Atlas of Procedures in Neonatology, 4th Edition

Vascular Access

26

Peripheral Intravenous Line Placement

Leah Greenspan-Hodor

Khodayar Rais-Bahrami

Martin R. Eichelberger

Percutaneous Method

  1. Indications
  2. Administration of intravenous (IV) medications, fluids, or parenteral nutrition when utilization of the gastrointestinal tract is not possible
  3. Equipment

Since the late 1960s, the variety of equipment available for peripheral vascular access has grown from a few sizes of metallic needles and stiff polyethylene tubes to an array of plastic cannulas, single- and multilumen catheters of different sizes and materials, and totally implantable devices (ports). The safest and more effective vascular access is obtained by carefully matching the neonate's size, therapeutic needs, and duration of required treatment with the most appropriate device and technique. Placement of peripheral IV lines is described in this chapter. Placement of central venous lines (excluding ports, which are not used routinely in neonates) is described in Chapter 31.

Sterile (Fig. 26.1)

  1. Povidone–iodine swabs or 70% alcohol swabs (or other antiseptic; see Chapter 4)
  2. Appropriate needle (minimum 24 gauge for blood transfusion)
  3. 21- to 24-gauge IV catheter (preferably shielded)
  4. Connection for cannula (i.e., T connector)
  5. 2- x 2-in gauze squares
  6. Isotonic saline in 3-mL syringe
  7. Heparinized flush solution (heparin 0.5 to 1 U/mL/mL normal saline) for heparin lock
  8. Scissors (for scalp IV placement)

Nonsterile

  1. Tourniquet
  2. Procedure light
  3. Materials for restraint (see Chapter 3)
  4. Transilluminator (optional)
  5. Warm compress to warm limb if necessary (heel warmer)
  6. Size-appropriate arm board
  7. Cotton balls
  8. Scissors
  9. Roll of 0.5- to 1-in porous adhesive tape, transparent tape, or semipermeable transparent dressings (1,2,3,4 and 5)
  10. If using tape, use the minimum amount necessary on fragile premature skin, and consider using a pectin barrier (Duoderm, ConvaTec/Bristol-Myers Squibb, Princeton, NJ, USA; Hollihesive, Hollister, Libertyville, IL, USA).
  11. Transparent tape or dressing will facilitate observation of IV site (Tegaderm, 3M Health Care, St. Paul, MN, USA).
  12. Precut self-adhesive taping devices are available from Veni-Gard Jr. (ConMed IV Site Care Products, Utica, NY, USA).
  13. Pacifier if appropriate. Sucking releases endorphins, which decrease pain. Consider tightly swaddling baby, leaving the limb needed for IV placement exposed. Swaddling is also a comfort measure. Some critically ill infants, such as a baby with persistent pulmonary hypertension (PPHN), may require pain medication, sedation, and/or paralysis prior to any invasive procedure, including IV line placement.
  14. Precautions
  15. Avoid areas adjacent to superficial skin loss or infection.
  16. Avoid vessels across joints, because immobilization is more difficult.
  17. Take care to differentiate veins from arteries.
  18. Palpate for arterial pulsation.
  19. Note effect of vessel occlusion.
  20. Limb vessel: arteries collapse, veins fill
  21. Scalp vessel: arteries fill from below, veins fill from above

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FIG. 26.1. Sterile equipment necessary for peripheral IV line placement.

  1. Note color of blood obtained (arterial blood is bright red and venous blood is darker).
  2. Look for blanching of skin over vessel when fluid is infused (arterial spasm).
  3. If limb requires warming prior to procedure, use a heel warmer (WarmGel, Prism Technologies, San Antonio, TX, USA). “Home-made” compresses such as a diaper soaked in hot water can cause severe thermal injury.
  4. Cut scalp hair using small scissors to allow for stabilization of the IV (do not shave the area).
  5. Apply tourniquet correctly (see D5 and Chapter 13).
  6. Minimize time applied.
  7. Avoid use in areas with compromised circulation.
  8. Avoid use for scalp vessels—tends to increase vessel fragility.
  9. When using peripheral scalp veins, avoid sites outside the hairline.
  10. Be alert for signs of phlebitis or infiltration.
  11. Inspect site hourly.
  12. Discontinue IV immediately at any sign of local inflammation or cannula malfunction.
  13. Long plastic catheters are not recommended for use in neonates because their relative rigidity increases the risk of damage to the vascular endothelium, thus increasing the possibility of venous thrombosis (6).
  14. Arrange tape dressing at IV site to allow adequate inspection or use transparent sterile dressing over site of skin entry (7).

Leibovici (8) was unable to show a positive effect of a daily change of the dressing, as compared with change every 72 hours, on the incidence of infusion phlebitis. Maki and Ringer (3) recommended not removing the transparent dressing until the catheter/ needle is removed.

  1. Consider use of protective skin preparation in small premature infants to prevent skin trauma upon removal of tape or dressing. No Sting Skin Protectant (3M Health Care, St. Paul, MN, USA) is a non-alcohol-containing product that is available commercially; however, it, as well as other commercially available skin protectants, has not been tested on neonates.
  2. Forms tough, protective coating, which bonds to skin
  3. Does not require removal when changing dressing
  4. The use of tincture of benzoin and other products to increase the adherence of tape should be limited, especially on the premature infant. These products create a tighter bond between the tape and the epidermis than the bond between the epidermis and the underlying dermis. This then causes stripping of the epidermis when the tape is removed. Using a protective skin preparation, for example, No Sting Skin Protectant, prior to the application of these products may decrease damage to the skin when tape is removed (9).
  5. Write date, time, and needle/cannula size on piece of tape secured to site.
  6. Loop IV tubing and tape onto extremity to take tension off the IV device.
  7. Limit to two to three placement attempts per person. Monitor carefully for clinical decompensation, particularly the very premature infant and babies with cardiac or respiratory compromise.
  8. Technique

Prepare as for minor procedure (see Chapter 4). Ensure that neutral thermal environment is maintained. It is often necessary to transfer small babies to a radiant warmer for peripheral IV placement to avoid cold stress. If the infant has received a recent enteral feeding, consider delaying the procedure until before the next feeding or placing a nasal or oral gastric tube to empty the stomach in order to prevent aspiration.

  1. Use transillumination to visualize vessel if needed (see Chapter 12).
  2. Select vessel for cannulation. The following is the suggested order of preference (see Fig. 26.2):
  3. Back of hand—dorsal venous plexus
  4. Forearm—median antebrachial, accessory cephalic veins

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FIG. 26.2. Simulated procedure showing IV needle held in dominant hand, while index finger and thumb of nondominant hand are used to anchor vein and stretch overlying skin.

  1. Scalp veins—supratrochlear, superficial temporal, posterior auricular
  2. Foot—dorsal venous plexus
  3. Antecubital fossa—basilic or cubital veins
  4. Ankle—small saphenous, great saphenous veins
  5. Cut hair with small scissors close to scalp if using scalp vessels. (Do not shave the area.)
  6. Warm limb with heel warmer, if necessary (rarely needed), for approximately 5 minutes.
  7. Apply tourniquet if anatomic site indicates.
  8. Place as close to venipuncture site as possible.
  9. Tighten until peripheral pulsation stops.
  10. Release partially until arterial pulse is fully palpable.
  11. Prepare skin area with antiseptic. Allow to dry.

In the United States, povidone–iodine solution and isopropyl alcohol are the most commonly used skin disinfectant solutions. Povidone–iodine has been shown to have greater efficacy than isopropyl alcohol and, in addition, is less damaging to skin tissue. Povidone–iodine solution should be applied to the proposed insertion site and allowed to dry for at least 30 seconds. It then should be removed with sterile saline or sterile water. The importance of removing the povidone–iodine solution cannot be overstressed, as there have been reports of burns, elevated iodine levels, and hypothyroidism in premature infants caused by prolonged contact and further absorption (9).

  1. Attach syringe and T connector to needle/cannula, and test patency by forcing a small amount of saline through.
  2. Detach syringe and T connector.
  3. Select straight segment of vein or confluence of two tributaries.
  4. Grasp catheter between thumb and first finger. For winged angiocath, grasp plastic wings (Fig. 26.2).
  5. Anchor vein with index finger of free hand and stretch skin overlying it. This maneuver may also be used to produce distention of scalp veins.
  6. Hold needle parallel to vessel, in direction of blood flow.
  7. Introduce needle through skin, a few millimeters distal to point of entry into vessel (see Chapter 13).
  8. Introduce needle gently into vessel until blood appears in hub of needle or in cannula upon withdrawal of stylet.

When using a very small vessel or in an infant with poor peripheral circulation, blood may not appear immediately in tubing. Wait. If in doubt, inject a small amount of saline after releasing tourniquet.

  1. Remove stylet. Do not advance needle farther, because back wall of vessel may be pierced.
  2. Advance cannula as far as possible.

Injecting a small amount of blood or flush solution into the vein prior to advancing the cannula may assist cannulation (Fig. 26.3) (10).

  1. Remove tourniquet.
  2. Connect T connecter and syringe, and infuse small amount of saline gently to confirm intravascular position.
  3. Anchor needle or cannula as shown in Fig. 26.4
 

FIG. 26.3. Injecting a small amount of flush solution will distend wall of vein and facilitate cannulation. (Redrawn from 

Filston HC, Johnson DG. Percutaneous venous cannulation in neonates: a method for catheter insertion without “cutdown.” Pediatrics 1971;48:896

, with permission of American Academy of Pediatrics.)

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  1. Attach IV tubing and secure to skin.
  2. If an armboard is necessary for securing site, place the affected extremity in an anatomically correct position before taping. Consider placing cotton or a 2 x 2-in gauze square beneath the hub of a T connector to prevent a pressure injury.
 

FIG. 26.4. Method for securing peripheral intravenous cannula with adhesive tape. A, B: Place an adhesive transparent tape over the cannula. C: Place tape 1 behind cannula as shown, with adhesive side up. D, E: Fold tape 1 anteriorly across the catheter–hub junction.F: Hold in place with tapes 2 and 3. The area of skin entry can be dressed with semipermeable sterile transparent dressing. Avoid obscuring with opaque dressing.

  1. Complications (11,12and 13)
  2. Hematoma—the most common but not usually significant complication. Hematomas can often be managed with gentle manual pressure.
  3. Venospasm—occurs rarely as a complication of venous access and usually resolves spontaneously
  4. Phlebitis (14,15)

Phlebitis remains the most common significant complication associated with the use of peripheral venous catheters. When phlebitis does occur, the risk of local catheter-related infection may be increased (15). Heparinized solutions (0.5 U/mL) have been shown to increase dwell time and reduce the frequency of complications such as phlebitis and erythema (16). The catheter material, catheter size, and tonicity of the infusate also influence the incidence of phlebitis. When peripheral lines are used for parenteral nutrition, the coinfusion of a lipid solution with the hyperosmolar total parenteral nutrition solution prolongs the life of the vein (17,18).

  1. Infiltration of subcutaneous tissue with IV solution. (For management of this complication, see Chapter 27.) This is unfortunately a common complication of peripheral IV infusion. Extreme vigilance and avoidance of hyperosmolar IV solutions will help to reduce the incidence to the minimum possible.
  2. Superficial blistering (Fig. 26.5)
  3. Deep slough, which may require skin graft (Fig. 26.6)
  4. Calcification of subcutaneous tissue due to infiltration of calcium-containing solution

Note that there may be some extravasation into adjacent tissues even though blood can be aspirated from the needle/cannula.

  1. Infection (19,20 and 21)

There is an increase in the incidence of both phlebitis and infection when a needle remains in place longer than 72 hours (7) and is heavily manipulated (21). An increase has also been reported with film-type dressings, but this remains controversial (1,2,3,4 and5,15). Catheters made with Teflon or polyurethane appear to be associated with fewer infections in adults than catheters made with polyvinyl chloride or polyethylene (15). Polyurethane catheters appear to have an approximately 30% lower risk of phlebitis than Teflon catheters in adults (15). Batton et al. (14) failed to confirm a difference in the incidence of infection when 25-gauge needles were compared with 24-gauge Teflon cannulas. However, the Teflon cannulas remained functional three times as long as steel needles, with no apparent increase in complications.

 

FIG. 26.5. Result of infusion of lidocaine into subcutaneous tissues of lower limb.

  1. Embolization of clot with forcible flushing
  2. Hypernatremia, fluid overload, or heparinization of the infant due to improper flushing technique or solution; also electrolyte derangements from IV fluid infused at an incorrect rate
 

FIG. 26.6. Extensive deep skin slough that required grafting, caused by IV infiltration.

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FIG. 26.7. A: Skin slough on scalp caused by inadvertent infusion into the frontal branch of the temporary artery. B: This is indicated by arrows.

  1. Accidental injection or infusion into artery with arteriospasm and possible tissue necrosis (Fig. 26.7)
  2. Burn from
  3. Transilluminator (Fig. 26.8; also see Chapter 12)
  4. Compress used to warm limb prior to procedure
  5. Prolonged povidone–iodine or isopropyl alcohol application to very premature skin
  6. Air embolus
  7. Ischemia or gangrene of lower extremity, complicating infusion into saphenous vein; mechanism unclear (21)
 

FIG. 26.8. Burn from transilluminator used to locate vein in antecubital fossa.

Cutdown Placement of IV Catheter in the Great Saphenous Vein

Modern vascular access catheters and techniques have made the traditional cutdown largely obsolete. However, this means of IV access is occasionally required in emergency situations, particularly shock, when time is of the essence. The saphenous vein at the ankle is the safest, quickest site for the physician with limited surgical experience. Intraosseous vascular access is an alternative method of obtaining IV access in an emergency and is described in Chapter 47. The method described has the advantage of avoiding incision of the vessel prior to introduction of the catheter. This is an important advantage in the very small infant, in whom it is difficult to avoid excessive venotomy and transection of the vein. Even in the most experienced hands, the cutdown procedure may take 10 minutes and

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last no longer than percutaneous IV access. When other methods cannot be performed, venous cutdowns may provide the only alternative means of emergency venous access.

  1. Indications
  2. To provide a route for peripheral IV therapy when the percutaneous method is not possible
  3. To provide a more stable and reliable IV line in situations where even brief cessation of therapy might compromise the infant
  4. To provide emergency IV therapy
  5. Contraindications
  6. Risk/benefit should be weighed carefully in the presence of bleeding diathesis.
  7. Should not be used as routine procedure for starting IV when percutaneous method is technically difficult but not impossible.
  8. Equipment

Sterile

  1. Gown and gloves
  2. Cup with antiseptic solution (e.g., an iodophor)
  3. Sterile aperture drape
  4. 0.5% lidocaine HCl in 2-mL syringe
  5. Two 25-gauge venipuncture needles
  6. Two curved mosquito hemostats
  7. 22-gauge cannula with needle stylet or a short length of small-diameter (0.6- to 1.2-mm outer diameter) silicone rubber catheter. The small silicone catheters reduce irritation but can slow the process of placing the line.
  8. T connector for cannula
  9. Heparinized saline (for heparin lock).
  10. Half-strength normal saline in a 5-mL syringe
  11. Absorbable suture or 5.0 nylon suture on small, curved needle. It is preferable to close the wound with subcuticular absorbable sutures, whenever possible, to avoid inflammation and formation of suture tracts (6).
  12. Needle holder
  13. 11 scalpel blade and handle
  14. Semipermeable, sterile transparent dressing

Nonsterile

  1. Materials for restraint (see Chapter 3)
  2. Transilluminator (cover with sterile plastic glove to maintain sterile field; see Chapter 12)
  3. Roll of 0.5- to 1-in porous adhesive tape
  4. Precautions
  5. Aspirate prior to injection of lidocaine to prevent inadvertent intravascular infusion.
  6. Take care not to make initial skin incision too deep, to avoid severing underlying vein.
  7. Avoid infusing extremely irritating or hypertonic solutions.
  8. Technique

Anatomic considerations: The great saphenous vein is constant in its anatomic position, just anterior to the medial malleolus. It is the only structure of importance in this area. The cutdown procedure is facilitated by the fact that the vein lies on tough periosteum and has sufficient elasticity to allow withdrawal through a small incision without the danger of rupture.

  1. Restrain foot in equinovalgus position.
  2. Palpate medial malleolus, and locate point of incision 1 cm anterior and 1 cm superior to malleolus (Fig. 26.9).
  3. Scrub, put on mask, gown, and gloves, and prepare area of incision, as for major procedure (see Chapter 4).
  4. Drape area.
  5. Indicate line of incision by marking skin with sterile surgical pen prior to infiltration with local anesthetic.
  6. Infiltrate skin along line of incision with 0.5 to 1 mL of lidocaine, and then extend infiltration into subcutaneous tissue.
  7. Wait 5 minutes for anesthesia to take effect.
 

FIG. 26.9. Position of restraint for cutdown on the great saphenous vein at the ankle, indicating site of incision.

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FIG. 26.10. Blades of curved hemostat are spread parallel to vein to dissect the subcutaneous connective tissue down to the periosteum.

  1. Make 1-cm transverse incision through skin, down to superficial subcutaneous fat. A vertical, rather than a transverse, incision is optional. The former has the advantage that it offers the opportunity to extend the incision cephalad, should the posterior wall of the vein be perforated on the initial attempt at cannulation. However, it has the disadvantage that it may be made too lateral or medial to the vein.
  2. Introduce curved hemostat into incision, with tip down. Spread blades of hemostat parallel to vein to dissect tissue down to periosteum. Continue this step until adequate visualization of vein is achieved (Fig. 26.10).
 

FIG. 26.11. A curved hemostat is used to “scoop” the vein into the incision.

 

FIG. 26.12. The hemostat has been carefully opened and the subcutaneous connective tissue spread, leaving the vein surface clean. A ligature is placed between the blades of the hemostat.

  1. Reintroduce curved hemostat into incision, with tip down, and pass down to periosteum. With a “scooping” motion, through approximately 180 degrees, isolate vein and draw into incision (Fig. 26.11).
  2. Open hemostat carefully. Spread subcutaneous tissue, leaving vein surface clean.
  3. Place 5-0 silk suture loosely around vein and clamp at end of suture with hemostat to allow for distal control of vessel (Fig. 26.12). (Do not tie ligature.)
  4. Place ligature with clamp across extended index finger and inside palm of nondominant hand, retracting it in an upward and caudad direction (Fig. 26.13).
 

FIG. 26.13. Outward and caudad traction is exerted on the suture.

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FIG. 26.14. Introducing the cannula into the vein.

  1. Introduce cannula/stylet into vein at a 45-degree angle, with bevel down. Once vein has been entered, angle cannula parallel to vein (Fig. 26.14).
  2. Advance cannula into vein while withdrawing inner needle stylet.
 

FIG. 26.15. Cystogram in infant who had not urinated for more than 24 hours despite “adequate” intravenous fluids. A: The bladder appears normal, but there is a “mass effect” displacing the intestines in approximate area indicated by arrows. B:Radiographic contrast material, injected through a long catheter introduced into the femoral vein via the great saphenous vein, has extravasated into the abdominal cavity.

  1. Advance cannula up to hub, and infuse small volume of saline flush solution to confirm intravenous position.
  2. Remove traction suture and close skin incision with subcuticular absorbable sutures or one or two simple 5-0 nylon sutures.
  3. Attach cannula to infusion tubing and regulate IV.
  4. Secure cannula to skin as shown in Fig. 26.4.
  5. Complications
  6. Same as for percutaneous method
  7. Inadvertent infusion of local anesthetic into artery or vein
  8. Severance of vein owing to excessively deep initial incision
  9. Infiltration of intravenous infusion into body cavity (Fig. 26.15)

This is a complication related to placement of very long catheters. When infusion of an extremely irritating or hypertonic solution is required, the catheter is preferably inserted into the central venous system (see Chapter 31).

  1. Varicose veins secondary to postinfusion phlebitis (22)

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Conversion of Peripheral IV Line to a Heparin Lock

  1. Technique
  2. Wash hands and put on gloves.
  3. Clean IV tubing and catheter connection with antiseptic solution.
  4. Stop IV infusion and remove IV tubing from hub of IV needle or cannula.
  5. Seal hub with a sterile plug or T-connector system (e.g., Argyle intermittent infusion plug [Consolidated Medical Equipment, Utica, NY, USA; Sherwood Medical Co., St. Louis, MO, USA] or Burron spin-lock port extension set [Burron Medical, Bethlehem, PA, USA] that has been primed with the required quantity of heparinized saline). As an improvisation, a stopcock with two dead heads may be used. However, at least 3 mL of flush solution is necessary to flush all parts of a stopcock. This increases the margin for error, with possible fluid overload in very small premature infants.
  6. Clean plug with antiseptic, and inject 0.4 to 0.8 mL of heparinized saline solution through plug to flush blood from needle or cannula.
  7. Clean plug with antiseptic prior to every use.
  8. Refill heparin lock with heparinized flush solution after every IV infusion. (Flush routinely every 6 to 12 hours, depending on frequency of use.)

References

  1. Wille JC, Blussae E, Vanovd Ablas A.A comparison of four film-type dressings by their antimicrobial effect on the flora of the skin.J Hosp Infect. 1989;14:153.
  2. Vernon HJ, Lane AT, Wischerater LJ, et al. Semipermeable dressing and transepidermal water loss in premature infants. Pediatrics.1990;86:357.
  3. Maki DG, Ringer M.Evaluation of dressing regimens for prevention of infection with peripheral intravenous catheters. JAMA.1987;258:3396.
  4. Craven DE, Lichtenberg DA, Kunches LM, et al. A randomized study comparing a transparent polyurethane dressing to a dry gauze dressing for peripheral intravenous sites. Infect Control.1985;6:361.
  5. Holland KT, Harnby D, Peel B.A comparison of the in vivo antibacterial effects of “Op-Site,” “Tegaderm” and “Ensure” dressings. J Hosp Infect. 1985;6:299.
  6. Ganderer MW.Vascular access techniques and devices in the pediatric patient. Surg Clin North Am. 1992;72:1267.
  7. Downing JW, Charles KK.Intravenous cannula fixing and dressing—comparison between the use of transparent polyurethane dressing and conventional technique. South Afr Med J. 1987; 721:191.
  8. Leibovici C.Daily change of an antiseptic dressing does not prevent infusion phlebitis: a controlled trial. Am J Infect Control.1989;17:23.
  9. Lund C, Kuller J, Lane A, et al. Neonatal skin care: the scientific basis for practice. JOGNN1999;28:241.
  10. Filston HC, Johnson DG.Percutaneous venous cannulation in neonates: a method for catheter insertion without “cut-down.”Pediatrics. 1971;48:896.
  11. Johnson RV, Donn SM.Life span of intravenous cannulas in a neonatal intensive care unit. Am J Dis Child. 1988;142:968.
  12. Duck S.Neonatal intravenous therapy. J Intravenous Nurs. 1997;20:121.
  13. Wynsma L.Negative outcomes of intravascular therapy in infants and children. AACN Clin Issues. 1998;9:49.
  14. Batton DG, Maisles JMAppelbaum JM.Use of intravenous cannulas in preterm infants: a controlled study. Pediatrics.1982;70:487.
  15. Centers for Disease Control.Special communication. Guideline for prevention of intravascular device-related infections. Am J Infect Control. 1996;24:262.
  16. Moclair A, Bates I.The efficacy of heparin in maintaining peripheral infusions in neonates. Eur J Paediatr. 1995;154:567.
  17. Pineault M, Chessex P, Pledboeuf B, et al. Beneficial effect of coinfusing a lipid emulsion on venous patency. J Parenter Enter Nutr.1989;13:637.
  18. Phelps SJ, Lochrane EB.Effect of the continuous administration of fat emulsion on the infiltration rate of intravenous lines in infants receiving peripheral parenteral nutrition solutions. J Parenter Enter Nutr. 1989;13:628.
  19. Lloyd-Still JD, Peter G, Lovejoy FH.Infected “scalp-vein” needles. JAMA. 1970;213:1496.
  20. Lozon, MM.Pediatric vascular access and blood sampling techniques. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia: Saunders; 2004:366–371.
  21. Cronin WA, Germanson TP, Donowitz LG.Intravascular cannula colonization and related blood stream infection in critically ill neonates. Infect Control Hosp Epidemiol. 1990;11:301.
  22. Shuster S, Laks H.Varicose veins following ankle cut-downs. J Pediatr Surg. 1973;8:245.