PALS Provider Course: Circulation & Vascular Access

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.
 

1️⃣ KEY CONSIDERATIONS FOR PEDIATRIC IV ACCESS

✅ Site Selection:

IV access sites vary by age and clinical condition:

Age GroupPreferred 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 AgeRecommended IV Catheter Size
Neonates & Premature Infants24G (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

 

1️⃣ 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.

2️⃣ 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.

3️⃣ 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.

4️⃣ 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.

5️⃣ 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).



2️⃣ CHALLENGES & TROUBLESHOOTING IV ACCESS IN CHILDREN

 

ChallengeCauseSolution
Difficult vein visualizationSmall or deep veinsUse transillumination, vein finder, or ultrasound-guided IV placement
Vein collapseExcessive negative pressure or dehydrationTry a larger vein, use warm compress, avoid excessive suction
Infiltration (IV fluid leaking into tissue)Poor catheter placement or dislodgementReposition or replace IV, monitor for swelling
Pain and distressFear, lack of sedationUse 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.



3️⃣ ALTERNATIVE ACCESS OPTIONS IF IV FAILS

If peripheral IV access is not achievable within 60-90 seconds, consider alternative routes:

Alternative AccessBest forKey Considerations
Intraosseous (IO) AccessEmergency fluid/medication administrationFirst-line alternative to IV in critically ill children
Umbilical Venous Catheter (UVC)NeonatesUseful in neonatal resuscitation
Central Venous Catheter (CVC)Long-term accessUsed 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.

 


4️⃣ 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.