Iv line insertion in children
- 1. Peripheral IV Insertion in Pediatric patients DR GABY FALAKHA PEDIATRICIAN & NEONATOLOGIST
- 2. Indications 1. Administration of fluids and electrolytes. 2. Administration of intravenous medications. 3. Administration of blood and blood products. 4. Blood sampling.
- 3. Contraindications Absolute 1. Do not insert through an infected site. 2. Do not insert through a burn. 3. Do not insert in an injured site. Relative 1. Avoid a paralyzed extremity. 2. Do not insert in a massively edematous extremity. 3. Do not insert an IV distal to injured organs (eg, do not use lower extremities when treating abdominal injuries). 4. Avoid joint area.
- 4. Equipment Caution: All equipment must be latex free. 1. Gloves. 2. Tourniquet or rubber band. 3. Tape and occlusive transparent dressing. 4. Alcohol wipes. 5. Povidone or chlorhexidine. 6. Syringe filled with injectable saline. 7. Gauze pads. 8. IV device: catheter or butterfly of appropriate size to fit the patient and the task. 9. Topical anesthetic cream. 10. Ultrasound guiding equipment (if available and if trained in its use).
- 5. Risks 1. Infection. 2. Hematoma. 3. Extravasation. 4. Compartment syndrome. 5. Severe vasoconstriction if vasoactive medications are infused through a peripheral IV and extravasate. 6. Venous thrombosis. 7. Embolization of air or catheter fragment.
- 6. Local anesthesia 4% Lidocaine cream is administered topically after disinfection of insertion site 2.5 grams applied to the skin and covered with an occlusive dressing (Tegaderm) overlying the IV site, 30 minutes before the procedure It effectively reduces pain and anxiety associated with venipuncture in children
- 7. Pearls and Tips 2 trial per person, maximum 6 trials per 3 persons Examine all possible sites carefully before choosing one. Let gravity work on your side Apply gentle circumferential pressure with 1 hand on the extremity to fill up the veins, which helps identify the most appropriate site. Apply heat to promote vasodilation In choosing the equipment and the site for the line, consider the patient’s needs Keep in mind other procedures After disinfecting the venipuncture site, let the alcohol dry for a while. IV insertion becomes much more painful when you do it using a needle coated with alcohol.
- 16. X
- 23. Identify the blood vessel by palpation, visualization, transillumination, or ultrasound. Flush the catheter and the connecting tube with saline (omit this step if you intend to draw blood through this catheter). Apply tourniquet. Use your nondominant hand to apply traction on the skin linearly or circumferentially in order to stabilize the vein. Enter the skin at a 20- to 30-degree angle proximal to or alongside the vein Reduce the angle as you advance the catheter and enter the vein. Watch for blood flashback in the hub of the catheter. Stabilize the catheter with the thumb and middle finger of your dominant hand and advance the catheter over the stylet using the tip of your index finger
- 24. Remove the stylet. Do not reinsert the stylet once it has been removed; it may damage the catheter. Release the tourniquet. Connect the extension tubing and saline-filled syringe to the catheter. Gently flush the catheter; observe for swelling, mottling, or color changes in the extremity. Secure the IV with occlusive transparent dressing and tape. Make a small loop in the IV tubing and tape it across. Attach the line to an IV infusion assembly and turn the pump on. Dispose of all sharp instruments in the proper secure container.
- 25. Fixation of the IV line Make a small loop in the IV tubing and tape it across
- 29. Patient Positioning Position the patient with the chosen site closest to you. Have a helper gently restrain and distract the child. Have the patient at a comfortable working height. For external jugular line placement, have the patient’s head lower than the trunk (Trendelenburg). Have a good injection site lighting Presence of parents?
- 31. The preferred sites for IV cannulation 1. Hand Dorsal arch veins Dorsal arch veins are best seen on the back of the hand, but are usually larger and easier to see and palpate over the back of the wrist. Skin entry should be more distally. IVs inserted here are easily splinted and any infiltration easily spotted, so these veins are the preferred site. Cephalic vein, in anatomical snuffbox The cephalic vein is often quite large and can often be felt better than it can be seen. It is one of the veins to try if you must cannulate ‘blind’ in a large baby. Cannulas in this position tend to last quite well, making this a good secondary site.
- 32. 2. Wrist Volar aspect Veins are easily seen on the volar side of the wrist. They are usually quite small and fragile and whilst easily cannulated, do not last well. They are useful secondary sites, but must be carefully watched when noxious substances (eg Dopamine, Vancomycin) are infused, as they are prone to ‘burn’.
- 33. 3. Cubital fossa Median antecubital, cephalic and basilic veins Median antecubital, cephalic and basilic veins are easy to hit and tend to last quite well if splinted properly. These veins are the preferred sites for insertion of percutaneous central venous catheters. These should be avoided unless absolutely necessary in any infant likely to need long term IV therapy. The median nerve and brachial artery are both in the same anatomical vicinity and therefore vulnerable to damage.
- 34. 4. Foot Dorsal arch Dorsal arch veins are small, but easily cannulated and last surprisingly well. The vein on the lateral aspect, running below malleolus, is easy to access, but must be splinted carefully and watched for infiltration. Veins leading up to short saphenous are often good options.
- 35. 4. Foot Saphenous vein, ankle The saphenous vein runs reliably just anterior to medial malleolus and is large and straight. It is easy to access and lasts well although is not always readily visualized. These veins are also good sites for insertion of percutaneous central venous catheters and should again be avoided in an infant likely to need long term IV access.
- 36. 5.Leg Saphenous vein at the knee The saphenous vein runs just behind the medial aspect of the knee and is often visible behind the knee and as it curves around the top of the tibia. Access is easy and lasts well if properly splinted. However, this vein is a good site for the insertion of percutaneous central venous catheters and should be avoided if possible, in any infant likely to need long term IV access.
- 37. 6. Scalp Scalp veins should only be used once other alternatives are exhausted. Mostly at least partial shaving of the head is required. It may take 6 months for hair to grow back properly, which may cause significant parental distress.
- 38. Superficial temporal vein The superficial temporal vein runs anterior to the ear and is accessible over a distance of 5-8 cm in most babies and lasts well if secured appropriately This vein is also a good site for the insertion of percutaneous central venous catheters and should be avoided if possible in infants likely to need long term IV access. The proximity of the temporal artery, which runs beside it, is a hazard. In small infants it can be almost impossible to tell the difference, even when the catheter has been inserted. It is important to try to identify the vessels separately, by careful palpation
- 39. Passive blood collection for infants Aspirating blood for culture or gas
- 41. Assess difficulty of intravenous cannulation History of 'difficult' IV access in the medical record Patient or caregiver reports a history of difficulty in cannulating or venipuncture Clinical assessment. The DIVA (Difficult Intravenous Access) score may be helpful Score of 4 or more means >50% chance of failed initial attempt The Sydney Children’s Hospital Network. Intravenous cannulation and venupuncture
- 45. Contraindications Absolute Trauma to the bone at or proximal to the insertion site (allows extravasation of fluids and therefore a risk of compartment syndrome). Bone diseases including: 1. osteogenesis imperfecta 2. osteoporosis 3. osteomyelitis. Infection of the tissues overlying the insertion site. Relative Previous orthopedic surgery near to the insertion site (prostheses, tibial nails) could lead to unpredictable flow due to disruption of bone matrix. Previous IO cannulation at the same site within the preceding 24-48 hours. Inability to locate landmarks. Clotting disorders.
- 46. Common insertion technique for all devices 1. Explain the procedure to patient and relatives. 2. Obtain skilled assistance as needed. 3. Universal precautions. 4. Identify site and position appropriately, manually stabilizing the bone (ensuring the hand is not placed under the limb). 5. Clean site and administer local anesthetic in the conscious child.
- 47. Common insertion technique for all devices 6. Once the needle is stable (unsupported) within the cortex, remove the stylet and aspirate blood marrow. 7. Syringe bolus: flush the catheter with 10 ml of normal saline (using lidocaine in the conscious patient for analgesia). 8. Apply stabilizer dressing. 9. Ensure the needle is flushed with at least 10 ml of fluid after drug administration. 10. Clear documentation of the procedure in the patient notes. 11. Frequent assessment of the IO site for signs of extravasation.
- 48. Diagnostic tests Cross match Carbon dioxide and platelet measurements (may be lower in intraosseous samples) Leukocyte count may be higher Sodium, potassium and calcium values obtained from blood and marrow mixtures may also be inaccurate Coagulation studies are inaccurate
- 49. Pain The pain associated with insertion of IO devices in the conscious patient is variable Infusion of drugs and fluids into the bone marrow cavity under pressure triggers multiple intraosseous pain receptors and the pain is severe. The infusion of 0.5 mg/kg of 2% lidocaine (without adrenaline and preservative free) prior to the infusion of drugs and fluids is effective in controlling this pain. Repeat boluses may need to be administered taking care to calculate the maximum safe dose of lidocaine (3 mg/kg).
- 50. Complications Complications resulting from IO cannulation are rare (thought to be less than 1%). Dislodgment of the cannula. Fracture of the target bone. Follow up radiograph should be obtained for all children in whom IO cannulation has been attempted. Infection of the bone (0.6%)3 or surrounding tissues: Extravasation of fluid or medications resulting in tissue damage or compartment syndrome. Pain on use. Skin necrosis. Growth plate injury.
- 52. Peripherally Inserted Central Catheters
- 60. Care for the IV line TOUCH for signs of temperature change (heat or warmth) or leakage at the IV site LOOK to make sure the IV site is dry and visible at all times. COMPARE the IV site (such as the hand or leg) with the opposite limb to look for signs of swelling
- 61. If an IV line is not working properly, your child may experience any of the following symptoms: 1. Hand with redness and leakage at IV site 2. General pain or pain to the touch at the IV site 3. Swelling of the area where the IV line is inserted 4. Numbness at the area 5. Redness 6. Bruising 7. Wetness at the area, suggesting that the IV line is leaking 8. Firmness at the area, which may be related to swelling 9. Warmth or coolness at the IV site Complications