Background

Most children who present to an emergency department do not need vascular access for drug or fluid therapy. Medications can usually be administered orally, transmucosally, intramuscularly or by inhalation. Even fluid administration in dehydrated children does not ordinarily require vascular access. Oral rehydration, performed slowly and methodically, is often successful in children with vomiting and/or diarrhoea. However, when oral rehydration is unsuccessful or when a child presents critically ill or injured, intravenous (IV) or intraosseous (IO) access (Chapter 23.11) becomes essential.

Finding veins to cannulate in infants and small children can be quite a challenge. The higher ratio of subcutaneous fat and smaller vessel size in young patients pose significant barriers to rapid venous cannulation. A peripheral venous site, rather than a central site, offers the highest benefit:risk ratio of any vascular access option. Fig. 23.10.1 illustrates common sites for peripheral IV line insertion.

Fig. 23.10.1 Common peripheral IV sites.

When a peripheral site is unavailable, an IO site provides a second option (Chapter 23.11). When peripheral venous and IO access cannot be obtained or if central venous pressure monitoring is required, consider cannulating central veins, such as the femoral vein, subclavian vein, or internal jugular vein. Avoid saphenous vein cutdowns in children, because they are technically difficult to perform and the technique is time consuming in infants and young children, even for experienced operators. Make every effort to provide the least invasive form of access required by the degree of the child’s illness.

Indications

• Peripheral IV access is indicated if oral, transmucosal, intramuscular or inhalation routes are not adequate to meet the patient’s needs for fluids and/or medications.

• Use a central IV for:

Central venous pressure monitoring. Administration of hypertonic solutions.

Essential access when peripheral and IO attempts have failed.

Contraindications

• Peripheral IV catheters are contraindicated if other, non-invasive, routes can meet the child’s needs.

• Central venous catheters are contraindicated if peripheral venous access sites are available and there are no special indications for central venous catheter placement.

• If possible, do not pass peripheral IV catheters:

Through cellulitic skin.

In an extremity that has a wound, e.g. burn or laceration.

Distal to unstable fractures or injured veins.

• Avoid placing central lines in non-compressible sites in patients with bleeding diatheses.

Peripheral venous line placement

Equipment

Table 23.10.1 lists peripheral IV equipment. Determine appropriate sizing of IV catheters by consulting a length-based resuscitation tape.

If time permits, consider anaesthetising the skin with an anaesthetic drug or by iontophoresis. To anaesthetise skin, apply a topical anaesthetic, such as the eutectic mixture of local anaesthetics (EMLA™) cream, under an occlusive dressing at the selected entry site at least 45 minutes prior to any IV attempt. The alternative technique of iontophoresis requires specialised equipment for delivery of a low amperage, painless electrical charge to the skin. The technique is safe, non-invasive and usually quite effective. Iontophoresis takes 10–20 minutes to numb skin for peripheral IV insertion.

Use over-the-needle catheters whenever possible. Butterfly needles are far less stable but are acceptable for short-term infusions. Use armboards/legboards and a plastic container to cover the IV to avoid unintentional (or deliberate!) dislodgement of the catheter. Prime the tubing, and set up the IV fluid chamber with microdrip and an infusion pump in advance. Carefully monitor infusions in infants and small children to prevent over-administration of fluids. Select the smallest sized catheter that will meet the patient’s needs for drug and fluid administration.

Table 23.10.1 Equipment for peripheral IV insertion
• Gloves • Arm or leg board • Tourniquet • Alcohol pads • Gauze pads • 22–24-gauge venous catheters • Saline flush • IV tubing, solution and pump • Protective covering for IV (small plastic cup, roller gauze) • Tape