PERIPHERAL INTRAVENOUS (IV) ACCESS IN CHILDREN
Peripheral intravenous (IV) access is critical in pediatric resuscitation, allowing for rapid administration of fluids, medications, and blood products. However, securing IV access in children is often challenging due to small veins, movement, and distress.
Why is IV Access Important?
- Provides immediate circulatory access for emergency medication and fluids.
- Essential for resuscitation, fluid resuscitation, and medication administration.
- In pediatric emergencies, IV access must be established quickly—but alternative routes should be considered if unsuccessful.
KEY CONSIDERATIONS FOR PEDIATRIC IV ACCESS
Site Selection:
IV access sites vary by age and clinical condition:
Age Group Preferred IV Access Sites
Neonates (<28 days) Dorsum of the hand, foot veins, scalp veins (if other sites unavailable)
Infants (1-12 months) Hand, foot, antecubital fossa, saphenous vein
Children (>1 year) Antecubital fossa, dorsum of the hand, wrist, foot veins
Avoid lower limb IV sites in critically ill children, as they may compromise circulation if intra-abdominal pressure increases.
Choosing the Right IV Catheter Size
Using the correct IV catheter size optimizes flow rates and prevents vein trauma:
Patient Age Recommended IV Catheter Size
Neonates & Premature Infants 24G (blue)
Infants (<1 year) 22-24G (blue/yellow)
Young Children (1-6 years) 20-22G (pink/blue)
Older Children (≥6 years) 18-20G (green/pink)
Smaller catheters (22-24G) are used for neonates and infants due to fragile veins. Larger catheters (18-20G) allow faster fluid resuscitation in older children.
Steps for Peripheral IV Insertion in Children
Prepare Equipment:
- IV catheter of appropriate size.
- Antiseptic wipes (chlorhexidine or alcohol).
- IV extension set, flush (normal saline), and dressing supplies.
- Pain management: Consider topical anesthetics (e.g., lidocaine-prilocaine cream) if time permits.
Position the Child Comfortably:
- Use swaddling for neonates and infants to minimize movement.
- Involve parents when possible to help calm the child.
- If necessary, use distraction techniques (e.g., toys, videos) or child life specialists.
Select the Best Vein & Clean the Site:
- Use transillumination or vein finders in difficult cases.
- Apply a tourniquet (not too tight in infants).
- Clean the skin thoroughly with antiseptic.
Insert the IV Catheter:
- Hold the vein taut and insert the catheter at a 10-30° angle.
- Advance slowly—watch for blood return.
- If successful, advance the catheter while withdrawing the needle.
Flush and Secure the IV:
- Flush with normal saline to confirm patency.
- Secure the IV with transparent dressing and tape.
- Label the IV site and document the placement.
Special Considerations: In neonates, avoid excessive force, as veins are fragile. If multiple IV attempts fail (after 2-3 attempts), switch to an alternative route (e.g., intraosseous access).
CHALLENGES & TROUBLESHOOTING IV ACCESS IN CHILDREN
Challenge Cause Solution
Difficult vein visualization Small or deep veins Use transillumination, vein finder, or ultrasound-guided IV placement
Vein collapse Excessive negative pressure or dehydration Try a larger vein, use warm compress, avoid excessive suction
Infiltration (IV fluid leaking into tissue) Poor catheter placement or dislodgement Reposition or replace IV, monitor for swelling
Pain and distress Fear, lack of sedation Use topical anesthetics, distraction techniques
Signs of IV Infiltration or Extravasation:
- Swelling at the IV site.
- Cool, pale skin.
- Pain or discomfort.
- Poor IV flow or resistance when flushing.
If extravasation occurs: Stop the infusion, elevate the limb, and consider antidote administration for vesicant medications.
ALTERNATIVE ACCESS OPTIONS IF IV FAILS
If peripheral IV access is not achievable within 60-90 seconds, consider alternative routes:
Alternative Access Best for Key Considerations
Intraosseous (IO) Access Emergency fluid/medication administration First-line alternative to IV in critically ill children
Umbilical Venous Catheter (UVC) Neonates Useful in neonatal resuscitation
Central Venous Catheter (CVC) Long-term access Used in critically ill patients for prolonged medication/fluid administration
Intraosseous (IO) access is the fastest alternative in emergencies! If a child is in shock or cardiac arrest and IV access cannot be secured, place an IO line immediately.
SUMMARY: WHY PERIPHERAL IV ACCESS IS CRITICAL IN PEDIATRIC RESUSCITATION
Peripheral IV access is the first step in providing life-saving medications and fluids. Site selection and catheter size should be tailored to the child’s age and condition. If multiple IV attempts fail, escalate to intraosseous (IO) or other alternative routes. Always secure the IV well to prevent dislodgement in active pediatric patients.
Takeaway: Quick and efficient IV access is crucial in pediatric emergencies. Mastering the technique ensures timely and effective interventions.