Dr. Rawan Alrashed (@rawalrashed)

PEM Physician

PoCUS Fellow

Reviewed and edited by: Dr. David Lewis

 

Background

Pediatric vascular access is one of the challenging skills in the medical field especially during an emergency, different guidelines have been established to facilitate the choice of the proper IV access one of which is the miniMAGIC that was published in 2020.¹ Choosing the right access is crucial for success taking in consideration the urgency of access, patient safety, infused fluid characteristic  to determine the right one especially with a peripheral IV catheter failure rate of 77% in the first attempt.² Difficult intravenous Access score (DIVA) is one of the tool that can be used to evaluate the feasibility of a peripheral IV and accordingly, the best next step for IV line insertion where Subjects with a DIVA score of 4 or more were more than 50% likely to have failed intravenous placement on first attempt.³

 

Figure-1: DIVA score.⁴

Types of vascular access

• Peripheral IV catheters (PIVCS)
• Intraosseous Access
• Central Venous Catheters (CVCs) (Non-tunneled) 
• US guided Access
• Umbilical Catheter
• Surgical cutdown

 

Figure 2: Vascular Access Locations.⁵

Consideration in pediatrics⁴

• Pain management is a critical step for the success of IV cannulation

Multiple choices are available starting from non-pharmacological distraction technique and non-nutritive sucking to the utilization of local anesthetic such as EMLA and LMX as well the needle-free lidocaine jet-injection

• Enhancing visualization of vein by using tourniquet, transilluminator with any available light source.
• Ultrasound guided peripheral IV access is the recommended current practice in difficult access.
• Ultrasound guided central IV access is the standard of care currently in comparison to anatomical landmark in critical care setting.

Indication of IV access

Patient resuscitation.

Delivering fluids, medication, Blood sampling.

Hemodynamics monitoring as well arterial blood gas.

Contraindications

Infection at the insertion site.

Thrombosis of the vein.

Bleeding diathesis in central line is a relative contraindication.

In IO Access, fracture on the same bone as well pathological disorder predisposing to fractures is a contraindication.

Peripheral IV catheter (PIVC)

Different veins can be used for PIVC starting with dorsal veins of the hand, then the feet and then proceeding to other choices including scalp vein in infants, external jugular vein, antecubital and the great saphenous vein as in Figure-2.⁵

Technique:⁵

1. Prepare instruments: cleansing solution, tourniquet, catheter needle, connecting tube, flush, dressing, gauze, and stabilizer tape.
2. Size of catheter as in the table: utilize the smallest gauge and shortest catheter as possible with exception in resuscitation where larger bore gauge is preferable or in case of midline cannulation where longer catheter is preferable.
3. Apply tourniquet proximal to the site of insertion to enhance visualization
4. Identify proper vein by visualization, palpation and utilizing the transilluminator or infrared light
5. Clean the skin as per the facility protocol
6. Hold the needle between the thumb and forefinger with the dominant hand and stretch the skin with the other hand
7. Enter with an angle of 10-30 degree then if blood seen shallow your angle to advance 1-2 mm then advance the catheter and once in pull your needle or retract it.
8. Flush to confirm patency and no swelling at the site then stabilize your catheter

 

	Neonate	Infant	Children	Length
PIV	24-26G	22G	20G	2-6cm
Midline Access	22G	22G	20G	15-30cm

 

Table-1: Size of PIV catheter.

 

US guided peripheral vascular access

A recent RCT by Vinograd et.al. evaluated 167 children showed 85% success rate of first attempt with US guidance compared to 45% with traditional methods. Also US guidance resulted in shorter cannulation time, less redirection and fewer attempts.⁶ 

Important consideration in US- guided PIV

• The diameter and depth of the vein have been found determinate factors for success of cannulation in adult studies where very superficial (< 0.3 cm) and very deep (> 1.5 cm) veins are difficult to cannulate.⁷
• The suggested veins are the cephalic vein in the forearm or the saphenous vein at the medial malleolus, while the antecubital vein might be an easy approach but the risk of brachial artery cannulation and the elbow bending make it less favorable. 7

Technique ⁷

• Use a linear probe with 5-15 MHz ( Alternatively a hockey stick or MicroConvex might be useful)
• Identify the vein and assess patency by being compressible and non pulsatile, for further confirmation utilize color or pulse wave doppler with augmentation to identify low status flow.

Longer catheter are preferable when using ultrasound guided insertion especially with a vein deeper then 0.5 cm to minimize the risk of dislodgment and infiltration (suggested to be longer than 2 cm). In a pilot study by Paladini, long catheter > 6 cm were associated with lower risk of failure in pediatric patients more than 10 years comparable to the short one <6 cm.⁸

• Static or dynamic guidance are acceptable with preference of the latter. 
• Two approach technique available with best outcome observed with out-of-plane in PIVC.

 

Out-of-plane (Short-Axis):

• Consider using the middle point on the ultrasound machine to enhance alignment
• The US wave perpendicular at right angle to the vessel.
• The needle is inserted close to the probe at 20-30^o angle then advance with meet and greet technique or dynamic needle tip positioning technique as in video

 

 

Pitfalls:

• The needle shaft might be misidentified as the needle tip thus the importance of advancing the probe then the needle to maintain visualization of the tip only.  Also sweeping in the same plane can help to follow the needle proximal and distal to confirm the tip from the shaft.
• Risk of posterior wall penetration and failure of cannulation.

 

In-Plane (Long-Axis):

• The US beam is parallel to the vessel.
• The whole needle shaft is visualized during insertion and advancement to the vein.
• To facilitate visualization of needle “Ski left” technique can be used.

 

 

Pitfalls:

• Maintaining the transducer static without any movement is difficult in small children as any movement would lead to loss of needle visualization, thus insertion will not be accurate (side lobe artifact)

No evidence of preferable technique in pediatrics but in adults out-of-plane proven to be superior for PIVC insertion.

 

How to Use US for PIVC:

https://www.coreultrasound.com/ultrasound-guided-peripheral-iv-access/

 

Intraosseous Access

It’s considered the best alternative IV access in emergencies (peri-arrest and arrest condition) after 2 failed attempts of PIVC within 60-90 seconds, AHA recommends IO catheter as first line access in cardiac arrest. Still the outcome of out of hospital cardiac arrest and best access need more delineation.^4,5

Technique⁴

• IO access can be accomplished using a manual needle or battery powered device such as EZ-IO or even a regular large bore needle.
• Place the knee in slight flexion with padding.
• Clean the skin and consider analgesia according to the urgency of the situation.
• Insert the needle at 90⁰ over the skin.
• Remove the stylet and aspirate then infuse saline.
• Confirmation of proper insertion by the needle standing still even if no backflow seen with lack of extravasation during fluid infusion.

Figure-2 (on green)  shows the possible site for IO insertion where the commonest one is the proximal tibial shaft about 1-2 cm from the tibial tuberosity avoiding the growth plate.

Complication⁴

• IO needle is a temporary access that can not last for more than 24 hours
• Longer use can predispose the child to complication including infection, thrombosis, fat embolism
• Other complications of insertion include through-and-through penetration of the bone, physeal plate injury, pressure necrosis of the skin, compartment syndrome, osteomyelitis, subcutaneous abscess

 

Confirmation of IO by POCUS²

• Use linear probe distal to the insertion site
• Apply color doppler and observe for saline flush site
• If above the bony cortical site or lateral or deep may indicate misplacement

 

Figure-3: POCUS confirmation of IO site.

 

 

Central IV Catheter (CIVC)

This an alternative longer duration route that can be utilized as an emergency line but less favorable compared to the IO during initial resuscitation. It is still considered a good choice in ill patients with difficulty of PIVC and failure of US guided peripheral access as well IO when fluid, high concentrated electrolytes and vasopressors are needed.⁴

The common site for insertion of non-tunneled CVC in pediatric is the internal jugular in critical care setting with higher success rate compared to femoral vein⁹ , but the femoral vein might be the first choice in PEM as it’s easily accessible and don’t interfere with resuscitation measures.¹⁰

Technique¹⁰

Always prepare your equipment and check them, also get consent when possible before attempting a central line

 

Age(years)	weight (kg)	Catheter gauge	French gauge	length (cm)
<1y	4-8	24	3	5-12
<1y	5-10	22	3-3.5	5-12
1-3y	10-15	20	4	5-15
3-8y	15-30	18-20	4-5	5-25
>8y	30-70	16-20	5-8	5-30

Table-2: CVC sizes.⁴

Anatomical Landmark⁵

Internal Jugular vein:

• Under aseptic technique with proper draping, put the patient in Trendelenburg position and turn the head slightly to the other side.
• Use the medial head of the sternocleidomastoid muscle or between the tow head at the level of the thyroid cartilage just lateral to the carotid artery guide your needle on a 45^o  toward the ipsilateral nipple while aspirating during insertion until you feel loss of resistance and have a backflow.
• follow with the guidewire into your needle and then dilator
• Complete by  inserting the catheter line and fixing it.

Subclavian vein:

Directly below the clavicle at the junction of the lateral one third with the medial two third directing the needle toward the sternal notch

Femoral vein:

1-2 cm below the inguinal ligament medial to the femoral artery, guide the needle toward the umbilicus

 

US Guided CVC

The use of ultrasound guided insertion is considered the standard of care for central line insertion. Ultrasound use reduces the number of attempts and procedure duration, increases the successful insertion rate, and reduces complications compared to the skin surface anatomic landmarks technique.⁹

This can facilitate visualization, increase the success rate with 95% first attempt success rate of ultrasound-guided venous punctures compared to 34% of the anatomical landmark and decrease the rate of complication that would occur with the anatomical landmark.¹¹

 

• Always start by identifying the land mark on US before starting the procedure (vein is compressible and less pulsatile than the adjacent artery)
• Probe position according to the site of insertion.  
• Prepare the patient under aseptic technique as well the probe with sterile sheet and the ultrasound counsel unless you have assistance.
• Infiltrate local anesthesia to the skin puncture site.
• Utilize sterile gel on the outside of the sterile sheet or alternatively sterile water or saline
• Use an out of plane technique to guide the needle into the vein (higher success rate).
• Start by inserting the needle at 45 degree angle from the probe and the same distance away as the vein from the skin
• Follow the dynamic needle tip positioning technique (meet &greet) to keep visualizing the needle tip while guiding it toward the vein
• If confusing the needle tip with the shaft try to slide the probe proximal and distal until confirmation
• Use the same steps in aspirating while inserting until having a backflow and confirming the needle is inside the vein lumen
• Complete the steps as before and confirm the position of the guidewire by ultrasound.
• Insert the central catheter and fix it with sutures and transparent dressing.

 

Internal jugular vein:

Subclavian vein

Femoral vein

 

Complication¹²

Confirm proper placement by US as well X-Ray

R/O complication as pneumothorax, hemothorax or hematoma, mis-displacement

Artery puncture, air embolism, thoracic duct injury, arrhythmia are possible complications.

 

Umbilical Catheter

• Can be used in neonate up to 7 days old.
• Apply tourniquet to umbilical stump then cut the upper dried part.
• Identify the vein which is single and thin walled while arteries are two and thick wall.
• Stent the vessel with a forceps then insert the catheter up to 3-4 cm until blood return (Do NOT advance further as the risk of complication and adverse events are high)

 

Venous Cutdown

It is uncommon access in pediatric patients with the availability of IO needle, if needed the classic site is the saphenous vein which is 2 cm superior and anterior to the medial malleolus.

 

 

Resources:

1. Ullman AJ, Bernstein SJ, Brown E, et al. The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC. Pediatrics. 2020;145(Suppl 3):S269-S284. doi:10.1542/peds.2019-3474I.
2. Delacruz N, Malia L, Dessie A. Point-of-Care Ultrasound for the Evaluation and Management of Febrile Infants. Pediatr Emerg Care. 2021;37(12):e886-e892. doi:10.1097/PEC.0000000000002300.
3. Yen K, Riegert A, Gorelick MH. Derivation of the DIVA score: a clinical prediction rule for the identification of children with difficult intravenous access. Pediatr Emerg Care. 2008;24(3):143-147. doi:10.1097/PEC.0b013e3181666f32.
4. Whitney R, Langhan M. Vascular Access in Pediatric Patients in the Emergency Department: Types of Access, Indications, and Complications. Pediatr Emerg Med Pract. 2017;14(6):1-20.
5. Naik VM, Mantha SSP, Rayani BK. Vascular access in children. Indian J Anaesth. 2019;63(9):737-745. doi:10.4103/ija.IJA_489_19.
6. Vinograd AM, Chen AE, Woodford AL, et al. Ultrasonographic guidance to improve first-attempt success in children with predicted difficult intravenous access in the emergency department: a randomized controlled trial. Ann Emerg Med. 2019;74:19–27.
7. Nakayama Y, Takeshita J, Nakajima Y, Shime N. Ultrasound-guided peripheral vascular catheterization in pediatric patients: a narrative review. Crit Care. 2020;24(1):592. Published 2020 Sep 30. doi:10.1186/s13054-020-03305-7.
8. Paladini A, Chiaretti A, Sellasie KW, Pittiruti M, Vento G. Ultrasound-guided placement of long peripheral cannulas in children over the age of 10 years admitted to the emergency department: a pilot study. BMJ Paediatr Open. 2018;2(1):e000244. Published 2018 Mar 28. doi:10.1136/bmjpo-2017-000244.
9. Pellegrini S, Rodríguez R, Lenz M, et al. Experience with ultrasound use in central venous catheterization (jugular-femoral) in pediatric patients in an intensive care unit. Arch Argent Pediatr. 2022;120(3):167-173. doi:10.5546/aap.2022.eng.167.
10. Skippen P, Kissoon N. Ultrasound guidance for central vascular access in the pediatric emergency department. Pediatr Emerg Care. 2007;23(3):203-207. doi:10.1097/PEC.0b013e3180467780.
11. De Souza TH, Brandão MB, Santos TM, Pereira RM, Nogueira RJ. Ultrasound guidance for internal jugular vein cannulation in PICU: a randomised controlled trial. Arch Dis Child. 2018; 103(10):952-6.
12. Georgeades C, Rothstein AE, Plunk MR, Arendonk KV. Iatrogenic vascular trauma and complications of vascular access in children. Semin Pediatr Surg. 2021;30(6):151122. doi:10.1016/j.sempedsurg.2021.151122