Anesthetic Management in Pediatric General Surgery: Evolving and Current Concepts

This book highlights remarkable new endoscopic, laparoscopic, and thoracoscopic approaches to the removal of surgical lesions for different pathologic conditions under general endotracheal anesthesia in infants and children. It details how newer techniques in airway management, monitoring, regional nerve blocks for these innovative minimally invasive approaches have resulted in a decrease in intraoperative and postoperative morbidity and early recovery process after pediatric anesthesia.

This unique book contains features that provide the audience with several clinical scenarios where exceptional surgical outcomes are achieved with optimum pre-op preparation via collaborative team efforts. To date there is no other textbook emphasizing the anesthetic and surgical management during the most innovative advances in endoscopic surgery in children. Per oral endoscopic myotomy (POEM) for the definitive treatment of achalasia in children is probably the most advanced endoscopic surgery done successfully in children. POEM is the best example of endoscopic surgery performed via natural orifices known as the Natural orifice transluminal endoscopic surgery (NOTES). Another new laparoscopic surgical intervention -Median Arcuate Ligament surgical release for Median Arcuate Ligament Syndrome (MALS) for patients with Postural Orthostatic Tachycardia Syndrome (POTS) is described with established perioperative protocols emphasizing the need for early admission, intravenous hydration, and premedication.  Novel approaches in the anesthetic management in children with short bowel syndrome for bowel lengthening techniques like the serial transverse enteroplasty (STEP) and in teenagers for laparoscopic bariatric surgery with adjustable gastric banding (AGB) and vertical sleeve gastrectomy (VSG) for morbid obesity are new areas that would enlighten the readers. 

Anesthetic Management in Pediatric General Surgery is an invaluable resource for pediatric anesthesiologists, surgeons, and their trainees specializing in the care of pediatric patients.    

• Language: English
• Publisher: Springer
• Release date: Oct 5, 2021
• ISBN: 9783030725518

Book preview

© Springer Nature Switzerland AG 2021

S. T. Verghese, T. D. Kane (eds.)Anesthetic Management in Pediatric General Surgeryhttps://doi.org/10.1007/978-3-030-72551-8_1

1. Peripheral Vascular Access in Children – Current Concepts

Connie Lin¹ and Susan T. Verghese¹  

(1)

Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Health System, Washington, DC, USA

Susan T. Verghese

Email: [e-mail]

Introduction

Vascular access has been an important component of medical therapy for patients throughout the history of medicine. The first documented intravenous (IV) therapy attempt was in 1492 by a doctor caring for Pope Innocent VIII in Rome, followed by IV experiments with opium on dogs at Oxford University in the seventeenth century [1]. However, it wasn’t until the cholera outbreak that technology for IV therapy developed from the works of Dr. Thomas Latta, which was further developed in the 1930s by Hirschfeld, Hyman, and Wanger with the invention of the micro-dripper. The use of vascular access for IV therapy was further solidified and made available to the public in the 1950s with the invention of the plastic catheter we use daily by the Mayo Clinic [1].

With the introduction of IV therapy, vascular access in children has evolved in the last couple of decades from just peripheral access to central vascular access for hemodynamic monitoring and administration of medications and blood products in the perioperative period.

Interventional radiologists with the help of ultrasound and fluoroscopy can easily obtain access into major venous vessels for total parenteral nutrition and for prolonged course of antibiotics and chemotherapy, in chronically ill patients under general anesthesia.

Peripheral Vascular Access

Indications

Peripheral intravenous catheter placement is one of the most common methods of establishing vascular access in neonates, infants, and children. It is safe, easy to place, and routinely used in multiple hospital settings such as the emergency department, inpatient wards, and most importantly the operating room, to administer fluids, medications, electrolytes, blood products, and resuscitation.

Equipment

The most common type of venous catheterization for peripheral venous access is over-the-needle catheters. These catheters are commonly made of Teflon, Silastic, polyurethane, and other flexible materials, with sizes ranging from 10 to 24 gauge with a length of ¾ to 3 inches. It is now federally mandated to have a safety feature to prevent needlestick injuries to the operator. Most hospitals carry IV catheters with self-retracting needles although non-safety catheters are also available (Fig. 1.1).

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Fig. 1.1

(a) 24-, 22-, 20-, and 18-gauge catheters with self-retracting needle safety features (BD Insyte™). (b) Pediatric IV kit

The typical catheter sizes for newborns and infants are 22–24 gauge and 18–20 gauge for older pediatric patients.

Techniques

During the perioperative period , peripheral vascular access is frequently obtained in children after the induction of inhalation anesthesia with sevoflurane for an elective surgical procedure. This helps eliminate the child’s phobia of needles, decrease undesirable patient movement, and dilate the veins for improved visualization and ease of access.

Peripheral veins can be identified visually or palpated in both the upper and lower extremities. Once a site is identified, a tourniquet is applied proximal to the vein to distend it for ease of entry. The area is then cleansed with an antiseptic solution, commonly alcohol or ChloraPrep wipe. The needle and catheter apparatus is introduced with the bevel facing up, usually at an angle, until the needle enters the vein lumen and a flash of blood is visible.

After the flash of blood appears, the angle of the needle and catheter is decreased and the whole unit is advanced into the vascular lumen to ensure that the needle and the outer catheter are both within the vein before threading the catheter further up into the lumen over the needle. A common error that occurs is when only the needle tip is in the lumen, but the outer catheter is not. As a result, the outer catheter which is not in an intraluminal position can cause venous injury when advanced causing extravasation of blood into the surrounding tissues, commonly known as a blown vein. Occasionally, the needle and the catheter could exit the lumen and make further advancement of the catheter impossible. One technique commonly used to save the vein from being blown is to remove the metal needle and then slowly pull back the catheter until there is free flow of blood, confirming its intraluminal position, followed by an upward twirling motion to advance it to the desired position. Many a punctured vein with an extraluminal position of the needle and catheter can be saved if this pull back and twirl technique is used (personal experience of author).

Once the catheter is threaded into the vein, the tourniquet is removed and saline is flushed via a tubing attached to the catheter. The free flow of blood through the catheter and the ability to easily flush saline through the catheter without any swelling in the adjacent tissue confirm successful placement of the venous catheter.

Insertion Sites

When selecting a site for venous access, one must take into consideration the type of surgery that the patient is undergoing, the location of the surgical site, a child’s preference and hand dominance, and the ease of access. Young children may sometimes have a favored hand for holding a security blanket or thumb sucking. This information can be elicited from parents to help decrease the child’s unnecessary stress and discomfort in the postoperative period [2].

Upper Extremities

The upper extremities are a common site for placement of peripheral IV catheters. Most veins can be identified by visualization or palpation. Common sites include the superficial veins in the dorsum of the hands, the wrists, and forearms (Fig. 1.2).

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Fig. 1.2

Dorsum of hand vein IV cannulation (notice skin tautness)

In children, whose veins are not easily visualized or palpable, the wrist vein is a common site used for access through a blind technique, located on the radial bone proximal to the anatomic snuffbox. Another common site is the vein on the dorsum of the hand between the fourth finger and the little finger. Veins on the ventral aspect of the wrist in children can be accessed also, but they tend to kink with wrist movement and may need to be replaced.

Other vascular structures in the upper extremities include the median, antecubital, basilic, and median cephalic veins. Although these structures are superficial and larger in size, they are usually reserved for peripheral central access and venipunctures, but can serve as peripheral access venous sites if all other sites are unavailable or inaccessible. It is important to avoid inadvertent arterial cannulation while accessing veins in the antecubital fossa by palpation technique.

Lower Extremities

The lower extremity is also a common peripheral vascular access site in children when the upper extremities are not available or if there is a need for a larger IV. It is also a popular choice for pediatric anesthesiologists for patients who will receive a neuraxial block (e.g., caudal block) as there will be less discomfort for the patients when they emerge from anesthesia.

Superficial veins can be found on the dorsum of the foot, on both the medial and lateral aspects. Another popular site in the lower extremity is the saphenous vein that is located on the medial side of the ankle, anterior to the medial malleolus (Fig. 1.3). It has a consistent anatomic location, and in children with difficult venous access, blind or by palpation technique of accessing the saphenous vein is a highly popular technique .

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Fig. 1.3

Saphenous vein catheterization

Although a common and popular site, it is important to avoid lower extremity access in situations where the inferior vena cava (IVC) may be occluded. These included cases of extensive IVC thrombosis and patients with intra-abdominal masses for open surgeries. Medications and fluids administered through lower extremity access will not fully circulate systemically if IVC flow is compromised .

Scalp

In neonates and infants, superficial scalp veins can be another alternative site of peripheral access if no other veins are available. There is less subcutaneous fat compared to other peripheral sites allowing easier visualization of veins and they are easily distended when infants cry or with digital pressure. The most common scalp veins used for cannulation and venipuncture include the superficial temporal, occipital, and pre- and post-auricular veins (Fig. 1.4) [3, 4].

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Fig. 1.4

Scalp veins

A rubber or elastic band, acting in a similar fashion as a tourniquet, is usually placed above the ears and eyes around the scalp to distend the veins. Shaving the hair around the skin above the vein is often necessary to facilitate the venous access, decrease risk of infection, and stabilize the catheter. However, even after all that planning, stabilizing the venous cannula on the scalp surface for a longer period is often difficult. It is important to inform the parents of the need to shave the scalp if plans are made for scalp vein catheterization [4].

Despite the ease of access, complications such as venous dural sinus air embolism are a risk due to the lack of valves in the scalp veins, and the provider should take preventative measures to avoid introducing air into the circulation. It is imperative to avoid injecting air into the scalp vein catheter or leaving the catheter open to air if the infant is in a head up position. Keeping the child in a supine or Trendelenburg position during cannulation and management of the catheter can help decrease the risk, as well as using an air occlusive dressing after catheter removal [4, 5].

Umbilical Vein

The umbilical vein (UV) is another modality to provide access to a newborn infant’s circulation and is used commonly in newborns younger than 10 days of age. The UV can remain patent up to 10–14 days after birth and provides access to the infant’s central circulation. It is commonly used in emergency situations such as resuscitation when peripheral access is unavailable. Accessing the UV allows infusion of vasoactive drugs, a route for exchange transfusion, volume restoration, and blood sampling [2, 6].

UV cannulation is carried out by distinguishing the vein from the two arteries in the umbilical cord. The neonate is restrained in a warm and comfortable position. After sterile preparation and draping of the field, a silk suture is looped around the base of the umbilical stump (Fig. 1.5a). Once the UV lumen is identified and held open with smooth forceps, it is cannulated with a round-tipped transparent non-thrombogenic catheter filled with heparinized saline. The catheter is then sutured in place, covered with antibiotic ointment, and taped to the abdominal wall (Fig. 1.5b). The ideal position of the UV catheter is at the junction of the IVC and the right atrium and should be confirmed by radiograph (Fig. 1.5c) [2, 6, 7].

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Fig. 1.5

(a) Umbilical vein catheterization. UV umbilical vein, UAs umbilical arteries. (b) UVC in a neonate taped to abdominal wall. (c) X-ray showing the tip of umbilical catheter above the diaphragm

Confirmation of correct placement of the catheter is imperative as displacement can cause an array of rare but adverse complications. These include thrombosis of the portal or mesenteric veins, portal cirrhosis and/or necrosis, endocarditis, cardiac tamponade, and, in rare cases, pulmonary infarction [6, 7].

Although UV catheters are a relatively safe, fast, and cost-effective means of establishing vascular access in neonates and providing IV therapy, it is imperative for providers to recognize any clinical changes or deterioration in an infant after UV cannulations as rapid diagnosis and treatment of complications can be life-saving [2, 6, 7].

External Jugular Vein (EJV)

The external jugular vein is another alternative location for peripheral vascular cannulation in children with difficult peripheral venous access. To access the vein, the child is placed in a 30° Trendelenburg (head down) position (Fig. 1.6) to facilitate venous pooling and dilatation of the vein. The head is extended with towels under the shoulder. The IV catheter is introduced in a similar fashion as a peripheral IV. A popular technique includes using a catheter over a needle with a syringe attached to the end of it. The operator aspirates the syringe that is attached to the needle frequently as he introduces the catheter-needle unit into the vein lumen. Once a flash of blood is obtained, the whole unit is advanced another millimeter with constant aspiration to ensure that it is still intraluminal. The catheter is advanced over the needle and attached to a saline flush tubing.

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Fig. 1.6

Left EJV for cannulation – note the head down position

Issues associated with EJV catheter include dislodgement and cessation of IV flow from changes in neck position. Other complications, although very rare, include air embolism, which has been reported in adult patients with EJV catheter, and thus care must be taken to prevent the complication [2, 6, 8].

Adjuncts to Help to SEE the Veins

Although safe and easy to place, establishment of vascular access can provide a major challenge in the perioperative period in patients with excess subcutaneous tissues, history of multiple venipunctures for repeated access, and other comorbidities which can make venous cannulation in a child difficult. In patients with difficult venous access, multiple techniques and technology may be employed to identify the peripheral veins for successful cannulation.

Transillumination

The method of transillumination utilizes a high-powered, cold source of light to illuminate deep tissues to help visualize veins for cannulation. It was first described in 1970 to help identify veins for cannulation, and currently multiple devices are available to facilitate the visualization of veins for cannulation [2].

Veinlite and Veinlite PEDI

The Veinlite , Veinlite LED, and Veinlite PEDI are devices produced by Translite (Sugarland, Texas) which utilizes transillumination to visualize veins. The Veinlite uses white light for transillumination, while the VeinliteLED and Veinlite PEDI (Fig. 1.7) utilize a light-emitting diode color lighting for transillumination. A previous study on the Veinlite showed that it facilitated successful IV placement within the first two attempts compared to the standard practice. A newer, more recent study showed that Veinlite PEDI had a higher success rate on first attempt and decreased time required for peripheral intravenous catheter placement compared to the standard of care [9, 10].

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Fig. 1.7

Veinlite PEDI

Vein Locator-Universal and Illumivein

The Vein Locator-Universal (VL-U Sharn Anesthesia, Inc., Tampa, FL) and the Illumivein (Illumivein, Long Branch, New Jersey) (Fig. 1.8a, b) are inexpensive, small portable, battery-operated illuminators that are used to transilluminate tissues for visualizing veins. Both of these devices utilize red LED light to transilluminate the tissues which provides better transillumination and produces less heat when compared to white light. Both of these gadgets are conveniently portable with belt attachments and relatively inexpensive (US $40 and US $29.95, respectively). Another transilluminator is the Wee Sight Transilluminator (Respironics, Inc., Murrysville, PA) which utilizes similar technology, but is less portable secondary to lack of a belt clip and more expensive (US $85) [2].

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Fig. 1.8

(a) Illumivein. (b) Wee Sight

Devices Utilizing Infrared and Laser Technology

AV300 (AccuVein, Cold Spring Harbor, NY)

The AV300 , by AccuVein , employs infrared light and laser technology, and the physical property of hemoglobin, to enable an accurate visualization of the veins under the skin. The device is handheld and approximately the sizes of a cordless phone (Fig. 1.9a). When activated and held approximately 7 inches above the skin, the AV300 detects a difference in hemoglobin concentration between the veins and tissues to provide an image of the vascular structures (Fig. 1.9b). Although this device improves visualization of veins, studies showed that it did not improve the success of peripheral vascular cannulation [11–13, 15].

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Fig. 1.9

(a) AV300 . (b) Veins visualized

Vein Viewer Flex and Vein Viewer Vision (Carestream Medical, Altamonte Springs, FL)

The Vein viewers (Carestream Medical) are devices that utilize near-infrared light to illuminate the subcutaneous veins and project a digital image of the vasculature on the surface of the skin in real time. Projection of the veins in real time allows operators to visualize the veins and their surroundings and allows clinicians to follow the course of the veins, find feeders and branches, and identify valves. The Vein view flex (Fig. 1.10a) is a more compacted and portable handheld device, whereas the Vein viewer vision (Fig. 1.10b) is a larger mobile device with a flexible head unit to position the infrared light source making it an easy and hands-free setup. Similar to the AccuVein , this device improves visualization of veins [14], but studies also showed that there was no difference in reduction in access time between utilization of the vein view and standard IV catheter placement [12]. In one study, the use of vein view actually worsened first-time attempt success rate in cannulation in infants and children with anticipated difficult IV access [16–22].

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Fig. 1.10

(a) Vein viewer flex. (b) Vein viewer vision

Ultrasound-Assisted Venous Cannulation

Point-of-care ultrasound is widely used across multiple settings of pediatric care. Ultrasound machines create images by directing high-frequency sound waves towards body tissues and then measuring the sound waves reflected back from the tissues.

Currently, smaller ultrasound machines with excellent image quality are available to enable the care team to access the vessels quicker in pediatric patients. Point-of-care ultrasound (POCUS) has become a standard of care in emergency rooms, intensive care units, inpatient and outpatient, as well as perioperative areas [23].

A recent review of overall evidence of ultrasound use in obtaining peripheral venous access concluded that use of ultrasound improves both safety and cannulation success in pediatric patients.

One interesting take-home point in this review the authors emphasized was the use of dynamic needle tip positioning (DNTP) during a short-axis out-of-plane ultrasound view of the vessel which enables precise needle placement prior to successful entry and advancement of the needle tip accurately even in small children. In this real-time ultrasound technique, the aim after identifying the needle tip in the vessel lumen is to move the ultrasound probe slowly to a proximal location until the needle tip disappears and then to advance the needle steadily until it reappears in the ultrasound probe held immobile in the proximal position [24].

Currently ultrasound guidance is regarded as a clinically helpful tool in identifying vasculatures for cannulation in patients with difficult access. Studies in both adult and pediatric patients have shown increases in overall success rate and decreases in number of attempts and time to success in vascular cannulations [25, 26].

It is not uncommon that despite all attempts peripheral venous access may be impossible in small children and infants. In these cases, internal jugular vein cannulation can be undertaken to provide venous access for surgery as long as it is undertaken with the help of an ultrasound device (Fig. 1.11).

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Fig. 1.11

Ultrasound image of internal jugular vein and carotid artery

The landmarks and palpation of carotid artery technique to access internal jugular vein in small children should not be considered now when ultrasound is easily available to visualize the vessels because of the high incidence of carotid puncture in this age group.

In 1999, in an original study in the author’s institution, the existing traditional method of accessing internal jugular vein (IJV) by palpation of carotid artery and other landmarks was compared to a newer method based on visual identification of the IJV by ultrasound imaging in 95 infants. In this study the authors found a 100% cannulation success rate in the ultrasound group, with no carotid artery punctures, and 77% success in the landmarks group, with a 25% incidence of carotid artery punctures. The cannulation time was less, the number of attempts was fewer, and the failure rate was significantly lower in the ultrasound group than in the landmark group. The authors concluded that the ultrasonographic localization of the internal jugular vein was superior to the landmark technique in terms of overall success, speed, and decreased incidence of carotid artery puncture. This ushered the era of using ultrasound for cannulation of the internal jugular vein in neonates and infants in our institution [27].

Methods to Minimize Pain of Venipuncture

The fear of being stuck by a needle is a common phobia that many children, and even some adults, have when presenting to a hospital or doctor’s office. Minimizing the pain associated with venipuncture is a good way to create a rapport with a child, ensure cooperation, decrease and prevent movement, and increase the chances of a successful IV placement. Preventing pain and effectively treating it rapidly when it occurs are important measures for their psychological health. Although anesthesiologists often tend to anesthetize children before placing intravenous lines, there are occasions when a line needs to be placed prior to anesthesia.

Non-medication Analgesia

Shot Blockers

Noninvasive , medication-free techniques have been developed to decrease pain and discomfort associated with injections. The most common ones (Fig. 1.12) are known as shot blockers (Bionix® and Buzzy®). These devices employ vibration and cold sensations to block painful sensation based on the gate control theory to decrease pain associated with injections and venous cannulation. Studies have shown that a combination of vibratory and cold sensation reduces pain associated with venous cannulations in adults compared to vibratory senses and cold sensation alone [28–31].

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Fig. 1.12

(Buzzy toy)

Numbing Medications for Dermal Analgesia

EMLA

EMLA (eutectic mixture of local anesthetics) is a topical cream composed of lidocaine 2.5% and prilocaine 2.5% in a 1:1 ratio. It produces anesthesia of the skin with application. The EMLA cream should be applied and covered with a transparent dressing 60 minutes prior to venipuncture for optimal effect (Fig. 1.13). A thick deposit rather than a thin layer is also more efficacious.

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Fig. 1.13

EMLA cream on the hand with occlusive dressing

Studies have shown that EMLA cream decreases venipuncture and IV insertion pain in pediatric patients compared to placebo. Of note, EMLA cream can produce skin blanching and vasoconstriction at the application site and can make IV cannulation difficult [2].

Synera™ Patch

The Synera™ patch is a single-use local anesthetic delivery system composed of a mixture of lidocaine 70 mg and tetracaine 70 mg for dermal anesthesia (Fig. 1.14a). It has a novel controlled heat-assisted drug delivery (CHADD) technology built inside it for skin vasodilation to facilitate drug delivery.

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Fig. 1.14

(a) Synera patch components. (b) Synera™ patch

It is self-contained and easy to use because of its peel and stick like a bandage appearance (Fig. 1.14b). It is important to warn the patient and the parent about the feeling of warmth on the skin after patch application because of the heat generated inside the patch on exposure to oxygen. For optimal effect, the skin surface should be cleaned prior to placement of the patch, and the patch should be placed for 20–25 minutes prior to venipuncture [2].

Its safety and efficacy have been studied and established in children 3 years and older. A study of its use in children aged 3–6 years showed its effectiveness in preventing venous access pain significantly more than placebo [32]. It is contraindicated in children with a sensitivity to para-aminobenzoic acid (PABA) and to local anesthetics of the amide or ester type (lidocaine, tetracaine).

Synera™ patch should not be cut or the holes on the top covered. It is not recommended to be used in MRI areas because the heating component contains iron powder.

ELA-Max

ELA-Max is another topical anesthetic composed of 4% lidocaine in a liposomal vehicle. There is a shorter time for analgesic effect, and the lipid carrier prolongs the localization of the lidocaine, thus providing a longer duration of analgesia.

Nitrous Oxide

Nitrous oxide has also been used and studied as an analgesic modality during IV cannulation. Studies showed that NO was just as effective as EMLA cream in dermal analgesia with an added effect of anxiolysis [33].

Iontophoresis

Iontophoresis is a non-invasive method which employs electric currents to facilitate the passage of lidocaine ions across the stratum corneum to provide dermal analgesia. Lidocaine iontophoresis (Numby Stuff, LidoSite, NeedleBuster) delivers ionized forms of 2% lidocaine with epinephrine through low-level electric currents. Studies showed that it provides a similar pain relief to EMLA for IV catheter cannulation. However, it has recently been utilized as a pain management modality for postoperative pain and in dental procedures [34, 35].

Needle-Free Lidocaine Delivery System

The needle-free lidocaine delivery system (J-Tip) is a FDA-cleared needleless system which utilizes carbon dioxide gas to deliver the liquid lidocaine through the skin and into the subcutaneous tissue. It is a quick, noninvasive method to provide dermal analgesia similar to that of EMLA for IV catheter placement (Fig. 1.15). It has an onset time of 1–2 minutes and lasts for 20–25 minutes. Two randomized control studies comparing the J-tip with ELA-Max and a vapocoolant spray showed that the J-tip provided quicker and more pain relief compared to the two other methods [36, 37].

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Fig. 1.15

Needle-free lidocaine delivery system

Complications with Peripheral Venous Access

Complications associated with peripheral IV catheters are relatively rare and infrequent, but may occur. Hematomas may occur if a vein was damaged during placement or threading of the catheter leading to extravasation of blood in the surrounding tissue. Infections such as cellulitis and osteomyelitis may also occur. Medications that are irritating to veins such as calcium, potassium, dopamine, and epinephrine may cause phlebitis [2, 37].

Other complications include loss of patency of the catheter secondary to development of thrombosis in the catheter or vessel. Heparin has been used to irrigate the IV catheters to maintain patency although there is an increased risk of developing phlebitis with heparin use. Catheters may also kink especially with the smaller sizes or placed in a location with an easy bend such as on the wrist or antecubital fossa. Infiltration and occlusion from peripheral venous cannulation were more common in children who were hospitalized with infiltration was more frequent in neonatal patients and younger children. Accidental dislodgement of an IV catheter is also a concern in awake children. It is important to carefully fix and secure the catheter as well as utilize an arm board to minimize dislodgement. Careful restraints with arm boards, covering the IV site securely with gauze, and use of mittens on the free limbs may help minimize and prevent accidental dislodgement in awake children [2, 38].

Intraosseous Access

Intraosseous (IO) access is another rapid way of establishing access to the circulation when there is difficulty with peripheral or central access. This is especially critical and useful in the event of an emergency when all options are exhausted. IO infusions rely on the anatomy and presence of veins that drain the medullary sinuses in the marrow of the long bones. Fluids and medications enter the systemic circulation from venous sinusoids in the medullary cavity via the emissary veins. The common sites include the proximal tibia (popliteal vein), femur (femoral vein), proximal humerus (axillary vein), and the manubrium of the sternum (internal mammary and azygos vein).

The broad flat anteromedial part of proximal tibia is the most commonly accessed site in infants and children under the age of 6 because of the absence of critical structures in this area. To access the tibial IO site, palpate the tibial tuberosity and identify the medial surface of the tibia. In infants and children, the proximal tibial site is approximately 2 cm below the tuberosity and 1 cm medial to the tibial plateau (Fig. 1.16a). In older children and adults, the site is approximately 1 cm above and 2 cm medial to the tuberosity.

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Fig. 1.16

(a) IO needle position for vascular access. (b) Intraosseous kit

The area is prepped with antiseptic solution and numbed with local anesthetic injection. Both manual IO needles and battery-powered devices are available for IO access (Fig. 1.16b). The IO needle is screwed and advanced into the bone at a 10–15° angle away from the growth plate . When a give or a pop is sensed which indicates the entry of the needle into the marrow, stop advancement of the needle and remove the stylet. Bone marrow should be aspirated upon removal of the stylet and flushed. Easily flushed and free flow of fluid and needle firmly seated without wobbling and without extravasation indicates successful access.

Complications of IO access occurrence are rare (<1%) and include skin necrosis, extravasation, compartment syndrome, bone fracture, and infection around the insertion site.

Contraindications include fracture bone at the site of insertion, extremity with vascular interruption from trauma or cutdown attempt, and infection such as cellulitis or osteomyelitis involving the access site.

Multiple studies show high success rates and time to insertion between IO and PIV access in both pediatric and adult patients. The IO technique is established in multiple resuscitation protocols including the Advanced Pediatric Life Support guideline and also recommended by the American Heart Association, American Academy of Pediatrics, American College of Surgeons, and International Committee on Resuscitation as a safe and effective means of vascular access [39–42].

Arterial Cannulation

Arterial cannulation is often used for monitoring of arterial blood pressure, blood gases, labs, hemoglobin, and other electrolytes in the body. It is utilized in multiple settings including but not limited to the ICU, operating room, and emergency department. Common sites include the radial, femoral, axillary, temporal, and umbilical arteries.

Radial

The radial artery which is preductal is cannulated in newborns for preductal measurements of blood pressure and saturation. It is more routinely used in older children for arterial blood pressure, gases, and electrolytes than in newborns. Radial artery cannulation is also a site of choice in children with coarctation of the aorta repair due to clamping of the left subclavian during the repair procedure. It is important to perform the modified Allen’s test to ensure collateral flow to the ulnar artery prior to cannulation of the radial artery [2].

In order to cannulate the artery, proper positioning is utmost important to increase chances of success. The hand is slightly extended on a hand board or roll of gauze and securely taped to remain in position. Care should be taken not to excessively extend or dorsiflex to avoid stretching and compressing the vessel (Fig. 1.17).

After draping and sterile preparation, the radial artery is palpated and a 22–24-gauge needle is positioned at a 20–30° angle over the maximal pulsation of the artery.

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Fig. 1.17

Palpation method of arterial cannulation

The artery can be cannulated by direct entry into the lumen or by transfixing the artery. Direct entry employs a similar technique as venous cannulation where the catheter is advanced into the lumen after a flash of blood is obtained. Transfixation of the artery employs a through and through method to gain entry during withdrawal of the catheter with the assistance of a guidewire. Both methods are commonly employed for cannulation, and choice of technique depends on the comfort, previous training, and ease of the clinician .

Another method in infants is to use a small 24-gauge catheter to enter the arterial lumen and then thread a guidewire into the artery and remove smaller catheter and thread the desirable-sized catheter in to be secured in position (Fig. 1.18a–d) .

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Fig. 1.18

(a–d) Percutaneous radial artery cannulation using a guidewire

Percutaneous arterial cannulation in neonates and infants is often difficult because of the arterial size and the depth from the skin. Usually a radial artery on either limb is chosen as the initial site to place arterial lines. Both dorsalis pedis and posterior tibial artery are attempted if radial artery cannulation is unsuccessful.

Ultrasound assistance (Fig. 1.19a–c) is useful in children in improving success in cannulation if percutaneous attempts fail.

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Fig. 1.19

(a–c) Radial artery cannulation with ultrasound image

Both audio Doppler assistance and visualizing ultrasound images of the vessels have been studied in children with the latter showing definite improvement in success. A Cochrane review evaluating ultrasound-guided arterial cannulation in pediatric patients reported that first and second attempt success rates improved with visual ultrasound guidance for radial artery cannulation compared to palpation or Doppler auditory assistance especially in infants and small children [43].

In our own institution, arterial line cannulation in pediatric patients was traditionally performed by palpation when arterial pulsations are present and by cutdown technique by the surgeon if they are not palpable. We observed decreased success in percutaneous arterial cannulation in infants and children with polycythemia [2]. A larger study evaluating factors affecting successful cannulation in infants and children undergoing cardiopulmonary bypass showed that despite the technical difficulty in cannulating the artery in infants, percutaneous method was still more efficient than a surgical cutdown [2]. Before subjecting the infants to a cutdown, we attempted to locate the vessel by an auditory technique using a Doppler device called the PD Access percutaneous Doppler Needle (Escalon Vascular Access, New Berlin, WI) system with a needle guide. It is now renamed as the Smart Needle vascular access system and currently owned by Vascular Solutions, Inc. (Minneapolis, MN) (Fig. 1.20).

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Fig. 1.20

Smart Needle vascular access system

It is a Doppler ultrasound system that uses audible blood flow signals for easy detection and differentiation of arteries and veins. This continuous auditory feedback allows the operator to locate the vessel and enter it. It consists of a small, portable, lightweight battery-operated handheld monitor and sheathed needles with a Doppler transducer located at its tip. The needle ranges in size from 18 G to 24 G.

Our pilot study evaluated the effectiveness of an audio Doppler device PD Access in 18 infants who had no palpable pulses in either of their radial arteries because of previous attempts. Twelve out of the 18 infants had successful cannulation with this Doppler device, and the time taken for cannulation with the audio device was still significantly less than in the 6 infants who required a cutdown technique to achieve arterial cannulation [2].

After prepping and draping the wrist for a line placement, the appropriate-sized sterile needle is positioned over the radial artery location. When the Doppler unit is turned, a continuous auditory feedback of sounds will be heard from the blood flow from the vessel which can help the operator to locate the arterial vessel. Once you become familiar with the distinct sounds from the artery, you can follow the sounds slowly keeping in mind that as soon as you enter the vessel the sounds may disappear momentarily. The auditory feedback is able to guide the operator to angle the needle and enter the desired vessel accurately. This hearing and directing the needle into the target is not a popular technique with those who have difficulty identifying variations in the degrees of tone change emanating from the needle as it nears vascular structures. The ease with which one can see a target vessel on ultrasound and move the needle to enter it under direct vision seems intuitively easier than the auditory method of relying on Doppler tone feedback.

A prospective randomized comparative study of children in critical care unit undergoing radial artery cannulation by palpation or by ultrasound guidance showed faster cannulation and improved success rate with lower complications [44]. A prospective observational study suggested a novel modification of the ultrasound technique to increase the success of arterial cannulation in children. The authors concluded that radial artery catheterization in pediatric patients was fastest and most reliable when the artery was 2–4 mm below the skin surface when visualized by ultrasound. For superficial arteries located <2 mm below the skin surface, their technique of increasing the depth to 2–4 mm by subcutaneous saline injection reduced catheterization time and improved the success rate [45]. A prospective randomized study looking at ultrasound-assisted cannulation in children where radial, dorsalis pedis, and posterior tibial artery were evaluated for cannulation showed that posterior tibial artery was comparable to radial artery and even better than dorsalis pedis on the basis of their average diameters on ultrasound images. The authors concluded that posterior tibial artery is a reasonable alternative to the radial artery for ultrasound-guided arterial cannulation in small children [46].

Femoral Artery Cannulation

The femoral arterial site is used if other arterial sites are unavailable. The location of this artery can be identified by anatomical sites. It is usually found by palpating the femoral pulse below the inguinal ligament. The femoral artery can be cannulated blindly by anatomic sites, or with an ultrasound (Fig. 1.21a, b Doppler flow image). Ultrasound guidance is recommended as it is more precise and can decrease the risk of vascular injury [5, 6].

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Fig. 1.21

(a, b) Femoral artery ultrasound images

Axillary

The axillary artery is another alternative cannulation site but less popular in older children. A study in the 1990s reported successful cannulation of 62 mechanically ventilated neonates with 22–24-gauge Teflon catheters for blood pressure monitoring and blood sampling with no reported complications related to the vessel during placement and after removal of the catheter [47].

Umbilical

The umbilical artery (UA) provides another site of arterial cannulation in the newborn period for the continued monitoring of arterial pressure, blood gases, and labs. Furthermore, infusions of fluids, glucose, and medication can also be administered through the catheter. Cannulation of the UA is similar to that of the UV, with extreme care taken to occlude the vessels and prevent blood loss. A cephalad traction is placed during the cannulation of the catheter. The optimal position of the catheter tip is approximately L3–L4 which corresponds to the location above the aortic bifurcation and below the renal arteries [2, 6].

Rare Sites for Arterial Cannulation

Occasionally cannulation of internal mammary artery (IMA) can be achieved if all other arterial cannulation sites are unavailable in infants especially during open cardiac surgery by the surgeon and can be of use in the postoperative period for monitoring in the CICU [48].

Complications of Arterial Cannulation

Complications associated with arterial cannulation in pediatric patients have been studied extensively. In a retrospective study of more than 10,000 patients by King et al., there was a 10.3% incidence of associated complications. The most frequent complications were catheter-related infection and inflammation, followed by mechanical and then embolic or thrombotic complications. A more recent retrospective study of 228 patients with associated arterial catheter complications identified risk factors which include insertion attempts at multiple sites and presence of more than one provider participating in line placement [49, 50].

An easy-to-apply clinical prediction rule that is useful for predicting difficult IV access has been created by a group of clinicians working in the pediatric emergency department. They called it the DIVA scale for difficult intravenous access – clinical prediction scale. It has a four-variable (vein palpability, vein visibility, patient age, and history of prematurity) proportionally weighted rule assigning 3 points for prematurity, 3 points for age younger than 1 year, 1 point for 1–2 years of age, 2 points for nonpalpable veins, and 2 points for vein not visible. They looked at 615 children aged 0–21 who underwent intravenous line placement and found the success rate for intravenous insertion to be 75% and that patients with a DIVA score of 4 or more were more than 50% likely to have failed intravenous placement on first attempt [51]. This DIVA clinical score has been further validated and refined by another prospective study in pediatric patients where they evaluated a three-variable rule (vein palpability, vein visibility, and patient age) and found that it too possessed similar predictive ability [52].

In summary, vascular access can be quite challenging to the inexperienced anesthesiologist. Many techniques to improve speed and success at first pass continue to evolve. Local warming, application of skin analgesics, and distraction techniques are helpful. Virtual reality (VR) engagements have been used successfully for intravenous line placements in children. VR distraction using Street Luge (5DT) presented via a head-mounted display has been studied in children and was found to be efficient as a distraction tool during IV placement [53].

VR technology is currently an underutilized technique which may become a resourceful tool in the future to engage children preoperatively to distract them and thus diminish their pain and anxiety regarding an IV placement.

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© Springer Nature Switzerland AG 2021

S. T. Verghese, T. D. Kane (eds.)Anesthetic Management in Pediatric General Surgeryhttps://doi.org/10.1007/978-3-030-72551-8_2

2. Central Venous Access in Children – Recent Trends

Bhupender Yadav¹   and Ranjith Vellody¹

(1)

Department of Radiology, Children’s National Hospital, George Washington University Hospital, Washington, DC, USA

Bhupender Yadav

Email: [e-mail]

Keywords

UltrasoundCentral venous accessPeripherally Inserted central catheterTemporary central venous catheterTunneled central venous catheterImplantable venous ports

Introduction

Establishing venous access is one of the most integral aspects of caring for pediatric patients. There are many different types of venous access available ranging from peripheral intravenous catheters (PIVs) to implantable subcutaneous venous ports [1]. The determination of which access is needed is multifactorial, including the length of time the access is needed, what the access will be used for, and the overall venous health of the patient. While there are recommendations for the best type of access to use for a given clinical need, remember that each patient should be seen as an individual case and may not fit neatly