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.
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
26.
27.
28.
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?
30.
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
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.
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
