Many pediatric patients will need some form of vascular access during their initial evaluation or hospitalization. The child’s severity of illness or injury, type of infusion needed, duration of therapy, and skill of the provider will often determine the type of line selected. Ultrasound-guided vascular access is an important advance in safety and efficacy and is discussed in a separate chapter. This chapter reviews the insertion and monitoring needed for peripheral intravenous access, central venous access, and peripherally-inserted central catheters (PICC lines).
Even at hospitals with a team dedicated to placing intravenous lines, the hospitalist may be called upon to obtain peripheral intravenous (PIV) access, especially when others have been unsuccessful.
PIV access is obtained to administer medications, fluids, or blood products. It may also be used for frequent phlebotomy draws. A line may be placed at the same time as obtaining a blood sample “just in case” the lab results should require IV access.
Avoid areas distal to a fracture, as there may be vascular disruption, and it may be difficult to assess for swelling associated with extravasated IV fluids or medications. When possible, avoid areas with edema, burns or cellulitis, or abnormal skin integrity. A vein that has been scarred from frequent use may be difficult to access.
Common IV sites include veins in the dorsum of the hand, the forearm, and the antecubital fossa. The cephalic vein that courses over the distal radius is a reliable site that is often overlooked and is affixed firmly to the underlying fascia. If the upper extremity is being used, the nondominant hand is preferable. Figure 191-1 shows common sites for placement of an IV catheter in the upper extremity. In infants, the lower extremities (i.e. feet) or the scalp can be considered as sites for IV placement. The saphenous vein is predictably located anterior to the medial malleolus and so can be accessed blindly. In general, attempt access distally first, in case additional attempts are required in the proximal extremities. The external jugular access site may be difficult to obtain as well as secure, and should be done by experienced personnel only.
Table 191-1 lists the equipment needed to place an IV line. It is important to have everything assembled and easily available before starting the procedure. In children, IV access often requires a second health care provider to help restrain the child properly. Most hospitals use over-the-needle catheters that include a safety, self-sheathing device. Use the largest bore and shortest catheter possible when rapid administration of medication, fluids, or blood is needed. A 24- or 22-gauge catheter is usually suitable for infants and young children and 18-, 20-, or 22-gauge catheters are used for older children.
| Appropriate-sized angiocatheter |
| Skin cleanser (e.g. 70% ethyl alcohol, povidone–iodine, chlorhexidine) |
| Tourniquet (or rubber bands if placing a scalp IV line) |
| T-connectors and needleless port |
| Normal saline flush and 3- or 5-mL syringe |
| Tape, transparent dressing, arm board, and other devices to secure catheter in place |
| Additional 3- or 5-mL syringes if blood is being drawn simultaneously or vacutainer blood transfer device to use with specimen tubes |
| Gauze |
| Gloves, nonsterile |
| Topical anesthetic—cream or spray (optional) |
| Topical antibiotic cream (optional) |
| Laboratory specimen tubes when applicable |
Most children consider needle sticks the most distressing and painful part of their hospital care. When time is available, it is important to prepare the family and child for the procedure honestly and in age-appropriate terms. The families of children who frequently undergo IV access may have helpful hints toward success. Parents, guardians, and child life specialists can provide comfort and distraction during the procedure.
When time permits, there are many topical anesthetic preparations that can be used in conjunction with nonpharmacological methods to reduce the pain and distress of IV insertion. These anesthetics are applied directly to the potential IV site(s). Onset of numbness varies between products, and may take up to 30 to 60 minutes to work. A small bleb of lidocaine buffered with sodium bicarbonate in a 9-to-1 ratio can be superficially injected over the vein for more immediate anesthesia, but it may obscure visualization and palpation of the vein.
Universal precautions should be used during the entire procedure.
Identify possible sites. Hand-held illuminators may assist in direct visualization of a vein.
If time permits, apply a topical anesthetic to numb the site.
Hot packs, tapping the vein, placing the extremity in a dependent position, or having the child open and close their hand may help with vasodilation and identification.
Prepare your equipment:
Cut tape and occlusive dressing.
Have any blood sampling tubes ready.
Hook the extension tubing to the needleless access port. If no blood is being drawn, flush the tubing/port with saline.
Apply a tourniquet proximal to the site. Make sure not to make it so tight that it impedes arterial flow.
Don gloves and apply the antiseptic in a circular fashion, allowing it to dry the required time before attempting access.
Have an assistant restrain the limb proximally.
With the bevel of the catheter facing up, puncture the skin at a 30- to 45-degree angle and slowly advance the needle until you see flashback of blood in the needle hub (Figure 191-2).
Advance the needle/catheter only slightly more to make sure the catheter is in the vein (Figure 191-3).
Tilt the needle parallel to the skin, advance the plastic portion, and activate the self-sheathing needle system (Figure 191-4).
Place your finger proximal to the catheter tip to staunch blood flow.
Connect your port/tubing to the catheter.
Clean and dry the area. A tincture of a topical antiseptic cream may be applied as well.
Secure the catheter in place using tape and/or transparent occlusive dressing (Figure 191-5).
To collect blood samples, attach an empty syringe or vacutainer to the extension tubing.
Remove the tourniquet and flush with saline.
Further secure the line by attaching an arm board to the extremity. Use of a soft circumferential arm restraint to further prevent IV dislodgement may be helpful in young children.
If there is no blood flow after an initial flashback, loosen the tourniquet, remove the metal stylet, and flush a small amount of saline. If it flushes easily without swelling subcutaneously you can continue to advance the catheter slowly into the vessel.
Once the metal stylet has been removed, it should not be reinserted into the catheter, as it may cause catheter shearing.
If the IV stops working after it is taped, apply gentle traction on the IV to locate a functional position and retape.
The IV line should be checked by medical personnel to ensure the adequacy of the site (no signs of infection, no erythema) and that it is infusing without any problem (e.g. pain, high pressure on the pump).
IV dislodgement and intravenous infiltrates are common complications. The amount and substance extravasated determines whether there will be local injury. Most infiltrates require only elevation and compression. However, hospital policy as well as consultation with your pharmacist and/or hospital vascular access team may help identify more specific therapies to prevent further tissue injury from certain vesicants. Serious complications are rare. Arterial puncture, phlebitis, cellulitis, thrombus formation, catheter fragment embolism or air embolism, and tendon/nerve injury are less common problems.
Central venous cannulation (CVC) involves percutaneously placing a vascular catheter into a high-flow vein located in either the thorax or the abdomen. It is an essential skill for the resuscitation and stabilization of critically ill or injured children. The main sites of access include the femoral, internal and external jugular, and subclavian veins.
CVC should be considered for patients needing the following:
Vascular access for circulatory failure if peripheral access is unobtainable
Infusion of vasoactive medications, blood products, or large volumes of fluid when rapid distribution and onset of therapy are vital
Insertion of devices such as transvenous pacemakers or Swan-Ganz catheters
Ongoing measurements of venous pressures or mixed venous blood gases
Delivery of hypertonic fluids such as total parenteral nutrition and chemotherapy
Long-term vascular access for repeated medication administration or frequent blood sampling.
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