-2 (06/15)

BD Medical 9450 South State Street Sandy, Utah 84070 1.888.237.2762 www.bd.com/infusion