# Thrombosis — GCMD Library living collection

Everything in the library about thrombosis — built automatically from dossiers that name it.

Updated: n/a · 3 episodes · 65 cited statements

## Episodes
### Medical Management
- [How do we manage thrombogenicity and thrombosis in the Fontan? New Horizons...](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886) — video · 16:51 · [machine version](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886.md)

### Surgical Management
- [Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870) — video · 13:54 · [machine version](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870.md)
- [Pediatric Vascular Access](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112) — podcast · 35:43 · [machine version](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=0) Introduction and thrombotic burden in Fontan circulation (Ep 1)
- [3:19](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=199) Case 1: Young adult with superficial thrombophlebitis and abnormal labs (Ep 1)
- [4:40](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=280) Pathophysiology: Virchow's triad in Fontan circulation (Ep 1)
- [5:48](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=348) Aspirin versus warfarin and time-in-therapeutic-range data (Ep 1)
- [7:41](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=461) Case 2: Active 10-year-old with factor V Leiden and challenges of universal anticoagulation (Ep 1)
- [9:16](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=556) Biomarkers for risk stratification and the honeymoon phase (Ep 1)
- [12:13](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=733) Proposed personalized monitoring approach and case management (Ep 1)
- [15:20](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=920) Direct oral anticoagulants: need for data and monitoring (Ep 1)
- [0:13](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=13) Types of Central Venous Access Devices (Ep 2)
- [1:54](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=114) Site Selection and Contraindications (Ep 2)
- [2:57](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=177) Preoperative Workup and Imaging (Ep 2)
- [3:59](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=239) Patient Positioning and Equipment Selection (Ep 2)
- [5:12](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=312) Internal Jugular Access Technique (Ep 2)
- [6:42](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=402) Subclavian Access Technique (Ep 2)
- [7:46](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=466) Catheter Tip Positioning and Confirmation (Ep 2)
- [9:03](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=543) Complications and Line Infection Management (Ep 2)
- [10:20](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=620) Antimicrobial Lock Solutions (Ep 2)
- [12:08](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=728) Salvage Access Techniques (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=0) Introduction and series overview (Ep 3)
- [0:38](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=38) Catheter sizing and micro-preemie technique (Ep 3)
- [6:50](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=410) Catheter tip positioning and measurement (Ep 3)
- [10:22](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=622) Ultrasound guidance evidence and technique (Ep 3)
- [14:57](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=897) Device selection for oncology patients (Ep 3)
- [18:17](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1097) Vascular imaging and salvage techniques (Ep 3)
- [21:31](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1291) Site selection and femoral access (Ep 3)
- [23:58](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1438) Coagulopathy management and heparin protocols (Ep 3)
- [27:00](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1620) Ethanol lock for infection prevention and treatment (Ep 3)
- [28:26](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1706) Thoracoscopic salvage access technique (Ep 3)
- [31:17](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1877) Skin preparation and catheter removal (Ep 3)
- [34:48](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=2088) Closing remarks (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "Fontan circulation is a profoundly prothrombotic state and thrombosis is a major cause of death in patients with Fontan circulation." — Joe (clinical) [Ep 1 · 1:01](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=61)
- "Many thrombotic events in Fontan patients are subclinical but clinically significant." — Joe (clinical) [Ep 1 · 1:10](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=70)
- "The prevalence of silent pulmonary embolism in adults with Fontan circulation may be as high as 1 in 5 (20%)." — Joe (host_summary) [Ep 1 · 1:23](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=83)
- "In Paul Monagle's study comparing aspirin and warfarin in newer style Fontans, patients had an overall cumulative risk of 22% for thrombotic events." — Joe (host_summary) [Ep 1 · 1:39](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=99)
- "The cumulative hazard risk of thrombotic events in Fontan patients increases over time, with Fontan circulation becoming essentially a freight train of thrombogenicity." — Joe (clinical) [Ep 1 · 2:19](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=139)
- "Fontan circulation's thrombotic risk is comparable to paroxysmal nocturnal hemoglobinuria (30-40% risk over 5 years), antiphospholipid antibody syndrome, and unprovoked venous thromboembolism (20-30% recurrence rate)." — Joe (clinical) [Ep 1 · 2:41](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=161)
- "Relative hypoxia and loss of pulsatile flow in the venous system is very thrombogenic for endothelial cells." — Joe (clinical) [Ep 1 · 4:52](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=292)
- "Hypoxia and loss of pulsatile flow result in upregulation of tissue factor expression (the primary initiator of the clotting cascade), upregulation of adhesion molecules that activate inflammatory cells, and increased secretion of factor VIII and von Willebrand factor." — Joe (clinical) [Ep 1 · 5:01](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=301)
- "Protein-losing enteropathy (PLE) results in increased inflammatory system activation in Fontan patients." — Joe (clinical) [Ep 1 · 5:17](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=317)
- "Liver synthetic dysfunction can develop over time in Fontan patients and worsen hemostatic system activation." — Joe (clinical) [Ep 1 · 5:22](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=322)
- "Overall data supports that warfarin is better thromboprophylaxis than aspirin in Fontan patients." — Joe (clinical) [Ep 1 · 6:05](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=365)
- "Reanalysis of Monagle's data showed that warfarin with time-in-therapeutic-range of 60% or better edged out aspirin over time." — Joe (host_summary) [Ep 1 · 6:14](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=374)
- "Retrospective data from Cedric Manliot's group showed warfarin was clearly better than aspirin, though both were significantly better than no thromboprophylaxis." — Joe (host_summary) [Ep 1 · 6:39](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=399)
- "Excellent time-in-therapeutic-range above 80% with warfarin is achievable using a paternalistic approach with aggressive monitoring and phone follow-up." — Joe (clinical) [Ep 1 · 7:05](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=425)
- "In patients with excellent time-in-therapeutic-range (>80%), Grushin's group observed only one thrombotic event over 53 patient-years." — Joe (host_summary) [Ep 1 · 7:14](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=434)
- "Even with well-managed anticoagulation, the bleeding risk is around 2% per year." — Joe (epidemiological) [Ep 1 · 8:33](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=513)
- "Warfarin is very problematic from a pharmacokinetic standpoint and poorly managed warfarin may actually increase thrombotic risk." — Joe (clinical) [Ep 1 · 8:43](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=523)
- "Direct oral anticoagulants (DOACs) such as rivaroxaban and apixaban seem superior to warfarin in many ways but are completely unproven in Fontan patients." — Joe (clinical) [Ep 1 · 8:52](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=532)
- "Thrombotic risk in Fontan patients follows a bimodal incidence: initial post-surgical risk, then a honeymoon phase of variable duration, followed by inexorable increase in thrombotic risk." — Joe (host_summary) [Ep 1 · 9:16](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=556)
- "The honeymoon phase duration can vary and may be predictable using biomarkers." — Joe (opinion) [Ep 1 · 9:40](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=580)
- "Elevated D-dimer is a strong marker of increased thrombotic risk in adults with unprovoked venous thromboembolism." — Joe (host_summary) [Ep 1 · 10:08](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=608)
- "Elevated factor VIII is a strong marker of increased thrombotic risk and can be elevated due to genetic factors, endothelial cell activation, or as an acute phase reactant indicating inflammation." — Joe (clinical) [Ep 1 · 10:17](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=617)
- "Factor VIII activity increases significantly post-Fontan, and in one study the four patients with the highest factor VIII levels were the ones who developed thrombotic complications." — Joe (host_summary) [Ep 1 · 10:49](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=649)
- "In Fontan patients, natural anticoagulants (antithrombin, protein C) are often lower, consistent with liver synthetic dysfunction developing over time." — Joe (host_summary) [Ep 1 · 11:10](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=670)
- "Despite lower procoagulants from liver dysfunction, Fontan patients have elevated prothrombin fragment 1.2, indicating they are at thrombotic risk rather than bleeding risk." — Joe (host_summary) [Ep 1 · 11:46](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=706)
- "Fontan circulation, even in the context of liver dysfunction, shifts the hemostatic balance toward a thrombophilic state." — Joe (clinical) [Ep 1 · 12:13](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=733)
- "Monitoring D-dimer, factor VIII, liver function tests, and albumin every 6 months can predict when the honeymoon period of relatively low thrombotic risk is ending." — Joe (opinion) [Ep 1 · 13:00](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=780)
- "Aspirin VerifyNow is an extremely reliable and reproducible test that confirms patients are taking aspirin and having an antiplatelet response." — Joe (clinical) [Ep 1 · 14:40](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=880)
- "DOACs need to be studied in the Fontan population before determining how good or bad they are." — Joe (opinion) [Ep 1 · 15:26](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=926)
- "To use DOACs routinely in Fontan patients, reliable monitoring methods are needed because organ function can change rapidly in these patients." — Joe (clinical) [Ep 1 · 15:36](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=936)
- "DOACs are most likely better than poorly controlled warfarin, but high time-in-therapeutic-range is achievable with warfarin in most patients." — Joe (opinion) [Ep 1 · 16:21](https://library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=981)
- "In the United States, approximately 5 million central venous catheter lines are placed annually, with several thousand in pediatric surgical patients." — Rod Gerardo (host_summary) [Ep 2 · 0:13](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=13)
- "At Cincinnati Children's Hospital, the transplant surgery team manages complex vascular access and catheter-based dialysis access." — Alex Bondoc (clinical) [Ep 2 · 0:26](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=26)
- "Central venous catheters are non-tunneled, typically for temporary hospital use, and can have 1 to 3 lumens." — Rod Gerardo (host_summary) [Ep 2 · 1:00](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=60)
- "Ports are for long-term access (months to years), have tunneled catheters with totally implantable reservoirs, are often used for chemotherapy, and can have 1 or 2 lumens." (host_summary) [Ep 2 · 1:10](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=70)
- "Broviac catheters are tunneled lines with cuffs, used for months to years for chemotherapy, parenteral nutrition, or frequent blood transfusions, and can have 1 or 2 lumens." — Rod Gerardo (host_summary) [Ep 2 · 1:25](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=85)
- "Hemodialysis or pheresis catheters can be temporary (uncuffed) or permanent (cuffed), and can have 1 to 3 lumens." (host_summary) [Ep 2 · 1:40](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=100)
- "From a logistical standpoint, chest and neck central venous access is preferred over femoral access." — Alex Bondoc (clinical) [Ep 2 · 2:09](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=129)
- "There is evidence suggesting an increased rate of complications and infection with femoral access compared to chest and neck access." (host_summary) [Ep 2 · 2:17](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=137)
- "Contraindications for central venous access include thrombosis, collateralization, and central stenosis of the SVC, which may require exotic concurrent procedures or alternative access sites." — Alex Bondoc (clinical) [Ep 2 · 2:39](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=159)
- "Unless patients have congenital anomalies (usually cardiovascular), routine pre-procedural ultrasound is not necessary for first-time line placement." — Alex Bondoc (clinical) [Ep 2 · 3:09](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=189)
- "For patients requiring multiple lines (line number 4, 5, or 6), Doppler venous ultrasound of the jugulars is recommended, and in small children the SVC and subclavians can sometimes be visualized." — Alex Bondoc (clinical) [Ep 2 · 3:20](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=200)
- "Pre-procedural imaging may be escalated to contrast-enhanced MR or CT venography, and sometimes intraoperative venography with fluoroscopy is performed." — Alex Bondoc (clinical) [Ep 2 · 3:37](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=217)
- "For small children, neonates, and infants, positioning over a vertically oriented shoulder roll (parallel with the spine) provides hyperextension of the neck and allows shoulder weight to drop posteriorly, giving access to bilateral subclavians and jugulars." — Alex Bondoc (clinical) [Ep 2 · 3:59](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=239)
- "For very small neonates, many surgeons prefer a cut-down approach over percutaneous access." — Rod Gerardo (host_summary) [Ep 2 · 4:43](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=283)
- "Dr. Bonddo prefers using a micropuncture kit with a 21-gauge finder needle for small babies, which is smaller than the 18-gauge needle in standard tunnel line kits." — Alex Bondoc (clinical) [Ep 2 · 4:55](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=295)
- "Using ultrasound for internal jugular central line placement is the number one preferred method, with the lowest risk of pneumothorax and carotid artery injury." — Alex Bondoc (clinical) [Ep 2 · 5:25](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=325)
- "For large-bore access like dialysis catheters, the patient should be stuck as low as possible on the neck, using the ultrasound probe (approximately 12mm diameter) levered against the clavicle as a landmark." — Alex Bondoc (clinical) [Ep 2 · 5:52](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=352)
- "Low neck puncture leaves more catheter to curve in the neck; mid-neck puncture creates lax catheter that can lead to problems with neck turning and catheter displacement from the SVC." — Alex Bondoc (clinical) [Ep 2 · 6:22](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=382)
- "Subclavian line placement should be considered when both IJ access sites are lost or the patient is in a cervical collar." (host_summary) [Ep 2 · 6:42](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=402)
- "For subclavian access, the insertion point is at the junction of the median and medial aspects of the clavicle, at least one finger breadth (approximately 1cm) inferiorly and laterally, to allow levering under the bone." — Alex Bondoc (clinical) [Ep 2 · 6:56](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=416)
- "When approaching the clavicle during subclavian access, the needle should be kept flat with downward pressure on the skin rather than angling at 30 degrees." — Alex Bondoc (clinical) [Ep 2 · 7:14](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=434)
- "For subclavian access, the needle should be aimed directly at the sternal notch initially, then angled wider toward the angle of the mandible in a radial motion if unsuccessful." — Alex Bondoc (clinical) [Ep 2 · 7:34](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=454)
- "The catheter tip should typically be positioned at the junction between the right atrium and superior vena cava." (host_summary) [Ep 2 · 7:46](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=466)
- "The right triangle technique for catheter tip positioning uses the trachea as the theoretical midline continued from the carina, with the right main stem bronchus as the hypotenuse; the catheter tip should be within this triangle to ensure atriocaval junction placement." — Alex Bondoc (clinical) [Ep 2 · 8:04](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=484)
- "Post-procedural chest X-ray is not routinely ordered for single-stick, uncomplicated line placement using fluoroscopy, based on data from Children's Mercy Hospital Kansas City." — Alex Bondoc (clinical) [Ep 2 · 8:38](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=518)
- "Post-procedural complications include pneumothorax, hemothorax, arterial injury (subclavian or carotid), and rare complications like chylothorax or thoracic duct injury." — Alex Bondoc (clinical) [Ep 2 · 9:06](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=546)
- "Long-term complications include thrombosis, catheter displacement, kinking, and eventual line degradation over extended periods." — Rod Gerardo (host_summary) [Ep 2 · 9:21](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=561)
- "For line infection management, the first clinical decision is whether the patient is septic from the line; if septic and in the ICU, source control requires bedside line removal under light sedation." — Alex Bondoc (clinical) [Ep 2 · 9:41](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=581)
- "For non-septic line-dependent patients with complex vascular access, the organism and antibiotic sensitivity are determined, serial blood cultures are obtained, and the line may be salvaged if sustained culture negativity is achieved." — Alex Bondoc (clinical) [Ep 2 · 10:04](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=604)
- "Traditional locking solutions are predominantly antibiotic locks, but they lead to development of bacterial resistance." — Paul Wales (clinical) [Ep 2 · 10:35](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=635)
- "Ethanol locks are antimicrobial without resistance development and kill both planktonic bacteria (floating in the lumen) and sessile bacteria (embedded in biofilm along the catheter wall)." — Paul Wales (clinical) [Ep 2 · 10:56](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=656)
- "Kite lock is a 4% tetrasodium EDTA solution that is antimicrobial without resistance, and has antifibrinolytic and antithrombotic properties." — Paul Wales (clinical) [Ep 2 · 11:24](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=684)
- "Kite lock is licensed for pediatric use in Canada, Europe, and Australia, but availability varies by region." — Paul Wales (clinical) [Ep 2 · 11:59](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=719)
- "For patients with exhausted femoral, IJ, and subclavian access options, translumbar line placement through the back musculature into the intrahepatic IVC is an alternative approach performed with interventional radiology." — Alex Bondoc (clinical) [Ep 2 · 12:19](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=739)
- "For emergency vascular access via facial vein cutdown, a horizontal incision is made just lateral to the sternocleidomastoid at the angle of the mandible with the head turned to the patient's left, and the facial vein is typically the first large vein encountered." — Alex Bondoc (clinical) [Ep 2 · 12:48](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=768)
- "For facial vein cutdown, the catheter should be beveled hard to allow blind passage without wire guidance, theoretically allowing it to follow a path without bumping against the vessel wall." — Alex Bondoc (clinical) [Ep 2 · 13:04](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=784)
- "In micro-preemies (1000g to 2kg), a 3-French soft silastic catheter is preferred because larger catheters as big as the vessel can cause vessel thrombosis." — Mark Wulkan (clinical) [Ep 3 · 1:30](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=90)
- "Needle-hole venotomy technique: isolate the internal jugular vein, make a needle hole with the kit needle, and slide the pre-tunneled catheter into that hole without ligating the vein, preserving it for future access." — Mark Wulkan (clinical) [Ep 3 · 2:33](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=153)
- "Beveling the catheter end is associated with slightly more catheter thrombosis than cutting straight across, but may be worth it to preserve the vein in micro-preemies." — Mark Wulkan (clinical) [Ep 3 · 3:23](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=203)
- "The atrial-caval junction is actually much deeper on chest X-ray than most surgeons think, not at the visible indentation where the silhouette widens." — Mark Wulkan (host_summary) [Ep 3 · 9:13](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=553)
- "A 2013 JACS study by Sanj Dutta, Sean St. Peter and others showed ultrasound guidance achieved first-stick success in 65% of patients versus 45% with landmark technique, and 95% success by three attempts versus 74%." — Mark Wulkan (host_summary) [Ep 3 · 10:25](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=625)
- "In the adult literature, the number of needle sticks is a good proxy marker for the risk of complications." — Mark Wulkan (host_summary) [Ep 3 · 11:25](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=685)
- "Subcutaneous ports (port-a-cath, meta-port) are used for most intermittent chemotherapy; cuffed lines (Broviac) are used for highly toxic agents like Adriamycin that cause tissue necrosis if infiltrated." — Mark Wulkan (guideline) [Ep 3 · 13:36](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=816)
- "Bone marrow transplant patients often require three lumens: a double-lumen perm-cath plus a single-lumen line." — Mark Wulkan (clinical) [Ep 3 · 14:32](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=872)
- "The smallest mini-port available is 5-French and can be placed in a 7-8 kg infant, though it requires special order." — Mark Wulkan (clinical) [Ep 3 · 14:57](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=897)
- "MRV is the gold standard for pre-operative vascular imaging in patients with multiple prior lines or history of DVT." — Mark Wulkan (guideline) [Ep 3 · 15:34](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=934)
- "A glide wire can sometimes pass through venous thrombosis when a standard wire cannot, finding a channel through the clot." — Mark Wulkan (clinical) [Ep 3 · 17:53](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1073)
- "Femoral lines in babies often result in leg swelling and DVT, so they are avoided in that population." — Mark Wulkan (clinical) [Ep 3 · 22:03](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1323)
- "Institutional heparin lock protocol: 10 units/mL for accessed lines (ports or cuffed lines), 100 units/mL for buried ports, and 1000 units/mL for dialysis catheters (which is withdrawn before use)." — Mark Wulkan (guideline) [Ep 3 · 24:40](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1480)
- "Ethanol lock therapy has substantially decreased line removal rates and has very high success rates for treating line infections." — Todd Ponsky (clinical) [Ep 3 · 25:31](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1531)
- "For gram-positive line infections, ethanol lock plus antibiotics through the catheter can clear the infection; for gram-negative infections, success rate is approximately 50%; for fungal infections (Candida), the line must be removed." — Mark Wulkan (guideline) [Ep 3 · 26:16](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1576)
- "Antibiotic-coated and heparin-coated temporary catheters have been shown to decrease catheter-associated bloodstream infection rates." — Mark Wulkan (epidemiological) [Ep 3 · 27:41](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1661)
- "Thoracoscopic-guided trans-mediastinal puncture technique: advance a needle through the thrombosed IJ track into the superior vena cava under thoracoscopic visualization; the SVC almost always recanalizes where the azygous vein enters." — Mark Wulkan (clinical) [Ep 3 · 28:26](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1706)
- "For thoracoscopic salvage access in larger patients (17-year-old mentioned), the standard kit needle may not be long enough and an extra-long spinal needle is required." — Mark Wulkan (clinical) [Ep 3 · 29:53](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1793)
- "The APSA Outcomes Committee meta-analysis in 2011 found Class A or B evidence that chlorhexidine-alcohol prep decreases line infections compared to betadine." — Mark Wulkan (host_summary) [Ep 3 · 31:17](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1877)
- "There is speculation (without definitive evidence) that betadine exposure causes silicone catheter deterioration, making old lines chalky and difficult to remove." — Mark Wulkan (opinion) [Ep 3 · 31:17](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1877)
- "Broviac cuffs placed far from the exit site are designed to break away with slow, steady traction, allowing bedside removal without cuff excision." — Mark Wulkan (clinical) [Ep 3 · 32:46](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1966)
- "In 17-18 years of practice, only one retained cuff developed infection requiring incision and drainage." — Mark Wulkan (clinical) [Ep 3 · 33:14](https://library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1994)

## Changelog
- Sep 19: 3 items added automatically

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