See also
Procedural pain management guideline
Peripheral Intravenous device
management guideline
RCH comfort kids resources
Key points
- Anxiety, pain, distress and subsequent needle phobia is associated with repeated attempts at intravenous access; appropriate preparation can minimise the distress caused.
- It is important to justify the need for the procedure and combine with blood sampling if needed.
- If available, ultrasound guidance should be considered if intravenous cannulation is predicted to be difficult or prolonged therapy is anticipated.
- Some children are at higher risk of decompensation with multiple IV attempts, e.g. child with congenital heart disease and single ventricle physiology.
Background
Multiple attempts at IV insertion can cause significant distress for patients so alternatives to IV access should always be considered within the clinical context e.g. Oral or NG fluids/medication, IM or IO medications in emergencies.
Cannulas inserted over joints, in areas of flexion or in the lower limb are more likely to fail than those inserted in the hand or forearm
Selection of Intravenous [IV] access
The following guidelines should be considered when referring patient for IV access
| Duration IV access required | Selection of cannula |
| hand > foot > cubital fossa Ultrasound guided peripheral IV access [may last up to 7 days] | |
| 7-14 days or failed peripheral IV attempts | Upper arm midline, PICC [peripherally inserted central catheter] or Percutaneous CVAD [Central Venous Access Device] |
| >14 days / longer term | PICC, percutaneous CVAD, consider tunnelled [surgical] CVAD or port |
If available, ultrasound guidance should be considered if intravenous cannulation is predicted to be difficult or prolonged therapy is anticipated [see table below]
Potential Complications
- Accidental arterial cannulation
- Consider intra-arterial cannulation if
- Bright red backflow of blood into IV cannula
- The cannula flashback appears pulsatile or there is pulsatile movement of blood in IV tubing
- Backflow of blood into IV tubing despite fluid bag at level higher than IV insertion site
- IV inserted in a "high risk" area i.e. antecubital fossa
- Management if uncertain
- Do not use cannula
- Urgent blood gas analysis from inserted cannula
- Consider intra-arterial cannulation if
- Extravasation injury
- Needle stick injury
- Thrombophlebitis / infection
- Unsuccessful procedure
Equipment, Analgesia, Anaesthesia and Sedation
| The patient | Infants 50% chance of failed initial attempt If difficult intravenous cannulation is predicted based on the above criteria, ultrasound guided insertion should be considered if the equipment and expertise is available. Some children are at higher risk of decompensation with multiple IV attempts, eg congenital heart disease with single ventricle physiology. If >2 attempts are required involve the senior clinician and consult the treating cardiology team. TechniqueHolding
Inserting the cannula
|
| | |
| Figure 3: passive blood collection for infants | Figure 4: aspirating blood for culture or gas |
Securement
- Remove tourniquet before strapping
- Connect the saline-primed 3-way connector to the end of the cannula by screwing it firmly on. Flush the connector tubing with more saline to confirm intravenous placement
- Use sterile tapes to secure the hub and a clear dressing over the cannula site such as Tegaderm™. Ensure that the proximal tip and area of skin around are always easily visible [Figure 5 below]. Extravasation injuries can occur especially if the site is not readily accessible for regular nursing checks
- Consider placing a small piece of cotton wool ball or gauze underneath the hub of the cannula to prevent pressure areas
- Tapes and splint should secure the limb proximal and distal to the cannula [keeping thumb free] but not too tightly [Figure 6 below]
- Arm splints are not required for lines placed in the cephalic vein in the forearm [typically ultrasound guided]. Cover the whole distal extremity in net bandage [eg surgifix tubular-fast]. In very young children, consider bandaging the other hand as well to prevent them from removing the cannula
Post-Procedure Care
- Running a 'drug line' [3-5ml/hr of Sodium Chloride 0.9%] through the cannula may keep it patent for a longer period of time
- Regularly inspect insertion site for complications [tenderness, blockage, inflammation, discharge] - check the other hand if it has also been bandaged
- Unless complications develop, the peripheral IV should remain insitu until IV treatment complete
Difficulty with IV insertion
Each clinician should have a maximum of 2 attempts before escalating.
Strongly consider ultrasound assistance, if available, after 3-4 attempts
*Experienced Clinician – at least 2 years of acute paediatric experience
For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services
See video
RCH specific information
For assistance with difficult intravenous access
- 0730 - 1730 [Mon – Fri]: Anaesthetics ASCOM 52000
- After hours / public holidays: PICU ASCOM 52327
Last updated September, 2019