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Vascular Access In Children: Solve the Puzzle

Pediatric vascular access is one of the challenging skills in the medical field especially during an emergency, different guidelines have been established to facilitate the choice of the proper IV access one of which is the miniMAGIC that was published in 2020. Choosing the right access is crucial for success taking in consideration the urgency of access, patient safety, infused fluid characteristic to determine the right one especially with a peripheral IV catheter failure rate of 77% in the first attempt.

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  Tough time obtaining venous access in a child?

"Hand veins are easiest, up until the 7- to 11-month range when extra padding can make it more difficult. Then hand veins become more pronounced again in the preschool to school-aged child," says Langley. "Feet and ankle veins are good places to start the search in the smallest infants, as well as scalp veins."

 MiniMagical Thinking

We have an array of IV devices and a variety of places to insert them. In 2020, the Michigan Appropriateness Guide for Intravenous Catheters (miniMAGIC) was published. Its aim was to improve the safe selection of IVs in children across a range of indications.

 The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC

In this study, we provide evidence-based criteria for intravenous catheter selection (from umbilical catheters to totally implanted venous devices) in pediatric patients across a range of clinical indications. miniMAGIC also highlights core vascular access practices in need of collaborative research and innovation.

 Vascular access in children

Transillumination technique facilitates the placement of peripheral venous cannula by highlighting the veins as light passes through the thin connective tissues in children <2 years. Light-emitting diodes are preferred over the regular light as they have greater transillumination power and lesser risk of burns

 Vascular access in first week of life

Another vascular access method to keep in mind is the umbilical venous line – the umbilical vein can stay patent up to 7-10 days of life! Soak the dry cord in saline soaked gauze to soften it, use a scalpel to cut straight across at 1-2cm from the base, look for the single large vein, insert a pre-flushed catheter with gentle pressure into the vein while pulling back on a syringe until you see a flash of blood.

Articles of Interest

Difficult Intravenous Access in Pediatrics: Improving First Attempt Success Rates

There still is much work to be done to help with increasing PIV success rates at first attempt/cannulation. The pediatric population has inherent challenges as the patient population ranges in size from one day old to eighteen years of age. Vein anatomy and structure is sensitive to fluid shifts and disease processes and makes it even more challenging for PIV insertions.

Paediatric Intravenous Cannulation – OSCE Guide

This paediatric intravenous (IV) cannulation guide provides a step-by-step approach to performing intravenous cannulation in children and young people. Our guide also covers how to collect blood samples during paediatric cannulation.

Pediatric IV Cannulation Tips and Tricks

Have a good look with your eyes +/- POCUS – the vein running across the proximal half of the 4th metacarpal joining with the vein running between the 4th and 5th metacarpal is likely to have a higher success rate than antecubital in the pediatric population; consider also the great saphenous vein at the ankle and the palmar aspect of the wrist. Go low, go slow – use an angle that is almost flat along the skin and advance slowly. Secure the IV as if your life depends on it with steristrips, tegaderm, 1 or 2 limb immobilization boards and bandaging.

Pediatric Peripheral IV Access

Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric peripheral IV placement.

Pediatric Ultrasound-Guided Peripheral IV Access

If you cannot find the needle tip, look for it by moving either the probe or the needle. Do not move both at the same time. Use the high-frequency linear probe with the smallest footprint available.

Vascular Access in Pediatric Patients in the Emergency Department: Types of Access, Indications, and Complications

It is a mainstay of any ED practice, and often a life-saving procedure: vascular access. But it is challenging to obtain and maintain in pediatric patients, especially in life-threatening cases when every second is critical. While peripheral intravascular (PIV) access is the most common method, failed attempts to place a PIV catheter can be painful and frightening, especially for children.

Resources

VeinViewer

VeinViewer is the only vein finder of its kind that can positively impact the entire Pre-, During and Post-access procedure and is proven to reduce the number of stick attempts on patients and greatly increase patient satisfaction.

International Emergency Medicine Education Project

Use an arm board in pediatric patients, to prevent catheter displacement from movement. Do not use flashlights for transillumination as they can burn skin, use transilluminator only. Lowering the room light during transillumination maximizes visualization.