Hyperammonemia, Neonatal — Vascular Access Considerations — Clinical Pathway: Emergency Department and ICU

Neonatal Hyperammonemia Clinical Pathway — PICU and Emergency Department

Vascular Access Considerations

  • Aim to have at least one point of peripheral access (PIV) while preparing to obtain central access.
  • Arrange for central venous line placement. This is important for key aspects of management including high dextrose containing fluids and continuous medication infusions (all vesicants).
  • Consider dialysis catheter placement concurrent with central venous access placement, particularly for high-risk children, who are likely to require CRRT. Concurrent procedures minimize time outside of the ICU and episodes of procedural sedation, as well as reducing time to initiating CRRT if needed.
Vascular Access Preferred Catheters
Listed in preferred order		 Personnel for Placement Additional Considerations
  • PERIPHERAL
  • Aim for at least one
  • Preferably more than one point of peripheral IV access
    • Allows for IV fluids and resuscitative medications
 24 g Any qualified provider
  • For difficult peripheral access, consider ultrasound guided PIV placement
  • Consider placing nursing notification to VAS in epic for additional assistance
  • CENTRAL
  • Double lumen preferred over single lumen for medication compatibility
  • Obtain as soon as possible
    • Optimizes GIR
    • High dextrose containing fluids are vesicants
  • Provides continuous medication infusions if amino acid and/or nitrogen scavenger therapies are required
  • 1st Choice
    • 2.6 Fr double lumen PICC
  • Credentialed provider for PICC placement
  • Consider coordinating PICC/CVL placement at the same time as dialysis catheter placement as long as there is no delay in optimizing IV infusions and titrating GIR
  • 2nd Choice
    • 4 Fr double lumen percutaneously placed CVL
  • If a credentialed provider for PICC placement is not immediately available
  • DIALYSIS
  • Goal
    • Dialysis catheter to be inserted < 3 hours after identifying child will require CRRT
  • Refer to table below
  • 1st Choice
    • 8 Fr temporary dialysis catheter placement in the IJ or femoral vein is preferred
      (Highlighted in green in table below)
  • 2nd Choice
    • 7 Fr catheter, 7 or 10 cm
      (Highlighted in yellow in table below)
  • 1st
    • Interventional Radiology
  • 2nd
    • General Surgery Fellow
  • 3rd
    • If IR and OR services unavailable within 3 hour window, Critical Care provider at PICU bedside
  • Temporary dialysis catheters are preferred because treatment for hyperammonemia is a relatively short course
  • Sedation
    • In general, procedural sedation will be provided by PICU team. In some cases, PICU may communicate with General Anesthesia for assistance with procedural sedation if it does not delay catheter placement

Guidance for Choosing a Dialysis Catheter for CRRT

Type Size Available Length Model Supplier PICU Stock Notes and Child Placement
Temporary Dialysis 8 French 12 cm REF SL12P
HEMO-CATH ST		 MEDCOMP   PREFERRED Catheter
  • Recommend dilation prior to catheter (7 or 9 Fr)
  • Kit wire is soft, use caution to avoid kinking
  • Consider tunneling if expected use > 2 weeks
  • IJ or Femoral
Temporary Dialysis 7 French 7 and 10 cm REF T73M/REFT
74M SOFT-LINE		 MEDCOMP 7 fr 10 cm ALTERNATIVE Catheter
  • At discretion of the physician performing the procedure
  • IJ or femoral
Temporary Dialysis 8 French 12 cm MAHURKAR MEDTRONIC   ALTERNATIVE Catheter
  • Cannot tunnel, only for larger children
  • IJ or femoral
Cuffed Dialysis Catheter 8 French 18 cm
(15 cm tip to cuff)		 REF SL18P
HEMO-CATH LT		 MEDCOMP   ALTERNATIVE Catheter
  • May be tunneled or cuff left external (if short term)
  • IJ or femoral