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Circulation procedures

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    Intra Osseous (IO) access


    • Venous Access may be difficult in children, sometimes more so in the critically ill child.
    • It is indicated in a child following two failed attempts at cannulation (90 seconds) when IMMEDIATE access is required.


    Intraosseous needles:

    Intraosseous needles

    • IO needle with handle attached
    • Sterile towels
    • Sterile gloves
    • Betadine or chlorhexidine
    • 5ml and 10 ml syringe
    • Normal saline ampoule

    Surface markings:

    Surface markings legs

    • Adhesive tape


    The preferred site is the anterior tuberosity, 2-3 cm below the tibial tuberosity (the anteromedial flat part of the tibia).

    If the Tibia is fractured, an alternate site is the inferior part of the femur, 3 cm above the external condyle.


    • Surgically prep the area.
    • If patient is conscious, use local anaesthetic.
    • Insert at 90 degrees to the skin, with a screwing motion into the anteromedial surface of the tibia. There is usually a sense 'loss of resistance' as the marrow cavity is penetrated.

    Insertion of needle:

    Insertion of needle

    • Attach the 5 ml syringe; aspirate and flush to confirm correct positioning.
    • Attach the N/S-filled syringe and push in the fluid boluses.
    • The IO should be replaced with IV cannulation once resuscitation has taken place.

    Venous cutdown


    Venous cutdown should be performed only as a last resort for venous access.

    The advantage is that with IV cutdown, a large-bore cannula can be inserted under direct vision. Usually using the long saphenous the procedure may be carried out away from and therefore not interfering with the on-going resuscitation

    Equipment required

    • IV cutdown pack
    • Sterile gown and gloves
    • Sterile towels x 2
    • Chorhexadine skin prep
    • 5ml syringe
    • 25g needle
    • Lignocaine 1% 5ml ampoule
    • N/Saline 10ml ampoule
    • Syringe for taking blood
    • 3/0 nylon suture and needle
    • IVC Large bore
    • Scalpel
    • 3- way tap with 10cm extension
    • Tegaderm
    • I.V fluids and tubing


    The distal saphenous vein in the ankle is the most common site for a venous cutdown. The saphenous vein is just anterior to the medial malleolus.


    • Surgically prepare the area.
    • Infiltrate the skin and subcutaneous tissues with local anaesthetic.
    • Make incision of 1-2 cm through the skin over the vein. Bluntly dissect down to the vein (using mosquito forceps to open up the tissues and expose the vein).
    • If you can't see the vein, gently run the point of the forceps over the tibia to locate it.
    • Pass two silk sutures under the vein, then apply traction on the distal of the two sutures to better expose the vein.
    • Incise the vein length-ways and pass a large bore cannula into the lumen.
    • Tie the proximal suture around the cannula in the vein - firmly, but not so tight as to occlude the lumen of the cannula.
    • Aseptically connect the IV giving set.
    • Suture the incision site closed and cover with a sterile dressing.