Gasto Público Latinoamerica - 2018
BUSCAR MAYOR COORDINACIÓN Y COOPERACIÓN INTERADMINISTRATIVA:
Dawn M. Walton Billie Lou Short
A. Indications (1,2,3,4, and 5)
• To locate artery or vein for:
o Puncture for sampling
o Vessel cannulation
o See also Chapter 36, for use in diagnosing thoracic air leaks (1,2,3,4 and 5).
B. Contraindications None
C. Precautions
• Use fiber-optic light source with appropriate filters to cool light and prevent burns (6,7).
• Place sterile surgical glove over tip of probe to preserve sterile field.
D. Equipment
• Transillumination source
o High-intensity fiber-optic light (black soft tube around probe can make light seal)
o Otoscope light may be used in some instances (8).
• Alcohol
• Sterile glove E. Technique
• Clean end of light source with an alcohol swab. Cover with sterile glove.
• Dim light in room. Some residual light is necessary to visualize operating field.
• Set light source at low intensity and increase as needed for visualization.
• Position probe to transilluminate vessel.
o Directly opposite to puncture site, through extremity
o Adjacent to vessel but out of way of procedure
• Identify vessel as dark, linear structure (Fig. 12.1).
o Edges may be indistinct.
o Arteries will be pulsatile.
• Compensate for distortion if light is not directly opposite puncture site.
• Do not maintain contact between light source and extremity for long periods of time.
F. Complications
• Burns from light probe (Fig. 12.2) (7)
• Cross-contamination from breach of sterile technique
FIG. 12.1. Transillumination. A: Arteries and veins on volar aspect of left wrist. B: Venous arch on dorsum of hand. C: Vessels in right antecubital fossa. D: Left posterior tibial artery.
P.83
FIG. 12.2. Burn from transilluminator.
References
1. Cole FS, Todres ID, Shannon DC. Technique for percutaneous cannulation of the radial artery in the newborn infant. J Pediatr. 1978;92:105.
2. Curran JS, Ruge W. A restraint and transillumination device for neonatal arterial/venipuncture: efficacy and thermal safety. Pediatrics. 1980;66:128.
3. Mattson D, O'Connor M. Transilluminator assistance in neonatal venipuncture. Neonatal Network.
1986;5:42.
4. Schwartz N, Eisenkraft JB. Transillumination aids the percutaneous cannulation of peripheral vessels. J Cardiothorac Anesth. 1989;3:675.
5. Dinner M. Transillumination to facilitate venipuncture in children. Anesth Analg. 1992;74:467.
6. Sajben FP, Gibbs NF, Friedlander SF. Transillumination blisters in a neonate. J Am Acad Dermatol.
1999;41:264.
7. Keroack MA, Kotilainen HR, Griffin BE. A cluster of atypical skin lesions in well-baby nurseries and a neonatal intensive care unit. J Perinatol. 1996;16:370.
8. Goren A, Laufer J, Yativ N, et al. Transillumination of the palm for venipuncture in infants. Pediatr Emerg Care. 2001; 17(2):130.
13-Venipuncture
Dawn M. Walton Billie Lou Short A. Indications
• Blood sampling
o Routine, particularly if a large volume of blood is needed
o Blood culture
o Central hematocrit
o Preferred (over capillary sample) for certain studies (1,2 and 3)
Ammonia (arterial optimal)
Drug levels
Cross-matching blood
Hemoglobin/hematocrit
Karyotype
Lactate and pyruvate levels (arterial optimal)
• Administration of drugs B. Contraindications
• Use of deep vein in presence of coagulation defect
• Local infection at puncture site
• Femoral or internal jugular vein (see G)
• External jugular vein in infants with respiratory distress, intracranial hemorrhage, or raised intracranial pressure
C. Precautions
• Observe universal precautions. Wear gloves.
• When sampling from neck veins, place infant in head-down position to avoid cranial air embolus. Do not use neck veins in infants with intracranial bleeding or increased intracranial pressure, except as a last resort.
• Remove tourniquet before removing needle, to minimize hematoma formation.
• Apply local pressure with dry gauze to produce hemostasis (usually 2 to 3 minutes).
• Avoid using alcohol swab to apply local pressure (painful, impairs hemostasis).
D. Special Considerations for Neonates
• Conserve sites to preserve limited venous access by using distal sites first whenever possible.
• Use small needle or scalp vein butterfly. A 23-gauge needle is best. Hemolysis or clotting may occur with a 25 gauge or smaller.
• Choice of veins (Fig. 13.1) in order of preference:
o Antecubital fossa
o Dorsum of hands
o Dorsum of feet
o Greater saphenous vein at the ankle
o Vein in center of the volar aspect of the wrist
o Scalp
o Proximal greater saphenous vein
o Neck
• Recent studies show that adequate pain control can be achieved during venipuncture with EMLA (Astra Pharmaceuticals, L.P., Wayne, PA, USA) cream applied 1 hour prior to procedure, if time allows (4,5).
• Oral sucrose solution (24% to 25%) provides quick and effective pain control for venipuncture (6,7).
• Heel lancing can be more painful and require more punctures than venipuncture in infants (4,8).
E. Equipment
• Gloves
• A 23- to 25-gauge venipuncture needle (a safety-engineered needle should be used) (Fig. 13.2).
• Syringe with volume just larger than sample to be drawn
• Prepared alcohol swabs
• Gauze pads
• Appropriate containers for specimens
• For blood culture:
o Povidone-iodine solution preparation (three swabs)
o Sterile gloves
o Blood culture bottle(s)
o Transfer needle
• Tourniquet or sphygmomanometer cuff
FIG. 13.1. The superficial venous system in the neonate.
FIG. 13.2. Safety-engineered needles for venipuncture.
F. Technique (See Procedures DVD for Video) General Venipuncture
• Locate the appropriate vessel. Use transillumination if necessary (see Chapter 12). Warm extremity with heel warmer or warm washcloth if circulation is poor.
• Apply anesthetic cream if time permits, and/or administer sucrose solution if possible.
• Restrain infant appropriately.
• Prepare area with antiseptic (see Chapter 4).
• Occlude vein proximally using either:
o Tourniquet or cuff inflated to level between systolic and diastolic pressure (Fig. 13.3)
o Direct pressure over vessel
o Rubber band (loop two bands together, tied as in Fig. 13.3)
FIG. 13.3. Correct application of a tourniquet for quick release.
FIG. 13.4. Anterior wall of vein removed. Needle penetrating skin a short distance from site of venipuncture.
• Remove occlusion device and replace to promote optimal vein distension.
• Check syringe function and attach to needle. Alternative method is to use Microlance needle (0.9 x 40 mm) (Becton Dickinson, Franklin Lakes, NJ, USA) without a syringe to collect samples by drip method. Drip method cannot be used for blood culture or coagulation studies (8).
• Penetrate skin first and position for entry of vein (Fig. 13.4).
o Angle of entry 25 to 45 degrees
o Bevel up preferred for optimal blood flow (less chance of needle occlusion by vein wall)
o Direction of entry with or against direction of blood flow
o If possible, insert needle at area where vessel bifurcates to avoid “rolling†of veins.
• Collect sample by gentle suction
o To prevent occlusion by vein wall
o To avoid hemolysis
• If Microlance needle is used, collect sample by drip directly into specimen container.
• Release tourniquet.
• Remove needle and apply local pressure with dry gauze for 3 minutes or until complete hemostasis.
FIG. 13.5. A: Anatomy of the femoral triangle as defined in the text. (Adapted from
Plaxico DT, Bucciarella RL. Greater saphenous vein venipuncture in the neonate. J Pediatr. 1978;93:1025 , with permission) B: Position of the femoral triangle on the abducted thigh.
Scalp Vein
• Shave adequate area of frontal or parietal scalp.
• Use scalp vein needle set or 23-gauge butterfly.
• Occlude vein proximally with finger, or place a rubber band around head circumference, avoiding eye area.
• Feel for a pulse to avoid tapping an artery.
• Use a shallow angle (15 to 20 degrees).
• See technique for general venipuncture.
Proximal Greater Saphenous Vein (9)
• Have assistant hold infant's thighs abducted with knees and hips slightly flexed.
• Locate femoral triangle (Fig. 13.5A).
o Proximal boundary: inguinal ligament
o Lateral boundary: medial border of sartorius muscle
o Medial boundary: lateral border of adductor longus muscle
• Enter skin and then vein at point approximately two-thirds along line from inguinal ligament to apex of triangle (Fig. 13.5B).
o Use relatively steep angle (60 to 90 degrees).
o After entering skin, advance while applying gentle suction 1 to 4 mm until blood return is achieved.
• See F, General Venipuncture.
External Jugular Vein
• Position infant in head-down position with head extended and rotated away from selected vessel (Fig. 13.6).
• Prepare skin over sternocleidomastoid muscle with antiseptic.
• Flick infant's heel to induce crying and optimize vein distension.
• Visualize external jugular vein running from angle of jaw to posterior border of sternocleidomastoid in its lower third.
• Puncture vessel where it runs across the anterior border of the sternocleidomastoid muscle.
• See F, “General Venipuncture.
FIG. 13.6. Infant positioned for puncture of external jugular vein.
G. Complications (10,11,12 and 13)
• Hemorrhage with
o Coagulation defect
o Puncture of deep vein
• Venous thrombosis or embolus, with puncture of large, deep vein (11)
• Laceration of adjacent artery
• During femoral vein puncture:
o Reflex arteriospasm of femoral artery with gangrene of extremity (12)
o Penetration of peritoneal cavity
o Septic arthritis of hip (13)
• During internal jugular puncture:
o Laceration of carotid artery
o Pneumothorax/subcutaneous emphysema
o Interference with ventilation owing to positioning for jugular vein puncture
o Raised intracranial pressure owing to head-down position aggravating intraventricular hemorrhage
• During scalp vein puncture:
o Laceration of artery
o Corneal abrasion or other eye damage if rubber band used improperly References
1. Baral J. Use of a simple technique for the collection of blood from premature and full-term babies. Med J Aust. 1968;1:97.
2. Shohat M. Preterm blood counts vary with sampling site [Letter]. Arch Dis Child. 1987;62:1193.
3. Thurlbeck SM, McIntosh N. Preterm blood counts vary with sampling site. Arch Dis Child. 1987;62:72.
4. Shah VS, Taddio A, Bennett S, et al. Neonatal pain response to heel stick vs venipuncture for routine blood sampling. Arch Dis Child Fetal Neonat Ed. 1997;77:F143.
5. Larsson BA, Tannfeldt G, Lagercrantz H, et al. Alleviation of the pain of venipuncture in neonates. Acta Paediatr. 1998;87:774.
6. Archarya AB, Annamali S, Taub NA, Field D. Oral sucrose analgesia for preterm infant venipuncture.
Arch Dis Child Fetal Neonat Ed. 2004;89:F17.
7. Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2004;(3):CD001069.
8. Larsson BA, Tannfeldt G, Lagercrantz H, et al. Venipuncture is more effective and less painful than heel lancing for blood tests in neonates. Pediatrics. 1998;101:882
9. Plaxico DT, Bucciarelli RL. Greater saphenous vein venipuncture in the neonate. J Pediatr. 1978;93:1025.
10. McKay RJ Jr. Diagnosis and treatment: risk of obtaining samples of venous blood in infants. Pediatrics.
1966;38:906.
11. Nabseth DC, Jones JE. Gangrene of the lower extremities of infants after femoral venipuncture. N Engl J Med. 1963;268:1003.
12. Kantr RK, Gorton JM, Palmieri K, et al. Anatomy of femoral vessels in infants and guidelines for venous catheterizations. Pediatrics. 1989;33:1020.
13. Asnes RS, Arendar GM. Septic arthritis of the hip: a complication of venipuncture. Pediatrics.
1966;38:837.