II. Risk Factors: Difficult Intravenous Access

  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]

III. 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. Intranasal Fentanyl
    2. Intranasal Midazolam
    3. Local Skin Anesthesia (e.g. EMLA cream, LET Anesthesia, Ethyl Chloride Spray)
  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

IV. 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)

V. 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

VI. Approach: Alternatives to Intravenous Access

  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

VII. 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

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