Pediatric Intravenous Cannulation
- Author: Gil Z Shlamovitz, MD, FACEP; Chief Editor: Vincent Lopez Rowe, MD more...
Pediatric intravenous (IV) cannulation is an integral part of modern medicine and is practiced in virtually every health care setting. Venous access allows the sampling of blood, as well as administration of fluids, medications, parenteral nutrition, chemotherapy, and blood products.
This topic describes the placement of an IV catheter in an upper extremity of a pediatric patient. A similar technique can be used for placement of IV catheters at different anatomic sites.
Indications for pediatric IV cannulation include the following:
Repeated blood sampling
IV fluid administration
IV medication administration
IV chemotherapy administration
IV nutritional support
IV blood or blood products administration
IV administration of radiologic contrast agents (eg, for computed tomography [CT], magnetic resonance imaging [MRI], or nuclear imaging)
No absolute contraindications exist for pediatric IV cannulation.
Peripheral venous access in an injured, infected, or burned extremity should be avoided if possible.
Vesicant solutions can cause blistering and tissue necrosis if they leak into the tissue. Irritant solutions (pH < 5, pH >9, or osmolarity >600 mOsm/L, including sclerosing solutions, some chemotherapeutic agents, and vasopressors) also are more safely infused into a central vein. Therefore, these solutions should only be given through a peripheral vein in emergency situations or when a central venous access is not readily available.
In an emergency situation or when patients are expected to require large volumes infused over a short period of time, the largest-gauge and shortest catheter that is likely to fit the chosen vein should be used. The catheter chosen should always be slightly smaller than the vein.
Veins have a three-layered wall composed of an internal endothelium surrounded by a thin layer of muscle fibers, which is surrounded by a layer of connective tissue. Venous valves encourage unidirectional flow of blood, prevent pooling of blood in the dependent portions of the extremities, and can impede the passage of a catheter through and into a vein. Venous valves are more numerous just distal to the points were tributaries join larger veins and in the lower extremities.
Veins with high internal pressure become engorged and are easier to access. The use of venous tourniquets, dependent positioning, pumping via muscle contraction, and the local application of heat or nitroglycerin ointment can contribute to venous engorgement.
The superficial veins of the upper extremities are preferred to those of the lower extremities for peripheral venous access because they interfere less with patient mobility and pose a lower risk for phlebitis. It is easier to insert a venous catheter where two tributaries merge and form a Y shape. It also is recommended to choose a straight portion of a vein to minimize the chance of hitting valves.
The scalp veins are easily accessed in infants. They can be engorged by placing a rubber band around the patient’s head at the forehead level.
Patient education and consent
Explain the procedure to the patient and/or the patient’s representative, and obtain verbal consent.
This topic describes the use of the over-the-needle type of IV catheter, in which the catheter is mounted on the needle (see the first image below). Such devices are available in various gauges (16-24 gauge), lengths (25-45 mm), compositions, and designs (see the second image below).
In general, the smallest gauge of catheter should be selected for the prescribed therapy, with the aims of preventing damage to the vessel intima and ensuring adequate blood flow around the catheter so as to reduce the risk of phlebitis.
Necessary equipment includes the following (see the images below):
Antiseptic solution (2% chlorhexidine in 70% isopropyl alcohol)
Local anesthetic solution
1-mL syringe with a 30-gauge needle
2 × 2 gauze
Venous access device
Vacuum collection tubes and adaptor
Saline or heparin lock
Saline or heparin solution
Padded arm board
The patient’s skin should be washed with soap and water if it is visibly dirty.
Because infants and young children are unlikely to cooperate, it is recommended that an assistant aid in stabilizing the extremity during the procedure.
Both intradermal injection of a topical anesthetic agent just prior to IV insertion and topical application of a local anesthetic cream about 30 minutes prior to IV insertion have been shown to significantly reduce the pain associated with IV catheterization. One or the other should be used unless the situation is an emergency.[5, 6, 7]
Make sure that there is adequate light and that the room is warm enough to encourage vasodilation. Adjust the height or position of the bed or chair to make sure that you are comfortable and to prevent unnecessary bending. Make sure that the patient is in a comfortable position, and place a pillow or a rolled towel under the patient’s extended arm.
Use properly fitted nonsterile gloves and eye protection device to prevent exposure via accidental blood splashes.
Pediatric IV cannulation is described in the following section and demonstrated in the video below.
Insertion of i ntravenous catheter
Place a venous tourniquet over the patient’s nondominant arm, and select a site for IV catheter insertion (see the image below). The veins of choice include the cephalic or basilic veins, followed by the dorsal hand venous network. For prolonged courses of therapy, it is recommended, though not always practical, to start distally and move proximally as distal catheters are replaced. In infants, the dorsal hand and dorsal foot veins are usually easier to access than the antecubital vein.
If difficulty is encountered in finding an appropriate vein, one of the following techniques may be used: inspection of the opposite extremity, opening and closing the fist, gravity (holding the arm down), gentle tapping or stroking of the site, or applying heat (warm towel/pack).
Ultrasound guidance has been shown to facilitate peripheral venous catheter placement in emergency department (ED) patients with difficult IV access and has been recommended when appropriate veins are not readily visualized or palpable.[8, 9, 10] Transillumination is another technique that can be used in patients with difficult IV access.
Apply an antiseptic solution such as 2% chlorhexidine solution or 70% alcohol with friction for 30-60 seconds, and allow to air-dry for up to 1 minute to ensure disinfection of the site and to prevent stinging as the needle pierces the skin (see the image below). Once the skin is cleaned, do not touch or repalpate it.
While the skin is allowed to dry, flush the saline or heparin lock with the appropriate solution. The syringe may be left attached to the tubing. If blood sampling via a syringe is planned (as in this illustrated case), you should not flush the saline/heparin lock, but you may connect an empty syringe to it.
If the patient is amenable to local anesthesia and the situation is not an emergency, infiltrate 0.5-1 mL of a local anesthetic using a 25- or 30-gauge needle to raise a wheal at the site of catheter insertion.
Stabilize the vein with your nondominant hand (thumb), applying traction to the skin distal to the chosen site of insertion. This will prevent superficial veins from rolling away from the needle. Stabilization should be maintained throughout the procedure.
Hold the venous access device in your dominant hand, bevel up. This will ensure smoother catheterization because the sharpest part of the needle will penetrate the skin first. Release the needle from the catheter and replace it, ensuring that the catheter was not damaged or fragmented. This will ensure smooth advancement once the venous access device is inside the vein.
The angle of the needle entry into the skin will vary according to the device used and the depth of the vein. Small superficial veins are best accessed via a small catheter (22-24 gauge) placed at a 10º-25º angle. Deeper veins should be accessed via a larger catheter placed at a 30º-45º angle. (See the image below.)
Upon entry into the vein, the practitioner might feel a “giving way” sensation, and blood should appear in the chamber of the venous access device (ie, flashback). (See the image below.) The angle of the venous access device should be reduced to prevent puncturing the posterior wall of the vein. It should be advanced gently and smoothly an additional 2-3 mm into the vein.
If no blood is observed in the flashback chamber, the device should be withdrawn to just beneath the skin level, and another attempt to recatheterize the vein should take place. Flashback may stop if the device punctured the posterior wall of the vein or if the patient is extremely hypotensive. If swelling develops, withdraw the device, release the tourniquet, and apply direct pressure for 5 minutes as a hematoma developed.
If venous catheterization is unsuccessful, the needle should never be reintroduced into the catheter. This could result in catheter fragmentation and embolism.
While maintaining skin traction with your nondominant hand after the hub of the venous access device was dropped to the skin, hold the needle grip portion of the venous access device in place between your dominant thumb and middle finger, while using your dominant index finger to slide the hub of the catheter over the needle and into the vein. (See the image below.)
At this time, you may apply a transparent dressing to the hub in order to stabilize the venous access device in the vein (see the image below).
While using your nondominant middle finger to apply pressure over the catheter to prevent blood spill and holding the hub in place with your nondominant index and thumb fingers, use your dominant hand to withdraw the needle and secure it in its safety cover, a dedicated biohazard sharps container, or both. (See the image below.)
If blood sampling is needed, use a syringe attached to the saline lock, and obtain the required samples. A Vacutainer adaptor or a syringe can also be directly attached to the venous access device. Release the tourniquet once the blood sample has been obtained. (See the image below.)
While applying pressure to the catheter to prevent blood spillage and while continuously stabilizing the hub and wings to the skin as described before, disconnect the blood sampling adaptor or syringe, and securely attach the preflushed saline or heparin lock to the hub of the venous access device.
Using the saline or heparin flush syringe, withdraw a small amount of blood to verify that the catheter is still inside the vein, then immediately flush the tubing with the remainder of the solution. Slide the plastic tubing lock, and continue to lock the tubing, if such a lock is available. Finish securing the tubing to the skin using tape. (See the image below.)
Place a label indicating date, time, and other facility-required information over the transparent dressing.
Keeping an IV line from being pulled out by pediatric patient can be challenging. The images below show some of the methods for securing such lines.
A study by Schreiber et al suggested that the patency of peripheral IV locks can be sufficiently well maintained by flushing with normal saline once every 24 hours and that the rate of catheter-related complications is not significantly different from that seen with flushing once every 12 hours.
Removal of intravenous catheter
Stop the infusion solution and disconnect the tubing, leaving just the saline/heparin lock tubing connected to the venous access device. Release the adhesive tape and transparent dressing from the skin. Withdraw the catheter outside of the vein, and apply direct pressure with gauze for at least 5 minutes.
Inspect the catheter for fragmentation, and document in the patient’s chart the date, time, and reason for catheter removal and the integrity of the catheter as inspected.
Place a 2 × 2 gauze pad or a cotton ball with a paper tape over the IV insertion site and instruct the patient to continue manual pressure for 10 more minutes in order to minimize hematoma formation.
Periprocedural and postprocedural complications may include the following:
Failure to access the vein
Blood stops flowing into the flashback chamber
Difficulty advancing the catheter over the needle and into the vein
Difficulty flushing after the catheter was placed in a vein
Peripheral nerve palsy
Skin and soft tissue necrosis
To minimize pain, application of anesthetic cream 30 minutes before the insertion attempt, subcutaneous infiltration of an anesthetic solution, or both should be used prior to peripheral IV insertion whenever possible.
Collapse of the vein, inadequate skin traction, incorrect positioning, and incorrect angle of penetration can all lead to a failed attempt. Either attempt insertion at a different site or, if the selected vein is accessible, withdraw the venous access device to just beneath the skin and reattempt to insert.
If blood stops flowing into the flashback chamber, the cause might be vein collapse, venospasm, needle hub position against a venous valve, or penetration of the posterior wall of the vein. Observation of a developing hematoma necessitates removal of the catheter. Release and then reapply the venous tourniquet and attempt to gently stroke the vein to engorge it with blood and release venospasm. Finally, attempt to withdraw the needle a few millimeters to move it away from a valve.
If there is difficulty advancing the catheter over the needle and into the vein, the cause might be failure to release the catheter from the needle before insertion, encountering a venous valve, removing the needle too far with the catheter being too soft to advance into the vein, poor skin traction, or venous collapse. Release the tourniquet and then reapply it to help engorge the vein. Connect a syringe with normal saline (0.9%) solution to the hub, then attempt to "float" the device in place by simultaneously flushing the catheter and advancing it.
If there is difficulty flushing after the catheter was placed in a vein, catheter tip position against a venous wall or a valve, blood clot, or piercing of the venous wall might be the cause. Observation of a hematoma necessitates removal of the catheter. Withdraw the catheter slightly to release it from a wall/valve, and attempt to flush it back in.
Palpate the vein carefully before attempting to insert a venous access device to ensure that there is no palpable pulse in the vessel. If an accidental arterial puncture did occur, as evidenced by arterial pulsation of blood out of the catheter, remove the catheter and apply direct pressure using gauze for at least 10 minutes.
Thrombophlebitis can be caused by thrombus formation with subsequent inflammation, infection, or both. Pain to the IV site along the path of the catheter, skin erythema and/or induration, swelling, drainage from the skin puncture site, or presence of a palpable venous cord are the signs of thrombophlebitis. Remove the catheter and treat with appropriate antibiotics if you suspect an infectious etiology.
Regularly and at least daily inspect the site of insertion for signs of infections. Some sources recommend the routine replacement of peripherally inserted IV catheters every 3-4 days, whereas others suggest that with proper antiseptic technique and at least daily monitoring of the insertion sites, less frequent replacement may be safe as long as no signs of phlebitis are present.
Accidental puncture of the median nerve is rare but possible, in that this nerve is located just posterior to the basilic vein in the antecubital fossa. Other peripheral nerves might be accidentally punctured, causing pain and (rarely) paralysis when other veins are selected.
Continuous infusion of solutions into a venous access device that extravasated into the surrounding tissue might result in a compartment syndrome. Make sure to monitor the site while the transfusion is taking place, and use extra caution in patients who are unable to communicate pain or discomfort. Some infusion pumps are preset to stop the infusion and sound an audible alert with any increase in resistance to flow.
Some vesicant and irritant solutions may cause severe soft tissue damage if they extravasate outside of the vein and into the surrounding tissue.
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