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1
RADIAL ARTERY:
If the umbilical artery catheter is not available or needs to be replaced, the radial artery is the preferred location for the newborn and, indeed, for all other patients
.
Method: Slightly extend the wrist with a rolled gauze pad, loosely tie the fingers to the hand plate with tape, and glue the thumb separately in the extension position to hold the surface skin
above the radial artery.
After sterile sterilization, the trocar that has been rinsed with heparinized saline is used as a "liquid probe" to increase the speed of
blood returning to the needle.
In the place near the strongest arterial pulse in the wrist striae, puncture the skin
at an angle of 15 ° ~ 20 °.
Palpation is a common method of identifying arteries, but if the pulse is weak, ultrasound Doppler localization may be helpful
.
A shallower level of anesthesia provides stronger arterial beats and increases catheter placement success
.
The success rate of the first puncture attempt is highest prior to hematoma formation or arterial dissection, so the operator should optimize conditions such as localization, illumination, and identification of blood vessels
.
A rapid return indicates that the needle has penetrated the artery
.
Continue to push the needle and cannula into the artery for 1~2mm, and then try to insert the entire cannula into the artery
.
The propulsion sleeve should have minimal resistance, and continuous blood return in the needle core is a sign of
successful tube placement.
If catheter placement is unsuccessful, the needle is carefully replaced in the cannula, at which point the needle and cannula may have penetrated the posterior wall
of the artery.
The needle is then removed and a 0.
015-gauge guidewire with a flexible tip can be used to assist in catheterization
.
Exit the cannula very slowly backwards, and when rapid arterial return occurs, push the guidewire through which the cannula is inserted into the artery
.
A very small resistance indicates successful
tube placement.
If catheterization is unsuccessful, further attempts may be made at the same site or slightly closer to the proximal end to avoid arterial spasm, thrombosis, or dissection
.
Distal catheter circulation
should be assessed by examining fingertip and nail bed color, capillary refill time, and signal quality of pulse oximetry.
The recommended method of fixing the catheter is to use a clear adhesive dressing and scotch pellucida so that the insertion and attachment of the catheter are always visible
.
2
FEMORAL ARTERY
The superficial femoral artery is a large blood vessel that can be easily inserted in almost all patients and is a second option
for cardiac surgery when radial artery access is not available.
In infants and young children, especially those with Down syndrome, up to 25% of patients with arterial placement using a 20Ga (3Fr) catheter will experience transient arterial hypoplasia
.
Therefore, we recommend that patients weighing less than 10 kg use the smallest commercially available catheter 2.
5Fr (equivalent to 21Ga).
Method: Place a small towel under the patient's buttocks so that the legs are slightly extended
to a neutral position.
Restrained the knee on the operating table with tape, rotating slightly outward to secure the proper position
.
After sterile preparation and clothing, palpate the beating of the superficial femoral artery and puncture 1~2cm below the inguinal ligament to avoid puncture above the pelvic margin, which may form a retroperitoneal hematoma
.
If the pulsation is weak (eg, coarctation of the aortic arch), ultrasound Doppler is effective in identifying vascular orientation
.
Puncture methods can be varied, including direct puncture with a trocar needle, or the use of a needle in a commercially available kit with Seldinger technology, or the use of a 21G butterfly needle
with an extension tube removed.
All of the above methods flush the needle with heparinized saline to increase the rate of
blood return.
Use a small flexible guidewire 0.
015 or 0.
018.
Polyethylene catheters can usually be passed through the guidewire without making a skin incision, and dilators are not recommended in any case to dilate channels and arteries; If the puncture site is large, this may cause arterial spasm, dissection, or bleeding
around the catheter.
Sutures are made at the entry site of the catheter and around the wings around the junction to secure the catheter.
Distal perfusion should be assessed immediately and pulse oximetry probes placed on the foot for continuous monitoring and early warning of arterial perfusion problems
.
3
Brachial artery
The brachial artery has been successfully used for monitoring cardiac surgery in children, but arterial surveillance
should generally be avoided because of the less collateral circulation than the radial, fetal, and axillary arteries.
Theoretically, the incidence of arterial insufficiency in this area should be higher, but Schindler et al.
study of 386 infants and children undergoing cardiac surgery using 22Ga and 24Ga catheters for brachial artery catheterization showed no permanent ischemic injury and only three temporary arterial occlusions
.
This site is selected only when other options are limited, such as when clipping is blocked to repair coarctation of the aortic arch, or if the aortic arch is dysplasia or is discontinued for cardiopulmonary bypass, and a right upper extremity arterial tubing is required to monitor blood pressure
.
Methods: Patients under 5 kg should use a 24Ga catheter.
The arm is bound to the hand plate in a neutral position, and the arterial pulse is palpated above the elbow striae and above the radial and ulnar
bifurcations.
The catheterization process is the same as that of the radial artery
.
Distal perfusion must be observed at all times, and catheter
removal should be indicated at any sign of ischemia.
Pulse oximetry monitors terminal beats to detect perfusion problems
early.
After aortic arch repair, the brachial artery catheter should be removed as soon as possible, or replaced in a site with better collateral circulation
.
4
AXILLARY ARTERY
Large axillary arteries with good collateral blood supply have demonstrated multiple series in critically ill children as a viable option when catheterization is not available elsewhere with a low
complication rate.
However, given the potential incidence of arm and hand ischemia, as well as the theoretical problem of intrathoracic bleeding, this site should be considered as a last resort
when the puncture site is limited.
Method: Extend the arm 90° and extend the shoulder slightly to expose the artery
.
The artery is palpated at the axillary roof and punctured using a trocar and then replaced with a longer catheter by a guidewire, or by the Seldinger technique
.
Catheters that are too short (such as 22Ga1 length) are often dragged out of the blood vessel when the
shoulder is extended.
Therefore, the recommended shortest catheter length is 5 cm
.
As with the brachial artery, special attention must be paid to distal perfusion
.
The position of the head should be determined by chest x-ray, not deeper than the first rib.
Due to its proximity to the brachiocephalic vessels, the catheter needs to be flushed very gently after blood draw, and no air bubbles or blood clots should be entered, as there is a risk of
retrograde cerebral embolism.
5
UMBILICAL ARTERY
The umbilical artery is available in the first few days of life and is the site
of choice for newborns who require surgery in the first week of life.
Placing the catheter tip in a high position (e.
g.
, above the diaphragm) has a lower
complication rate than when placed in a low position (e.
g.
, at the level of the third lumbar spine).
The catheter can be left for 7~10 days
.
It has been shown to be associated with intestinal ischaemia and necrotizing colitis, and enteral nutrition in the setting of umbilical artery catheter indwelling is controversial
.
Umbilical artery catheterization
is usually performed by neonatal staff shortly after birth, either in the delivery room or in the neonatal intensive care unit.
The technique involves cutting the umbilical cord stump with an umbilical cord around the base to stop bleeding, dilating the umbilical artery, blind probing into a 3.
5r catheter, resetting it to a certain depth according to the body, and then determining the location
of the catheter by radiological examination as soon as possible.
Complications such as lower extremity embolism, vascular insufficiency, and renal artery thrombosis have been reported
.
However, because it is a large central artery that allows accurate pressure monitoring at all stages of neonatal surgery, and preserves access for future interventions, the overall risk is low, so this site is highly desirable
.
6
Temporal artery
The superficial temporal artery is located just above the zygomatic arch and is large and easy to place in neonates, especially premature infants
.
It was widely used in neonatal intensive care units in the 70s of the 20th century, but it quickly lost favor due to the realization that its serious complications were very common, such as retrograde cerebral embolism
.
This method should only be used if surgery must measure brachiocephalic pressure and there is a subclavian artery abnormality, so the only way to measure pressure when performing aortic blockade or extracorporeal bypass is by measuring aortic pressure directly or through the superficial temporal artery
.
For example, coarctation of the aorta, dissociation or hypoplasia of the aortic arch, right subclavian artery
Abnormalities arise distal
to the area of aortic occlusion.
Catheters should only be used while the lesion is present, minimizing blood drawing and flushing, and must be removed
as soon as possible after lesion repair.
Methods: Newborns are catheterized using a 24Ga catheter
.
The location of the palpable artery is anterior and upper to the auricularis, above
the zygomatic arch.
A very shallow puncture angle, that is, 10 ° ~ 15 °, is used, and arterial catheterization
is performed according to the method described by radial artery puncture.
7
Dorsal/posterior tibial artery
When radial arteries are not available, these arteries are often easy to place and are useful
for monitoring and blood collection during surgery.
It is known that in the early period after cardiopulmonary bypass, there is peripheral vasoconstriction and vasomotor instability, and superficial arteries of the foot should not be used for extracorporeal circulation, since these arteries manifest themselves more pronounced
than the radial arteries.
Methods: The dorsal foot artery is slightly plantar flexed to straighten the artery, and the artery runs between
the second and third metatarsals.
A superficial angle is taken to puncture the artery and catheterization
.
Posterior tibial artery—the dorsum of the foot is extended to expose the artery between the medial malleolus and the
Achilles tendon.
Arteries are usually pierced deeply, so steeper penetration angles
are required.
A recent study evaluated the suitability of posterior tibial artery versus dorsal foot artery in patients with a median age of 13 months
.
The first phase of the study was to measure the diameter and cross-sectional area of the arteries by ultrasound, and the second phase was a randomized trial
conducted in 275 participants.
The posterior tibial artery is similar in size to the radial artery [(1.
4±0.
3) mm and (1.
3±0.
3) mm], but thicker than the dorsal foot artery [(1.
0±0.
2) mm, P<0.
001].
The success rate of first attempts at the posterior tibial artery was similar to that of the radial artery (75% and 83%, respectively), but higher than that of the dorsal foot artery (45%, P <0.
001).
If no other arteries are available, the posterior tibial artery may be used as an option
for foot artery catheterization.
(Our hospital has a posterior tibial artery for a 2.
6kg COA patient)
8
ULNAR ARTERY
The ulnar artery should only be used as a last resort if there are no other options, as it is usually considered only if an unsuccessful radial attempt or thrombosis has formed due to past punctures
.
If perfusion to both the radial and ulnar arteries is significantly impaired, the risk of hand ischaemia is high
.
Nevertheless, the incidence of ischemia in a group of 18 critically ill infants and children was not different from that of radial and femoral catheterization, which was 5.
6%.
With the increased use of high-resolution ultrasound in ductus arteriosus placement, it is clear that in some patients the diameter of the ulnar artery is sometimes larger than that of the radial artery, especially in
Down syndrome.
If this is indeed the case, some anesthesiologists will try to use the ulnar artery as the site
of the first catheterization attempt.
Text/Wu Yajun
Typesetting/jingle balls
