Vascular (venous) access for pediatric resuscitation and other pediatric emergencies

INTRODUCTION — This topic will discuss the selection of a site for vascular access as well as techniques for peripheral and central percutaneous access and venous cutdown.

Intraosseous (IO) cannulation and ultrasound-guided vascular (venous) access are discussed separately. (See "Intraosseous infusion" and "Basic principles of ultrasound-guided venous access".)

GENERAL APPROACH — Establishment of reliable vascular access is a critical step in pediatric resuscitation, but it can be difficult to obtain in a critically ill infant or child. Successful resuscitation is more likely if vascular access is achieved within the first few minutes [1]. The preferred venous access site during pediatric resuscitation is the largest, most accessible vein that does not require the interruption of resuscitation [2].

The general approach to vascular access during pediatric resuscitation is provided in the algorithms (algorithm 1 and algorithm 2).

Key principles include:

●During cardiopulmonary resuscitation (CPR) or the treatment of severe septic shock, intraosseous (IO) cannulation (see "Intraosseous infusion") should be placed immediately; access can often be obtained in less than one minute [3-5]. At the same time, the resuscitation team should also prepare for peripheral or central venous access by identifying a site with ultrasound and obtaining an appropriate insertion kit and catheter or, in newborns younger than 10 days of age, setting up for an umbilical venous line [6,7]. The clinician should use the largest catheter that can be placed (see 'Catheter selection' below). Even when peripheral venous or IO access is achieved, most patients who are resuscitated from cardiac arrest or who have shock that is not fluid responsive will require central venous access to provide long-term and secure venous access for continuous drug administration, to allow for repeated blood sampling, and to permit monitoring.

For emergency access in patients who are more stable, peripheral and, whenever available, ultrasound-guided intravenous (IV) placement should be attempted initially, followed by IO cannulation if access is not rapidly achieved.

●Attempts at peripheral and central venous access in the head, neck, and chest should be limited during CPR to avoid interruption of ventilation and chest compressions.

●When selecting a catheter length and size (table 1), one should recognize that the flow rate through a catheter is directly proportional to the internal diameter of the catheter and inversely proportional to its length. In addition, the resistance to flow decreases by the fourth power of the change in the radius as the radius of the catheter increases [8]. Therefore, shorter, larger bore catheters permit more rapid delivery of fluid and are preferred to longer catheters, although specialized catheters designed for placement using ultrasound, such as the micropuncture catheter, have equivalent flow rates.

●The use of a protocol that sets a time limit for peripheral IV line insertion during resuscitation can facilitate the rapid establishment of venous access and has been associated with a significantly shorter time to vascular access [9,10].

Peripheral versus central — For the rapid delivery of isotonic solutions in patients with shock, large bore shorter peripheral catheters are preferred in most cases to central catheters because they can typically be placed more quickly and are shorter. The lower resistance of the shorter peripheral catheters permits a faster flow rate. For example, based upon in vitro studies, the mean flow rate by gravity drainage through a peripheral 22 gauge (length 1 inch) catheter is 20 mL/min compared with 11 mL/min through a 20 gauge (length 5 cm) central catheter. Use of a pressure bag at 300 mmHg increases the rate to 64 mL/min via the peripheral 22 gauge catheter versus 38 mL/min via the central catheter [11].

Although peripheral or IO access is recommended instead of central venous access during initial resuscitative efforts, in some situations, access with a larger bore catheter may only be achieved centrally. In addition, central venous access may be more secure than peripheral and permits reliable infusion of irritant drugs (eg, vasoactive agents, calcium chloride, or potassium chloride). Therefore, central venous access should be considered early during resuscitation whenever feasible.

With respect to drug delivery during cardiopulmonary arrest, although animal models have suggested that central venous drug administration can produce more rapid onset of action and higher peak drug levels than peripheral venous or IO administration, these differences are not clinically important, especially in pediatric models [12-15]. Regardless of route, drug delivery is enhanced when the resuscitation drug is followed by a bolus of 5 to 10 mL of normal saline [9].

PERIPHERAL ACCESS — Peripheral venous catheters are typically the easiest and safest means of achieving vascular access during the initial resuscitation of patients, particularly for clinicians who do not have experience with central venous catheterization.

Catheter selection — The most common type of peripheral venous catheter used in children is the over-the-needle catheter, typically 22 to 24 gauge in newborns and infants and 18 to 20 gauge for older children. The size of the cannula used in resuscitation should be the largest that can be inserted reliably. In shock or severe hypovolemia, a smaller cannula may be used for initial fluid resuscitation until a larger vein can be cannulated. Butterfly needles should be avoided because they infiltrate easily.

Sites — Potential sites include the upper and lower extremities, the scalp, and the external jugular vein. Depending on the length and the position of the catheter tip, external jugular venous cannulation also may provide central venous access.

Upper extremity — The cephalic, basilic, and median cubital veins in the forearm and the dorsal veins of the hand offer a route for rapid drug and fluid delivery in the upper extremity (figure 1). The cephalic (also called antecubital) vein is relatively easy to cannulate. However, catheters placed in this location must be well secured with an armboard to prevent elbow flexion, which can cause kinking of the catheter as well as infiltration [16].In severe hypovolemia or shock, a rare complication is unintentional cannulation of the brachial artery, which could lead to limb ischemia. Use of ultrasound may help to mitigate this complication.

Any of these sites may be difficult to locate in a well-nourished infant. If peripheral intravenous (IV) access is not rapidly established, then other means of vascular access (ie, intraosseous [IO] cannulation or central venous access, depending upon the clinical situation) should be promptly performed. (See 'General approach' above.)

Transillumination of the palm with a high-powered cold light source has been successfully used in infants and young children to locate veins for cannulation in the dorsum of the hand. Near-infrared and dynamic ultrasound have also been used for peripheral IV access. Trials of these techniques have not demonstrated an advantage over the standard approach to peripheral venous access for most children. However, during resuscitation, peripheral and, whenever available, ultrasound-guided IV placement should be attempted simultaneously and should also be considered for patients who are likely to have difficult access or who have already failed previous attempts.

Lower extremity — In children, the great saphenous vein at the ankle is the most accessible vein in the lower extremity because of its large size and consistent anatomy. The veins of the dorsal arch can also be used (figure 2).

Scalp — The small superficial veins of the scalp rarely are useful during cardiopulmonary resuscitation (CPR) but may be helpful in less urgent situations. This location is less desirable because the scalp may have to be shaved to expose the vein, and doing so may cause the parents/caregivers unnecessary concern about a "needle in the head" [17].

A circumferential tourniquet, such as a rubber band, is placed around the forehead to make the veins visible (figure 3). Boluses of fluid may be given via a scalp IV in an attempt to improve circulating volume, making other peripheral venous sites more visible and accessible. Caution must be used when accessing scalp veins because the temporal artery or its branches can be cannulated inadvertently. Cannulation of an artery is indicated by blanching of the scalp distal to the catheter when the saline flush is introduced [18].

External jugular — The external jugular vein is another useful site for vascular access in young children because no adjacent arterial or neural structures are present. However, it cannot be used as a primary site during resuscitation of infants or children with airway compromise, concern for cervical spine injury, or respiratory failure because cannulation of the external jugular vein requires extension and rotation of the neck.

Cannulation of the external jugular vein usually requires that the infant or child be placed in a 30-degree head-down (Trendelenburg) position (figure 4). The right external jugular vein is preferred for access because it provides a more direct path to the superior vena cava (SVC). Cannulation of this vessel is difficult because of its tendency to roll. In addition, short external jugular catheters are easily dislodged and difficult to immobilize, particularly in infants [17,19].

Technique — Usually over-the-needle catheters are used for peripheral venous access, regardless of the site. Universal precautions should be employed. The techniques for insertion are as follows [19].

●Step 1 – The chosen extremity or site to be used is immobilized and/or isolated. The vein is located and stretched gently. If the antecubital fossa vein is to be cannulated, a soft roll of gauze can be placed behind the elbow to fully extend it. If the dorsal hand veins are to be cannulated, the hand is held firmly with the wrist flexed. If the dorsal foot veins are to be cannulated, the foot is held firmly with the ankle extended (foot in plantarflexion).

●Step 2 – A tourniquet is applied proximal to the vein, and the skin over the vein is cleansed with an antiseptic solution.

●Step 3 – The needle/catheter is inserted with the bevel of the needle facing up. It is advanced slowly into the vein until a flash of blood is seen in the hub.

●Step 4 – The needle/catheter is advanced a few millimeters to ensure that the catheter is in the vein. The catheter is then advanced over the needle into the vein, which activates a safety feature in which the needle is withdrawn into a protective sheath.

●Step 5 – Free backflow of blood through the catheter suggests that the vein has been successfully cannulated. Inadvertent cannulation of an artery results in pulsatile back flow of blood in patients with adequate cardiac output. In this situation, the catheter should be removed and pressure applied to the cannulation site until bleeding stops (minimum of five minutes). Peripheral venous access is then obtained at a different site.

●Step 6 – The tourniquet is removed.

●Step 7 – The ability to easily flush saline through the catheter with no swelling at the insertion site confirms IV placement.

●Step 8 – The catheter is taped firmly in place, and any air in the connecting tubing is evacuated. An infusion set is attached, and a sterile dressing is applied to the insertion site. In a resuscitation situation, fluid boluses may be pushed directly through the connecting tubing by using a three-way stopcock and a large syringe.

Complications — The complication rate associated with peripheral venous catheters is relatively low, and severe complications are infrequent. Complications include hematoma formation, cellulitis, osteomyelitis, thrombosis, phlebitis, pulmonary thromboembolism, infiltration, and skin slough [17,20]. Medications that are irritating to the veins, such as calcium, dopamine, potassium, or epinephrine, should be diluted and administered through the largest peripheral vein possible to avoid the development of phlebitis. Vesicant or irritant fluids (pH <5 or >9, osmolarity >600 mOsm) should not be administered through a peripheral IV access site. (See "Central venous access: Device and site selection in adults", section on 'Nature of infusate'.)

INTRAOSSEOUS ACCESS — Intraosseous (IO) cannulation is the recommended form of access in infants and children in cardiopulmonary arrest, severe shock, or trauma who do not have readily available intravenous (IV) access. IO cannula placement is discussed separately. (See "Intraosseous infusion".)

CENTRAL ACCESS — In infants and children, central venous catheters are a reliable means for administering large volumes of fluids or potentially irritating solutions. Infiltration rarely occurs when drugs are infused by this route [19]. In addition, central venous catheters can be used to collect blood samples and monitor hemodynamic variables, such as central venous pressure or mixed venous hemoglobin-oxygen saturation [21]. Finally, careful attention to technique and verification of catheter tip placement are necessary to avoid complications. Ultrasound guidance should be used for placing central venous catheters whenever the equipment and operator experience are available. (See "Basic principles of ultrasound-guided venous access".)

Catheter selection — When choosing a catheter for central venous placement in infants and children, the length must be sufficient to permit secure placement within the vessel and the bore large enough to achieve high flow rates.

The following table describes various catheters based upon the age and weight of the child (table 1). Children younger than one year, less than 10 kg, and shorter than 75 cm in length had higher complication rates if ≥6 French catheters were used [22]. For short-term access during a pediatric resuscitation, single-, double-, or triple-lumen polyethylene catheters are used most frequently. Polyethylene catheters are not suitable for long-term access because they have a higher rate of infection and thrombosis than do silastic central venous catheters [21].

Sites — In infants and children, the three primary sites for central venous access are the femoral vein, subclavian vein, and the internal jugular vein (figure 5). There are no significant differences in risk of infection between sites, although femoral lines may carry a higher risk of thrombus [23,24]. In neonates younger than 10 days of age, the umbilical vein is the preferred site. (See 'Umbilical vein access' below.)

The femoral vein is the site used most frequently by pediatric emergency physicians because it is relatively easy to access and is distant from the major sites of activity during resuscitation. The femoral site is less desirable outside the emergency department or the intensive care unit because it is not suitable for long-term access in a mobile patient. In addition, it should not be cannulated in patients who have suspected disruption of the inferior vena cava (eg, trauma, abdominal catastrophe) [25].

Subclavian vein and internal jugular vein cannulation should be performed only by individuals specifically trained in the procedure because the complication rate is significant when cannulation is attempted by inexperienced personnel [19]. Cannulation of the subclavian vein in children has a lower complication rate than cannulation of the internal jugular vein [26]. Thus, many pediatric surgeons prefer to use the subclavian vein for central venous access in children [27,28].

Technique — The Seldinger technique is particularly useful for establishing central vascular access in children (figure 6) [29]. This technique permits the introduction of catheters into the central venous circulation after initial percutaneous venous entry using a small-gauge, thin-walled needle or an over-the-needle catheter. Once free flow of blood is achieved using the small needle or catheter, a guidewire is threaded through the needle or catheter into the vessel, and the small-gauge needle or catheter is withdrawn over the guidewire while the guidewire is held in place. A larger catheter then is threaded over the guidewire into the vessel after vessel dilation, and the guidewire is withdrawn.

Femoral vein — The femoral vein is the most commonly accessed central line site in pediatric resuscitation. The stepwise technique for its cannulation is described below [8,19]. As always, universal precautions should be employed. Ultrasound guidance should be used for this procedure when equipment and operator expertise are available.

●Step 1 – The leg is restrained with the hip slightly abducted and in slight external rotation. A towel can be placed under the gluteal muscle to improve exposure of the vein (figure 7). The femoral vein lies 0.25 to 0.5 cm medial to the femoral artery in most children. The femoral artery usually lies 1.5 cm below the inguinal ligament. In the patient without a pulse, the location of the femoral artery can be approximated at the point midway between the anterior iliac crest and the symphysis pubis and is easiest to access at a level just distal to the femoral crease [18]. When chest compressions are performed, pulsations in the femoral area may originate from the femoral vein or the femoral artery. In this situation, needle puncture should be attempted at the point of pulsation [30].

●Step 2 – A sterile field is established, and the skin is cleansed with a povidone-iodine or chlorhexidine solution. The area is draped using sterile gloves.

●Step 3 – All the equipment should be checked prior to proceeding with skin puncture. The introducer needle, the central venous catheter, and all connecting tubing are flushed with sterile saline.

●Step 4 – The femoral artery is palpated, and the introducer needle is held with a saline-filled syringe attached parallel to the blood vessel and 30 to 45 degrees above the horizontal (figure 8).

●Step 5 – The skin is punctured 0.5 cm medially to the arterial pulsation. Gentle suction is applied to the syringe while advancing the needle.

●Step 6 – The needle is advanced 1 to 2 mm after the point of initial blood return. Blood return is reassessed before the syringe is disconnected, and a finger is placed over the needle hub to decrease blood loss and prevent entrance of air. The needle should be withdrawn when failure to locate the vein occurs. Adjusting the needle while it is still in the subcutaneous tissue risks lacerating the vein, artery, or both [21].

●Step 7 – The guidewire is grasped using the free hand near the end that has a soft straight tip. The guidewire is advanced through the needle, at least several centimeters past the needle tip cephalad into the vein. The guidewire should pass easily; otherwise, it usually is not in the lumen of the vein. The guidewire is removed if difficulty occurs, and the needle is repositioned to establish return of blood flow. The wire is then replaced.

●Step 8 – The guidewire is stabilized in a sterile fashion against the thigh distally with the hand that inserted it. The needle is withdrawn from the vein along the wire. Once the needle has been pulled out enough to expose the wire at the puncture site, the wire is stabilized at the puncture site and the needle is gently pulled off the guidewire, leaving the wire in place.

●Step 9 – Before inserting larger bore catheters, a dilator is advanced over the wire to the skin entry site. Using a scalpel, a nick is made in the skin at the insertion site with the blade facing away from the wire. While twisting the dilator around the wire at the insertion site, it is then advanced over the wire up to its hub, while the wire is held in place distally. The dilator is then removed and pressure is applied immediately with a gauze pad at the insertion site.

●Step 10 – The central venous catheter is picked up at the proximal end and advanced over the wire to the skin entry site. If a dilator was not used previously, a nick is made in the skin with a scalpel at the insertion site. The catheter should be twisted at the skin entry site and advanced over the wire in a cephalad direction while the wire is held distally. The rotary motion helps enlarge the skin puncture site. Alternatively, a small nick can be made in the skin at the insertion site and may be necessary when inserting larger central venous catheters. Special care must be taken to control the wire either proximal or distal to the central venous catheter to prevent irretrievably advancing the wire in to the blood vessel.

●Step 11 – The guidewire is withdrawn while the catheter is held in place. Blood will be visible in the catheter if the vein has been cannulated successfully.

●Step 12 – The infusion tubing is attached to the catheter after it is taped or, preferably, sutured in place.

Subclavian vein — Subclavian vein cannulation in infants and children can be performed by the infraclavicular route, but it has been associated with a high-complication rate when performed during emergency resuscitation [31]. The risk of complications is lower in children older than one year, but the subclavian vein is not considered to be the ideal site of vascular access during resuscitation. Use of ultrasound for the subclavian route may improve the success rate (figure 9). (See "Central venous access in adults: General principles", section on 'Infraclavicular venous access'.)

●Step 1 – The child is placed in the Trendelenburg position; adding a rolled towel may decrease vessel size and should not be used [32,33].

●Step 2 – A sterile field is established, and the skin is cleansed with a povidone-iodine or chlorhexidine solution. Local anesthesia is administered at the entry site. The area is draped using sterile gloves.

●Step 3 – A small puncture can be made at the intended entrance site using a scalpel blade. The puncture site should be at the juncture of the medial and distal thirds of the clavicle near the depression created by the deltoid and the pectoralis major muscles. The use of this slightly lateral puncture site decreases the risk of infection by maintaining a greater distance between the skin surface and the entry into the subclavian vein [25].

●Step 4 – The introducer needle is inserted through the puncture site. It is held parallel to the frontal plane and directed toward the posterior aspect of the sternal notch. The needle should be advanced along the inferior surface of the clavicle (as parallel to the horizontal plane of the chest as possible) to decrease the risk of puncturing the pleura. Gentle steady aspiration is applied to the syringe as the needle is advanced.

●Step 5 – Blood will flow back briskly when the needle enters the vein. The needle then is advanced 1 to 2 mm to ensure that it is fully in the vein.

●Step 6 – The guidewire should be inserted during a positive-pressure breath or spontaneous exhalation to prevent entraining of air into the blood vessel [19]. Development of ventricular ectopy during insertion of the guidewire implies irritation of the myocardium. The guidewire should be withdrawn to an extracardiac position if it occurs [18].

●Step 7 – Holding the guidewire, gently remove the puncture needle from over the guidewire.

●Step 8 – Advance the central venous catheter over the guidewire. If the catheter meets resistance at the puncture site, a dilator may be used to enlarge the site. This procedure is accomplished by passing the dilator over the guidewire until the hub of the dilator meets the puncture site. Then the dilator is removed while the guidewire is held in place. The catheter should pass easily over the guidewire until the hub of the catheter meets the puncture site. The end of the guidewire should extend beyond the end of the catheter. Special care must be taken to control the wire either proximal or distal to the central venous catheter to prevent irretrievably advancing the wire in to the blood vessel.

●Step 9 – Gently remove the guidewire while holding the catheter in place.

●Step 10 – Aspirate blood from each port of the central venous catheter and then flush all ports with sterile saline.

●Step 11 – The central venous catheter should be sutured in place. A chest radiograph or ultrasound image is then obtained to confirm that the catheter tip is correctly positioned at the superior vena cava (SVC)-right atrial junction, as well as to exclude a complication such as pneumothorax or hemothorax [19]. The chest radiograph can also be used to adjust the location of the catheter tip if it is not in the correct position.

Internal jugular — The emergency placement of an internal jugular catheter is best left to those who are experienced in the technique. It has a higher complication rate than does the subclavian approach [26]. However, it may be preferred in some situations, particularly when abdominal trauma is present or concern about inferior vena cava (IVC) disruption exists [25]. Ultrasound guidance should be used for this procedure when equipment and operator expertise are available. (See "Basic principles of ultrasound-guided venous access".)

The right internal jugular vein is preferred to the left because the catheter is more likely to pass directly from the innominate vein into the SVC and risk of pneumothorax or damage to the thoracic duct is less [21].

Three possible approaches to internal jugular vein cannulation are the central (medial), posterior, and anterior routes (figure 10) [34]. The anterior approach is used rarely in children and will not be described further. The central and posterior approaches have similar ease and complication rates [35,36]; however, usually the central approach is used in children [19].

●Step 1 – The child should be placed in 30 degrees of Trendelenburg (head below feet) with the head turned slightly away from the side of cannulation (figure 10) [8,34]. Mild hyperextension of the neck tenses the sternocleidomastoid muscle and permits better visualization of the landmarks. The internal jugular vein is easiest to cannulate as it emerges below the apex of the triangle that is formed by the clavicle and the sternal and clavicular heads of the sternocleidomastoid muscle.

●Step 2 – One of two approaches is used to advance the cannulating needle into the internal jugular vein in children:

•Central approach – The needle should be inserted into the apex of this triangle at a 45-degree angle in the caudad direction and directed toward the ipsilateral nipple while withdrawing the plunger on the syringe. All needle punctures should be made lateral to the carotid artery pulse. The internal jugular vein usually will be entered after only 1 to 2 cm of penetration. If the attempt is unsuccessful, the needle is withdrawn and redirected in a more lateral approach.

•Posterior approach – The needle is inserted at the lateral edge of the sternocleidomastoid muscle at the junction of the middle and lower thirds while withdrawing the plunger on the syringe. This site usually is just above the point where the external jugular vein crosses the muscle. The needle is directed at an angle of 30 to 45 degrees to the skin and toward the sternal notch. The vein should be entered after only 1 to 2 cm of penetration.

●Step 3 – Once aspiration of blood and visualization of the needle in the vein by ultrasound confirms proper placement, the guidewire is introduced and stabilized, the puncture needle or catheter removed, the central catheter introduced, and the guidewire withdrawn as described above.

●Step 4 – A chest radiograph or ultrasound image should be obtained to verify correct catheter position and to rule out pneumothorax or hemothorax.

Catheter tip positioning — Placement of a short catheter in the femoral vein can be verified when blood is easily aspirated through the catheter and, in patients with adequate cardiac output, is not pulsatile. For patients in low flow cardiac states, confirmation of venous cannulation is often necessary immediately after resuscitation in shock states. In addition to confirmation by imaging, venous (versus arterial) access can be confirmed by transducing the pressure in the catheter and by obtaining a blood gas and interpreting the partial pressure of oxygen (pO₂). This is most relevant for femoral lines because imaging cannot accurately differentiate between arterial and venous placement.

The position of all other catheters should be identified with a chest and/or abdominal radiograph or ultrasound image, to insure that the catheter will function properly for infusions and vascular pressure monitoring. In addition, proper placement of the catheter tip is necessary to avoid injury to the vessel or the myocardium [37].

Perforation of the myocardium is a rare, but catastrophic, complication that can occur when a catheter tip remains in the right atrium [38]. A safe position for the tip, when the catheter is placed from a site above the heart, is at the junction of the SVC and the right atrium junction. For femoral vein sites, the catheter should be located below the diaphragm. Proper placement in the inferior vena cava without migration into the hepatic or renal veins should be assured by appropriate imaging (plain film or ultrasound image).

The carina may be a reliable landmark for proper catheter tip placement on a chest radiograph in adults [39,40]. This appears to be true for children as well [41,42].

Complications — The site, experience of the clinician, and the clinical condition of the patient affect the incidence of complications. Complications of central venous catheterization are more common in the pediatric age group than in adult patients [19,22-24,26,32,33,38,43-50] . For example, in one study of nearly 370 central venous catheterizations in children in a pediatric intensive care unit, there was a 1.3 percent overall rate of serious complications [50]. Insertion-related complications included 9 percent arterial punctures, 7 percent malposition, 5 percent hematomas, 3 percent minor bleeding, and 0.8 percent with pneumothorax. Complications were less common after access in femoral and internal jugular veins than the subclavian vein. Pneumothorax is more likely to occur after cannulation on the left side because the cupula of the lung is higher on the left side than on the right side [19].

Catheter sepsis, either isolated or associated with thrombus formation, is a common and serious problem with long-term central venous access, especially in immunosuppressed children [47] (see "Intravascular catheter-related infection: Epidemiology, pathogenesis, and microbiology"). A prospective study of children in a pediatric intensive care unit reported blood stream infections in 5 percent of the 155 children with central lines and catheter thrombus in one femoral and two internal jugular veins [43].

Complications of central venous catheters in adults are discussed separately. (See "Central venous catheters: Overview of complications and prevention in adults".)

UMBILICAL VEIN ACCESS — During the resuscitation of newborns younger than 10 days of age, emergency umbilical venous access can provide a reliable route for emergency medication and fluid administration during resuscitation and may be easier to perform and to maintain than intraosseous (IO) cannulation [51,52]. The umbilical vein can remain patent for up to 10 to 14 days after birth, but emergency umbilical vein access is most commonly used during delivery room resuscitation.

Umbilical vein catheterization is contraindicated in neonates with anatomic wall defects (eg, omphalocele, gastroschisis, omphalitis, or peritonitis). Studies of IO versus umbilical vein catheterization using simulated neonatal models suggest that an IO may be placed about 45 to 80 seconds faster than an umbilical venous line [53,54]. However, our experience suggests that IO placement can be technically difficult in newborns and frequently becomes dislodged during resuscitation. Thus, we favor umbilical venous access for emergency resuscitation of newborns when the provider has appropriate training and experience.

Standard trays for umbilical vein cannulation are commercially available. Essential equipment for the procedure includes:

●Antiseptic solution (eg, povidone-iodine solution) or iodine swabs

●Sterile gloves

●Umbilical vein catheter (UVC, 5 French for infants <3.5 kg, 8 French for infants ≥3.5 kg) flushed with normal saline and attached to a 10-cc syringe using a three-way stopcock

●Linen umbilical tape

●Scalpel (No. 11 or 15 blade)

●Small, curved hemostats

●Adhesive tape

Emergency UVC placement does not permit time for full sterile precautions [52]. The clinician should don sterile gloves and make every effort to keep the UVC sterile during the procedure. The technique for emergency umbilical vein catheterization is as follows (figure 11) [51,52]:

●Step 1 – With the infant supine, prepare the umbilical stump with antiseptic solution.

●Step 2 – Secure the umbilical tie around the base of the umbilicus using a firm half knot that will provide control of bleeding from the umbilical stump but still permit passage of the UVC.

●Step 3 – Cut the residual umbilical cord approximately 2 cm above the skin.

●Step 4 – Locate the umbilical vein (thin-walled, typically cephalad in the 12 o'clock position, and, in newborns, bleeds after cutting). For patients undergoing resuscitation outside of the delivery room, identify and remove any blood clot from the umbilical vein using a small, curved hemostat.

●Step 5 – While holding the base of the umbilicus with the nondominant hand, insert the preflushed UVC into the vein approximately 3 to 5 cm in a full-term infant (2 to 4 cm in a premature infant) and check for blood return.

●Step 6 – Once blood return is confirmed, secure the catheter manually or with adhesive tape and administer medications. Because emergency UVCs can frequently become misplaced during resuscitation, check for blood return prior to each use.

A clinical video of emergency umbilical venous access is provided in the reference [52].

Complications of emergency UVCs include air embolism, infection, and thromboembolism [51,52]. UVCs that are placed too deeply can lodge in hepatic vessels where medications may cause hepatocellular damage.

VENOUS CUTDOWN — The saphenous vein is a reliable site for venous access, even in small infants, and it is sufficiently removed from the region of most activity during cardiopulmonary resuscitation (CPR). Saphenous venous cutdown is an acceptable alternative means of vascular access if peripheral venous, central venous, and intraosseous (IO) cannulation are not achieved [55-58]. However, the other techniques are preferred because they are more often successful, have lower infectious complication rates, and take less time [14,43,44]. Saphenous vein cutdown should only be performed by clinicians with proper training and experience with the technique. In most settings, consultation with a surgeon with pediatric expertise is necessary.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Basic and advanced cardiac life support in children".)

SUMMARY AND RECOMMENDATIONS

●Approach – In infants and children with cardiac arrest, severe septic shock, or other conditions requiring emergency vascular (venous) access, intraosseous (IO) cannulation and peripheral venous access should be pursued simultaneously while preparing in parallel for ultrasound-guided central venous access (algorithm 1). (See 'General approach' above and 'Intraosseous access' above.)

For newborns younger than 10 days of age, umbilical vein cannulation is an alternative to IO access (algorithm 2). (See 'Umbilical vein access' above.)

For emergency access in other pediatric patients who are more stable, initial attempts at peripheral and, whenever available, ultrasound-guided intravenous (IV) placement should be attempted followed by IO cannulation if access is not rapidly achieved during resuscitation. (See 'Peripheral access' above.)

●Peripheral access – For the rapid delivery of isotonic solutions in patients with shock, large bore shorter peripheral catheters are preferred in most cases to central catheters because they can typically be placed more quickly and are shorter. (See 'Peripheral access' above.)

The preferred peripheral venous access site during pediatric resuscitation is the largest, most accessible vein that does not require the interruption of resuscitation. The use of a protocol can facilitate the rapid establishment of venous access. (See 'Sites' above.)

Although peripheral or IO access is recommended instead of central venous access during initial resuscitative efforts, in some situations, access with a larger-bore catheter may only be achieved centrally. (See 'Peripheral versus central' above.)

●Central access – Central venous catheters provide a reliable means for administering large volumes of fluid or potentially irritating solutions. They also permit monitoring of hemodynamic variables such as central venous pressure or mixed venous hemoglobin-oxygen saturation and reliable collection of blood samples. Ultrasound guidance should be used for central venous catheters whenever the equipment and operator experience is available. If central line placement is not possible in a timely fashion, then emergency consultation with a surgeon or intensivist with pediatric expertise should occur to obtain vascular access. (See 'Central access' above.)

●Umbilical vein access – During the resuscitation of newborn infants, emergency umbilical venous access provides a reliable route for emergency medication and fluid administration during resuscitation and may be easier to perform and to maintain than IO cannulation for providers with appropriate experience and training (algorithm 2). (See 'Umbilical vein access' above.)

●Techniques – Techniques for placement of the following types of venous access are described above:

•Peripheral (see 'Technique' above)

•Femoral vein (figure 7 and figure 8) (see 'Femoral vein' above)

•Subclavian vein (figure 9) (see 'Subclavian vein' above)

•Internal jugular vein (figure 10) (see 'Internal jugular' above)

•Umbilical vein (newborn infants) (figure 11) (see 'Umbilical vein access' above)

The technique for IO access is discussed separately. (See "Intraosseous infusion".)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Pamela Bailey, MD, who contributed to an earlier version of this topic review.