II. Types: Needles
- Over the Needle Catheter (Preferred)
- Age < 1 year: 22, 24 gauges
- Age 1-8 years: 18, 20, 22 gauges
- Age >8 years: 16, 18, 20 gauges
- Large Bore: 14-16 gauge
- Butterfly Needle
- Newborn: 23-25 gauges
- Age <8 years: 23, 21, 20 gauges
- Age >8 years: 21, 20, 18 gauges
III. Types: Sites
- Upper Extremity: Antecubital
- Lower Extremity
- Great Saphenous Vein
- Descends through medial leg and ankle
- Lies anterior to medial malleolus
- Extends over dorsum into dorsal venous arch
- Median Marginal Vein
- Great Saphenous Vein
- Scalp
- Small superficial veins
- Not recommended in Resuscitation
IV. Technique
- Consider Local Anesthesia at catheter insertion site
- See Difficult Intravenous Access in Children
- Subcutaneous 1% Lidocaine 5 minutes before
- Topical Lidocaine (ELA-Max, LMX) occluded 30 min. before
- J-Tip (transdermal Lidocaine device)
- Luhmann (2004) Pediatrics 113:e217-20 [PubMed]
- Consider limb warming prior to IV cannula insertion
- Mitt for hand and Forearm warmed to 125 F (52 C)
- Increases success rate and decreases insertion time
- Lenhardt (2002) BMJ 325:409-10 [PubMed]
- Immobilize the extremity
- Locate and stretch the vein
- Soft roll of gauze to hyperextend the elbow
- Flex the wrist to extend the dorsal hand veins
- Extend the ankle to extend the dorsal foot veins
- Consider Ultrasound guidance for difficult IV starts
- Ultrasound is helpful for difficult IVs, but interferes with placement of easy IV starts
- McCarthy (2016) Ann Emerg Med 68(1): 10-8 +PMID: 26475248 [PubMed]
- Apply a Tourniquet to proximal vein
- Consider Blood Pressure cuff (inflated to 150 mmHg on arm)
- Very effective at maintaining non-compressible veins for peripheral vein cannulation
- Kule (2014) J Emerg Med S0736-4679(13) [PubMed]
- Consider Blood Pressure cuff (inflated to 150 mmHg on arm)
- Antiseptic to cannulation site
- Flush the needle catheter with sterile saline
- Enter Skin
- Puncture distal to the site
- Enter at 45 degrees with bevel down
- Pull the skin to the side while entering skin
- Avoid entering the vein with needle
- Cannulate vein
- Slowly advance catheter/needle until free Blood Flow
- Advance catheter/needle a few millimeters
- Advance the remainder of the catheter of needle
- Remove the needle and confirm backflow
- Remove the Tourniquet
- Secure intravenous catheter
- Consider Skin Glue (Tissue Adhesive, Dermabond)
- One drop over skin entry and one drop under plastic hub
- Decreases dislodgment risk
- Budgen (2016) Ann Emerg Med 68(2):196-201 +PMID: 26747220 [PubMed]
- Cover with Transparent Film Dressing (e.g. Tegaderm)
- Consider Skin Glue (Tissue Adhesive, Dermabond)
V. Technique: Difficult IV Access
- See Intraosseous Access
- See Ultrasound-Guided Internal Jugular Vein Catheterization
- See Ultrasound-Guided Antecubital Line
- External Jugular Vein Catheterization
-
Tourniquet Infusion Technique
- Obtain distal IV Access (e.g. 22 gauge) in a small hand vein or similar
- Apply Tourniquet above the elbow
- Infuse 100 cc Normal Saline into the hand vein to result in arm vessel engorgement
- Place standard size (e.g. 18 gauge) IV into one of the proximal engorged Forearm or antecubital veins
- Central Vein Placement of peripheral IV
- Identify a central vein for access (e.g. internal Jugular Vein) via Ultrasound
- Use a long peripheral catheter (48 mm is ideal if available, or use the angiocatheter in the Central Line kit)
- Sterilize the region
- Cannulate the vessel at a shallow angle with peripheral catheter under Ultrasound guidance
- Remove peripheral catheter within 72 hours
VI. References
- Strayer in Herbert (2018) EM:Rap 18(8): 16-7
- Quinn (2014) Emerg Med J 31(7): 593 [PubMed]
- Maayedi (2009) J Emerg Med 37(4): 419 [PubMed]