3. Take time and care to dilate lumen artery before

attempting to insert catheter.

4. Catheter should not be forced past an obstruction.

5. Never advance catheter once placed and secured.

6. Loosen umbilical tie slightly upon completion of procedure and obtain radiographic confirmation of

position.

7. Avoid covering the umbilicus with dressing. Dressing may

delay recognition of bleeding or catheter displacement.

8. Always obtain radiographic (including a lateral view) or

ultrasound (15) confirmation of catheter position.

(16,17).

9. Be certain that catheter is secure, and examine frequently when infant is placed in prone position,

because hemorrhage may go unrecognized.

Fig. 29.1. Graph for determination of length of catheter to be

inserted for appropriate low aortic or venous placement. Length of

catheter is measured from umbilical ring. Length of umbilical

stump must be added. The shoulder–umbilicus distance is the

perpendicular distance between parallel horizontal lines at the

level of the umbilicus and through the distal ends of the clavicles.

(Adapted from Dunn P. Localization of the umbilical catheter

by postmortem measurement. Arch Dis Child. 1966;41:69, with

permission.)

A B

Fig. 29.2. A: Graph for distance of catheter insertion from the umbilical ring for L3, L5, and aortic

bifurcation. Large dots represent catheters positioned at L4. B: Graph for catheter insertion to level T8

using total body length. (From Rosenfeld W, Biagtan J, Schaeffer H, et al. Evaluation of graphs for insertion of umbilical artery catheters below the diaphragm. J Pediatr. 1981;98:628, with permission.)

158 Section V ■ Vascular Access

10. Take care not to allow air to enter the catheter. Always

have catheter fluid filled and attached to closed stopcock prior to insertion. Check for air bubbles in catheter before flushing or starting infusion.

11. When removing catheter, cut suture at skin, not on

catheter, to avoid catheter transection.

E. Technique (See also Umbilical

Catheterization on

the Procedures Website)

Anatomic note: The umbilical arteries are the direct continuation of the internal iliac arteries. Their diameters at

their origins are 2 to 3 mm. As they approach the umbilicus,

their lumina become small and the walls thicken significantly. In a full-term infant, each artery is approximately

7 cm long (Fig. 29.4). A catheter introduced into the umbilical artery will usually pass into the aorta from the internal

iliac artery. Occasionally, it will pass into the femoral artery

via the external iliac artery or into one of the gluteal

arteries. The latter two sites are unsuitable for sampling,

pressure measurement, or infusion.

1. Placement of UAC in high position should be used

exclusively. In rare cases if high position is not successful a low position can be used (Fig. 29.5).

High position is associated with fewer episodes of

blanching and cyanosis of the lower extremities (18).

High catheters were found to have decreased incidence

of clinical vascular complications with a relative risk of

0.53 (95% confidence interval, 0.44 to 0.63) with no

statistically significant increase in any adverse sequelae,

including the incidence of hypertension, intraventricular hemorrhage, hematuria, necrotizing enterocolitis,

or death (19).

 

Fig. 29.3. Estimates of insertion length of umbilical catheters

(umbilical artery catheter tip inserted between T6 and T10;

umbilical vein catheter tip inserted above diaphragm in inferior

vena cava near right atrium) based on birthweight (BW) (with

95% confidence intervals). Modified estimating equations utilizing BW are as follows: umbilical artery length = 2.5 BW + 9.7

(top) and umbilical vein length = 1.5 BW + 5.6 (bottom), where

BW is measured in kilograms and lengths are measured in centimeters. (From Shukla H, Ferrara A. Rapid estimation of insertional length of umbilical catheters in newborns. Am J Dis Child.

1986;140:787, with permission.)

Fig. 29.4. Anatomic relations of the umbilical arteries, showing relationships with major arteries supplying

buttocks and lower limb.

 

g. 5-French (Fr) gauge for infants weighing >1,200 g

h. 3.5-Fr gauge for infants weighing <1,200 g

5. Three-way stopcock with Luer-Lock

6. 10-mL syringe

7. 0.45 to 0.9 normal saline (NS) flush solution (saline

with heparin, 1 to 2 U/mL)

In very small premature infants, particularly in the

first week of life, hypernatremia may result from receiving excess sodium in flush solutions. We recommend

using 0.45 NS rather than more concentrated saline

solutions in these infants. The use of hypotonic (0.25

NS) or dextrose solutions has been associated with

hemolysis of red blood cells and should be avoided if

possible (6). Use of heparinized flush solution is common practice. Rajani et al. and Ankola and Atakent

(7,8) have shown that using a heparinized solution containing 1 U/mL heparin for flushing the umbilical arterial line prolonged catheter life by reducing the

incidence of fibrin thrombus formation in the catheter

lumen. Horgan et al. (9) found that the use of 1 U/mL

heparin did not reduce the incidence of umbilical

artery catheter (UAC)-related thrombi but did lower the

Chapter 29 ■ Umbilical Artery Catheterization 157

incidence of their sequelae. Butt et al. (10) could demonstrate no significant benefit associated with increasing the

rate of infusion from 1 to 2 mL/h (heparin 1 U/mL), and

Bosque and Weaver (11) showed that continuous infusion

of 1 U/mL heparin is more effective than intermittent

infusion in maintaining patency of the UAC. More

recent data have indicated that heparin decreases the

incidence of thrombotic complications (12), and a

Cochrane Database Review found that the use of as little

as 0.25 U/mL heparin in the infusate decreases the likelihood of line occlusion (13).

8. Tape measure

9. 20-cm narrow umbilical tie

10. No. 11 scalpel blade and holder

11. 4- × 4-inch gauze sponges

12. Two curved mosquito hemostats

13. Toothed iris forceps

14. Two curved, nontoothed iris forceps

15. 2% lidocaine HCl without epinephrine

16. 3-mL syringe and needle to draw up lidocaine

17. Small needle holder

18. 4-0 silk suture on small, curved needle

19. Suture scissors

Nonsterile

1. Cap and mask

2. Wooden tongue depressor

D. Precautions

1. Avoid use of feeding tubes as catheter (associated with

higher incidence of thrombosis) (14).

2. Fold drapes so as not to obscure infant’s face and upper

chest.

 

Chapter 28 ■ Management of Extravasation Injuries 155

References

1. Wilkins CE, Emmerson AJB. Extravasation injuries in regional

neonatal units. Arch Dis Child Fetal Neonatal Ed. 2004;89:F274.

2. Casanova D, Bardot J, Magalon G. Emergency treatment of accidental infusion leakage in the newborn: report of 14 cases. Br J

Plast Surg. 2001;54:396.

3. Friedman J. Plastic surgical problems in the neonatal intensive

care unit. Clin Plast Surg. 1998;25:599.

4. McCullen KL, Pieper B. A retrospective chart review of risk factors for extravasation among neonates receiving peripheral intravascular fluids. J Wound Ostomy Continence Nurs. 2006;33:133.

5. Zenk KE, Dungy CI, Greene GR. Nafcillin extravasation injury.

Use of hyaluronidase as an antidote. Am J Dis Child. 1981;135:1113.

6. Subhani M, Sridhar S, DeCristafaro JD. Phentolamine use in a

neonate for the prevention of dermal necrosis caused by dopamine: a case report. J Perinatol. 2001;21:324.

7. Amjad I, Murphy T, Nylander-Householder L, et al. A new

approach to management of intravenous infiltration in pediatric

patients. J Infusion Nurs. 2011;34:242.

8. Thigpen JL. Peripheral intravenous extravasation: nursing procedure for initial treatment. Neonatal Netw. 2007;26:379.

9. Doellman D, Hadaway L, Bowe- Geddes LA, et al. Infiltration

and extravasation: update on prevention and management. J

Infusion Nurs. 2009;32:203.

10. Montgomery LA, Hanrahan K, Kottman K. Guideline for IV infiltrations in pediatric patients. Pediatr Nurs. 1999;25:167.

11. Chandavasu O, Garrow D, Valda V, et al. A new method for the

prevention of skin sloughs and necrosis secondary to intravenous

infiltration. Am J Perinatol. 1986;3:4.

12. Harris PA, Bradley S, Moss ALH. Limiting the damage of iatrogenic extravasation injury in neonates. Plast Reconstruct Surg.

2001;107:893.

13. Fox MD. Wound care in the neonatal intensive care unit.

Neonatal Netw. 2011;30:291.

14. Gault DT. Extravasation injuries. Br J Plast Surg. 1993;46:91.

15. Kuenstig LL. Treatment of intravenous infiltration in a neonate.

J Pediatr Health Care. 2010;24:184.

16. Denkler KA, Cohen BE. Reversal of dopamine extravasation

injury with topical nitroglycerine ointment. Plast Reconstruct

Surg. 1989;84:811.

17. Wong AF, McCullough LM, Sola A. Treatment of peripheral tissue ischemia with topical nitroglycerine ointment in neonates.

J Pediatr. 1992;121:980.

18. Siwy BK, Sadove AM. Acute management of dopamine infiltration injury with Regitine. Plast Reconstruct Surg. 1987;80:610.

19. Cisler-Cahill L. A protocol for the use of amorphous hydrogel to

support wound healing in neonatal patients: an adjunct to nursing care. Neonatal Netw. 2006;25:267.

20. Rustogi R, Mill J, Fraser JF, et al. The use of Acticoat in neonatal

burns. Burns. 2005;31:878.

21. Falcone PA, Barrall DT, Jeyarajah DR, et al. Nonoperative management of full thickness intravenous extravasation injuries in

premature neonates using enzymatic debridement. Ann Plastic

Surg. 1989;22:146.

22. Tiras U, Erdeve O, Karabulut AA, et al. Debridement via collagenase application in two neonates. Pediatr Dermatol. 2005;22:

472.

 

23. Schafer T, Kukies S, Stokes TH, et al. The prepuce as a donor site

for reconstruction of an extravasation injury to the foot in a newborn. Ann Plast Surg. 2005;54:664.

24. Chen TK, Yang CY, Chen SJ. Calcinosis cutis complicated by

compartment syndrome following extravasation of calcium gluconate in a neonate: a case report. Pediatr Neonatol. 2010;51:

238.

156

Mariam M. Said

Khodayar Rais-Bahrami

29 Umbilical Artery Catheterization

A. Indications

Catheters should remain in place only as long as primary

indications exist, with the exception of secondary indication

A3. Because of the risk of complications, catheters should

usually not remain in place for more than 2 weeks.

Primary

1. Frequent or continuous (see Chapter 10) measurement

of lower aortic blood gases for oxygen tension (PO2) or

oxygen content (percent saturation)

2. Continuous monitoring of arterial blood pressure

3. Angiography

4. Resuscitation (use of umbilical venous line may be first

choice)

Secondary

1. Umbilical artery is not usually used for infusion of maintenance glucose/electrolyte solutions or medications. If

this line is to be used to provide IV nutrition, the same

aseptic techniques used for any central line must be

used to prevent line-related sepsis (see Chapter 32).

2. Exchange transfusion

3. To provide vital infusions (1) and a port for frequent

blood sampling in the extremely low-birthweight infant

B. Contraindications

1. Evidence of vascular compromise in lower limbs or

buttock areas

2. Peritonitis

3. Necrotizing enterocolitis (2)

4. Omphalitis

5. Omphalocele

6. Acute abdomen etiology

C. Equipment

Several standardized graphs for premeasurement of catheter length to be inserted are available (Figs. 29.1–29.3).

Sterile

1. Sterile gown and gloves

2. Cup with antiseptic solution

3. Surgical drape with central aperture (transparent drape

recommended)

4. Catheter

a. Single hole

(1) Reduces surfaces for potential thrombus formation

(2) Recorded pressure tracing will change when

hole is occluded.

b. Made of flexible material that does not kink as it follows the curves of vessels

c. Relatively rigid walls with frequency characteristics

suitable for accurate measurement of intravascular

pressure

d. Small capacity (minimum volume of blood to be

withdrawn to clear catheter prior to blood sampling)

e. Radio-opaque: The need to visualize the catheter

position on x-ray film outweighs the theoretical risk

of increased thrombogenicity related to a radioopaque strip (3).

f. Smooth, rounded tip (4), nonthrombogenic material (5)

 

Table 28.1 Staging of Extravasation Injury (10)

Stage Characteristics

1 Pain at site—crying when IV cannula is flushed

IV cannula flushes with difficulty

No redness or swelling

2 Pain

Redness and slight swelling at site

Brisk capillary refill

3 Pain

Moderate swelling

Blanching of area

Skin cool to touch

Brisk capillary refill below site

Good pulse below site

4 Pain

Severe swelling around site

Blanching of area

Skin cool to touch

Area of skin necrosis or blistering

Prolonged capillary refill time (>4 s)

Decreased or absent pulse

Fig. 28.1. A: Stage IV extravasation injury with blistering of skin. B: Same area 2 weeks later, with eschar

formation.

154 Section V ■ Vascular Access

may be repeated every 8 hours if perfusion has

not improved (17)

Precautions: Absorption through the skin may

lead to hypotension.

Phentolamine (6,18)

i. Effective in treating extravasations of vasopressors such as dopamine and epinephrine, which

cause tissue damage by intense vasoconstriction

and ischemia

ii. Mechanism of action: Competitive alpha-adrenergic blockade, leading to smooth muscle relaxation and hyperemia

iii. Effect should be seen almost immediately; most

effective within 1 hour but may be used up to 12

hours. The biologic half-life of subcutaneous

phentolamine is <20 minutes.

iv. Doses have not been established for newborn

infants. The exact dose is dependent on the size

of the lesion and the size of the infant.

v. Recommended doses range from 0.01 mg/kg

per dose to 5 mL of 1-mg/mL solution.

vi. Administration: 0.5 to 1 mg/mL of solution

injected subcutaneously into infiltrated area,

after removal of IV catheter

vii. Precautions: Hypotension, tachycardia, and dysrhythmias may occur; use with extreme caution

in preterm infants; consider using repeated

small doses.

e. Wound management

(1) Goal: The goal of wound management in neonates who have partial- or full-thickness skin loss is

to achieve primary or secondary healing while avoiding scarring, contractures, and operative intervention. There are several purposes for dressing wounds.

(1) Maintain a moist pH-balanced environment to

promote re- epithelialization.

(2) Manage exudates.

(3) Decrease disruption of healing tissue.

(4) Provide an antimicrobial barrier to prevent local

and systemic infection.

(5) Decrease pain.

(2) Wound care: Wound care regimens differ among

experts and institutions (1,3,7,13,19). Consultation

with a wound ostomy care nurse is often helpful.

(1) Evaluate the wound: Size, depth, edges, wound

bed, presence of exudate, necrotic tissue, eschar,

undermining of margins, evaluation of skin

around the wound for signs of inflammation or

for maceration (13).

(2) Evaluate wound healing every day. Time to heal

ranges from 7 days to 3 months.

(3) Dressing changes can be painful. Consider

using comfort measures, sucrose, and analgesics, as needed.

 

(4) Irrigate wound with sterile saline to remove exudate and debris.

(5) Topical agents may be used if the wound is colonized, infected, or at risk of being infected.

Routine use of antiseptic solutions is not recommended because most solutions destroy granulation tissue.

i. Silver sulfadiazine cream is contraindicated

in infants less than 30 days of age because

the sulphonamides increase the risk of kernicterus. In addition, the cream can obscure

the wound by forming a difficult to remove

opaque layer.

ii. Use of povidone–iodine is not recommended because absorption of iodine may

suppress thyroid function.

iii. Antibacterial creams and ointments have

limited roles.

(6) Wound dressing

i. The selection of dressing material depends

on the depth of the wound, the property of

the wound bed (presence of granulation tissue, moist, dry, exudative) (19).

ii. Wet wounds require absorptive dressing,

whereas dry wounds benefit from hydrating

dressings.

iii. Amorphous hydrogels consisting of carboxymethylcellulose polymer, propylene glycol,

and water have been shown to keep the

wound moist and facilitate wound healing

(13,19). They are available in the form of

gels or sheets, which may be applied directly

to the wound surface and held in place

by a secondary dressing. The gel is easily

removed with saline and is generally

changed every 3 days. More frequent dressing changes may be required if there is excessive exudation.

iv. Silver-impregnated dressings are postulated

to decrease wound infection (20).

v. Alginate dressings are fibers derived from

brown seaweed and useful for wounds with

moderate to heavy exudates (19).

vi. Polyurethane foams are also useful for

wounds with exudates.

(7) If the scar involves a flexion crease, passive rangeof-motion exercises with each diaper change

may help to prevent contractures.

(8) Plastic surgical consultation

a. Recommended for all full-thickness and

significant partial-thickness extravasation

injuries

b. Enzymatic or surgical débridement or skin

grafting may be required (3,21–24).

Chapter 28 ■ Management of Extravasation Injuries 153

iii. Hyaluronidase: Dispersing agent effective in

extravasations involving calcium, parenteral

alimentation fluids, antibiotics, sodium bicarbonate, etc. Although standard reference manuals state

that hyaluronidase is not recommended for treatment of vasopressor extravasation injury, there

have been reports of successful treatment of such

extravasations with a combination of hyaluronidase

and saline irrigations, as described above (2,12).

Mechanism of action: Breakdown of hyaluronic

acid, the ground substance or intercellular

cement of tissues; minimizes tissue injury by

enhancing dispersion and reabsorption of extravasated fluids

Formulations available:

i. Animal derived: Ovine-derived Vitrase

(Alliance Medical Products, Irvine, California)

or bovine-derived Amphadase (Amphastar

Pharmaceuticals, Rancho Cucamonga,

California). Amphadase contains small quantities of thimerosal, so it is not recommended

in neonates.

ii. Recombinant human hyaluronidase

(rHuPH20) (Hylenex, Baxter Healthcare,

Deerfield, Illinois): This product is reported

to have up to 100 times greater enzymatic

activity than the animal-derived form, but

there is little literature available on its effectiveness in extravasations (15)

Most effective within 1 hour; may be used up to

12 hours

Administration: Use 25- or 26-gauge needles to

inject 1 mL (150 USP units/mL of Vitrase) as

five separate 0.2-mL injections around the

periphery of the extravasation site. If using

recombinant human hyaluronidase, a single

subcutaneous injection of 150 units using a

25-guage needle may be equally effective (15).

Most effective within 1 hour; may be used up to

12 hours after the extraversation.

Adverse effects: None reported in neonates, rare

sensitivity reactions to the animal formulations

of hyaluronidase reported in adults

d. Specific antidotes

Topical nitroglycerine (16,17)

i. Effective in treating injury due to extravasation

of dopamine

ii Mechanism of action: Vascular smooth muscle

relaxant

Application: 2% nitroglycerine ointment, 4 mm/

kg body weight, applied over the affected area,

A B

 

1. In all cases

a. Stop the IV infusion promptly.

b. Remove constricting bands that may act as tourniquets (e.g., armboard restraint).

c. Elevation of the limb may help to reduce edema.

d. The application of warm or cold packs is controversial.

Warm packs may, by local vasodilation, help to reabsorb infiltrating solutions. However, warm moist packs

have been reported to cause maceration of the skin.

2. Stage 1 or 2 extravasation

a. Remove IV cannula.

b. Consider antidote (see stage 3 or 4 extravasation

below).

3. Stage 3 or 4 extravasation

a. Leave the IV cannula in place and, using a 1-mL

syringe, aspirate as much fluid as possible from the

area. Usually, very little fluid can be aspirated.

b. Remove the cannula unless it is needed for administration of the antidote.

c. Consider use of hyaluronidase or a specific antidote

(see below).The use of hyaluronidase may obviate

the need for the multiple puncture or saline washout techniques described below.

i. Multiple-puncture technique (11): In infants who

develop tense swelling of the site with blanching

of the skin owing to infiltration of acidic or hyperosmolar solutions, multiple punctures of the

edematous area using a blood-drawing stylet (and

strict aseptic technique) has been used to allow

free drainage of the infiltrating solution, decrease

the swelling, and prevent necrosis. The area is

then dressed with saline soaks to aid drainage.

ii. Saline flush out: A technique of saline flushing of

the subcutaneous tissue has been advocated by

some authors (2,12,14). After cleaning and infiltrating the area with 1% lidocaine, 500 to 1,000

units of hyaluronidase is injected subcutaneously.

Four small stab incisions are then made in the tissue plane with a scalpel blade at the periphery of

the area. Saline is injected through a blunt cannula inserted subcutaneously through one of the

puncture sites and flushed through the other puncture sites, massaging the fluid toward the incisions

to facilitate removal of the extravasated material.

 

Chapter 27 ■ Peripheral Intravenous Line Placement 151

19. Pearson ML. Guideline for prevention of intravascular devicerelated infections. Part I. Intravascular device-related infections:

an overview. The Hospital Infection Control Practices Advisory

Committee. Am J Infect Control. 1996;24:262.

20. Shah PS, Ng E, Sinha AK. Heparin for prolonging peripheral

intravenous catheter use in neonates. Cochrane Database Syst

Rev. 2005;4:CD002774.

21. Pineault M, Chessex P, Pledboeuf B, et al. Beneficial effect of coinfusing a lipid emulsion on venous patency. J Parenter Enter Nutr.

1989;13:637.

22. Phelps SJ, Lochrane EB. Effect of the continuous administration of

fat emulsion on the infiltration rate of intravenous lines in infants

receiving peripheral parenteral nutrition solutions. J Parenter Enter

Nutr. 1989;13:628.

23. Lloyd-Still JD, Peter G, Lovejoy FH. Infected “scalp-vein” needles. JAMA. 1970;213:1496.

24. Lozon MM. Pediatric vascular access and blood sampling techniques. In: Roberts JR, Hedges JR, eds. Clinical Procedures in

Emergency Medicine. 4th ed. Philadelphia: Saunders; 2004:366.

25. Cronin WA, Germanson TP, Donowitz LG. Intravascular cannula colonization and related blood stream infection in critically

ill neonates. Infect Control Hosp Epidemiol. 1990;11:301.

26. Shuster S, Laks H. Varicose veins following ankle cut-downs.

J Pediatr Surg. 1973;8:245.

152

Jayashree Ramasethu

Management of Extravasation

Injuries

28

Extravasation or inadvertent infiltration of IV administered

solutions into subcutaneous tissue is a common adverse

event in intensive care nurseries and may result in partial or

complete skin loss, infection, and nerve and tendon damage, with the potential risk of cosmetic and functional

impairment (1–3). Parenteral alimentation fluids, calcium,

potassium, and sodium bicarbonate solutions, vasopressor

agents, and antibiotics such as nafcillin, are often implicated (1,4–6). Early identification and appropriate management are vital to minimize damage (7–9).

A. Assessment (Fig. 28.1;

see also Figs. 27.5 and 27.6)

1. Staging of extravasations is recommended for objective

evaluation to determine the degree of intervention

required. Several staging systems are in use (7–10).

Table 28.1 describes one that is commonly used.

2. Detailed descriptions or digital photographs provide

better documentation of the extent of the wound and

the healing process

3. Fussiness, crying, or withdrawal of the limb when flushing the IV cannula are early warning signs, but these

may be absent in an infant who is sedated or critically ill.

4. Blistering and discoloration of skin often portend at

least partial skin loss, but visible skin changes do not

always indicate the severity of underlying injury, which

may evolve over several days (7).

B. Management

The degree of intervention is determined by the stage of

extravasation, the nature of the infiltrating solution, and the

availability of specific antidotes. There is no consensus on

management of stage 3 or 4 lesions. In the absence of randomized controlled trials, some institutions have established

management protocols to guide therapy, based on local

experience, case series, and anecdotal evidence (1,7–13).

 

Chapter 27 ■ Peripheral Intravenous Line Placement 149

12. Place 5-0 silk suture loosely around vein and clamp at

end of suture with hemostat to allow for distal control

of vessel (Fig. 27.12). (Do not tie ligature.)

13. Place ligature with clamp across extended index finger

and inside palm of nondominant hand, retracting it in

an upward and caudad direction (Fig. 27.13).

14. Introduce cannula/stylet into vein at a 45-degree angle,

with bevel down. Once vein has been entered, angle

cannula parallel to vein (Fig. 27.14).

15. Advance cannula into vein while withdrawing inner

needle stylet.

16. Advance cannula up to hub, and infuse small volume

of saline flush solution to confirm IV position.

17. Remove traction suture and close skin incision with

subcuticular absorbable sutures or one or two simple

5-0 nylon sutures.

18. Attach cannula to infusion tubing and regulate IV.

19. Secure cannula to skin, as shown in Fig. 27.4.

F. Complications

1. Same as for percutaneous method

2. Inadvertent infusion of local anesthetic into artery or

vein

3. Severance of vein owing to excessively deep initial incision

4. Infiltration of IV infusion into body cavity (Fig. 27.15)

 This is a complication related to placement of very

long catheters. When infusion of an extremely irritating or hypertonic solution is required, the catheter is

preferably inserted into the central venous system (see

Chapter 32).

5. Varicose veins secondary to postinfusion phlebitis (26)

Conversion of Peripheral IV

Line to a Saline Lock

A. Technique

1. Wash hands and put on gloves.

2. Clean IV tubing and catheter connection with antiseptic solution.

3. Stop IV infusion and remove IV tubing from hub of IV

needle or cannula.

4. Seal hub with a sterile plug or T-connector system

(e.g., Argyle intermittent infusion plug [Consolidated

Medical Equipment, Utica, New York; Sherwood

Medical Co., St. Louis, Missouri] or Burron spin-lock

port extension set [Burron Medical, Bethlehem,

Pennsylvania] that has been primed with the required

Fig. 27.12. The hemostat has been carefully opened and the

subcutaneous connective tissue spread, leaving the vein surface

clean. A ligature is placed between the blades of the hemostat.

Fig. 27.13. Outward and caudad traction is exerted on the

suture.

Fig. 27.14. Introducing the cannula into the vein.

 

150 Section V ■ Vascular Access

quantity of saline). As an improvisation, a stopcock

with two dead heads may be used. However, at least

3 mL of flush solution is necessary to flush all parts of

a stopcock. This increases the margin for error, with

possible fluid overload in very small premature

infants.

5. Clean plug with antiseptic, and inject 0.4 to 0.8 mL of

saline solution through plug to flush blood from needle

or cannula.

6. Clean plug with antiseptic prior to every use.

7. Refill lock with flush solution after every IV infusion.

(Flush routinely every 6 to 12 hours, depending on frequency of use.)

References

1. Wille JC, Blussae E, Vanovd Ablas A. A comparison of four filmtype dressings by their antimicrobial effect on the flora of the skin.

J Hosp Infect. 1989;14:153.

2. Vernon HJ, Lane AT, Wischerater LJ, et al. Semipermeable dressing and transepidermal water loss in premature infants. Pediatrics.

1990;86:357.

3. Maki DG, Ringer M. Evaluation of dressing regimens for prevention of infection with peripheral intravenous catheters. JAMA.

1987;258:3396.

4. Hoffmann KK, Western SA, Kaiser DL, et al. Bacterial colonization and phlebitis-associated risk with transparent polyurethane

film for peripheral intravenous site dressings. Am J Infect Control.

1988;16:101.

5. Holland KT, Harnby D, Peel B. A comparison of the in vivo antibacterial effects of “Op-Site,” “Tegaderm” and “Ensure” dressings.

J Hosp Infect. 1985;6:299.

Fig. 27.15. Cystogram in infant who had not urinated for more than 24 hours despite “adequate” IV

fluids. A: The bladder appears normal, but there is a “mass effect” displacing the intestines in approximate

area indicated by arrows. B: Radiographic contrast material, injected through a long catheter introduced

into the femoral vein via the great saphenous vein, has extravasated into the abdominal cavity.

6. Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database

Syst Rev. 2010;CD001069.

7. Ganderer MW. Vascular access techniques and devices in the

pediatric patient. Surg Clin North Am. 1992;72:1267.

8. Downing JW, Charles KK. Intravenous cannula fixing and

dressing—comparison between the use of transparent polyurethane dressing and conventional technique. South Afr Med J.

1987;721:191.

9. Leibovici C. Daily change of an antiseptic dressing does not prevent infusion phlebitis: a controlled trial. Am J Infect Control.

1989;17:23.

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