Difficult Intravenous Access in Children


Difficult Intravenous Access in Children, Pediatric Peripheral IV Access, Peripheral Intravenous Access Anesthetic Premedication

  1. Children <3 years old (especially less than 1 year old)
    1. Infants require at least 2 IV attempts in most cases (and an average of 33 minutes for access)
    2. Weight <5 kg (11 lb)
    3. Prematurity
  2. Other conditions
    1. Obesity
    2. Edema
    3. Burn Injury
    4. Sclerosed veins (Chemotherapy, Sickle Cell Disease, Cystic Fibrosis)
  3. References
    1. Yen (2008) Pediatr Emerg Care 24(3): 143-7 [PubMed]
  • Approach
  • Adjunctive measures
  1. Calm children and their parents
    1. Prepare them for Intravenous Access
    2. Distract the child (videos, child-life specialist)
  2. Premedication options
    1. Local Skin Anesthesia
      1. J-Tip (transdermal Lidocaine device)
        1. Creates eraser sized wheel of Lidocaine that has been shot through the skin without needle
        2. Onset of Anesthesia within 3 minutes of use
        3. May also be used for Lumbar Puncture
      2. Topical Lidocaine (LMX4 - topical liposomal Lidocaine 4%) occluded 30 min. before
      3. EMLA cream (Lidocaine 2.5%, Prilocaine 2.5%)
        1. EMLA creamAnesthesia reaches a depth of 3 mm at 1 hour, and 5 mm at 1.5 to 2 hours
        2. Not effective in age <3 months for venipuncture (see EMLA cream)
    2. Other devices
      1. Buzzy Bee Vibrating Device (effective in ages 3-18 years; not effective in infants)
        1. Wings of device are stored in the freezer (use within 10 minutes of removing from freezer)
        2. Device and wings are placed on skin 5 cm proximal to venipuncture site (or Immunization site)
        3. Cold and vibration prevents pain fibers from transmitting painful stimuli (gate theory)
        4. Apply to skin for 1 minute before procedure
    3. Light Procedural Sedation
      1. Oral sucrose 24% (infants aged birth to 6 months)
      2. Intranasal Fentanyl
      3. Intranasal Midazolam
    4. References
      1. Claudius and Behar in Herbert (2019) EM:Rap 19(12): 3-5
  3. Optimize access sites
    1. Warm the access sites with blankets and warm packs
  4. Ultrasound
    1. Moderately helpful for pediatric peripheral IV if skilled in Ultrasound guided procedures
  5. Infrared vein viewer (not supported by literature)
    1. Helps visualize the veins, but does not assist in vein cannulation
  • Approach
  • Ultrasound guided IV sites in difficult access
  1. General Ultrasound techniques
    1. Use high frequency linear transducer (small parts, vascular Ultrasound probe) with adequate gel
    2. Apply minimal skin pressure to avoid collapsing vessels
  2. Distal cephalic vein
    1. Site: Medial aspect of the radial wrist
    2. Consider using bevel down needle orientation in younger children
      1. Black (2005) Pediatr Emerg Care 21(11): 707-11 [PubMed]
  3. Greater saphenous vein
    1. Site: Anterior to medial malleolus
    2. Track the vessel proximally with Ultrasound until diameter adequate for IV cannulation
    3. Requires steeper angle
      1. Consider placing 2x2 gauze secured under cathater to prevent kinking off flow
  4. Upper arm veins (basilic vein, cephalic vein, deep brachial vein)
    1. Sites
      1. Cephalic vein (lateral/radial Forearm)
      2. Basilic vein (medial/ulnar Forearm)
    2. Pearls
      1. Vein caliber typically maintained even in severe Dehydration or Sepsis
        1. More difficult to access than in adults
      2. Flash may not be seen (consider saline flush under Ultrasound to confirm placement)
  • Approach
  • Non-Ultrasound guided IV sites in difficult access
  1. External Jugular Vein
    1. Place patient in Trendelenburg position with towel roll under neck to keep it extended
    2. External Jugular Veins may be more evident with respiratory distress (Auto-PEEP)
    3. Flash may not be evident
  2. Scalp veins
    1. Sites
      1. Superficial temporal vein (avoid temporal artery)
      2. Auricular vein
    2. Apply Rubber band around the scalp
      1. Above the eyes and ears anteriorly
      2. Around the Occiput Posteriorly
    3. Pearls
      1. Identify straighest vein available (arteries are typically tortuous)
      2. Place the patient in Trendelenburg position
      3. Use a smaller gauge needle (e.g. 24 gauge)
    4. Precautions
      1. Do not place IV over Anterior Fontanelle
  1. Intraosseous Access
    1. Much faster than central access, and indicated when emergent access is needed and failed peripheral access
  2. Femoral Central Line
  3. Can non-IV sites be used?
    1. Intramuscular, subcutaneous, oral or intranasal medication delivery
    2. Gastric Tube fluid delivery
  • References
  1. Lin and Kornblith in Herbert (2014) EM: Rap 14(12): 3-4
  2. Claudius, Behar, Chang and Santillanes in Herbert (2016) EM:Rap 16(4): 3-4