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Intravenous Cannulation Pediatric intravenous cannulation is an integral part of modern medicine and is practiced in virtually every health care setting. Venous access allows the sampling of blood, as well as administration of fluids, medications, parenteral nutrition, chemotherapy, and blood products. This topic describes the placement of an intravenous catheter in an upper extremity of a pediatric patient. A similar technique can be used for placement of intravenous catheters in different anatomical sites. Indications Indications for pediatric intravenous cannulation include the following:
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Repeated blood sampling Intravenous fluid administration Intravenous medication administration Intravenous chemotherapy administration Intravenous nutritional support Intravenous blood or blood products administration Intravenous administration of radiological contrast agents (eg, computed tomography, magnetic resonance imaging, nuclear imaging)

Contraindications No absolute contraindications exist for pediatric intravenous cannulation. Peripheral venous access in an injured, infected, or burned extremity should be avoided if possible.

Vesicant solutions can cause blistering and tissue necrosis if they leak into the tissue. Irritant solutions (pH < 5, pH >9, or osmolarity >600 mOsm/L, including sclerosing solutions, some chemotherapeutic agents, and vasopressors) also are more safely infused into a central vein. Therefore, these solutions should only be given through a peripheral vein in emergency situations or when a central venous access is not readily available. Technical Considerations Best Practices In an emergency situation or when patients are expected to require large volumes infused over a short period of time, the largest gauge and shortest catheter that is likely to fit the chosen vein should be used. The catheter chosen should always be slightly smaller than the vein. Veins have a three-layered wall composed of an internal endothelium surrounded by a thin layer of muscle fibers, which is surrounded by a layer of connective tissue. Venous valves encourage unidirectional flow of blood, prevent pooling of blood in the dependent portions of the extremities, and can impede the passage of a catheter through and into a vein. Venous valves are more numerous just distal to the points were tributaries join larger veins and in the lower extremities. Veins with high internal pressure become engorged and are easier to access. The use of venous tourniquets, dependent positioning, pumping via muscle contraction, and the local application of heat or nitroglycerin ointment can contribute to venous engorgement. The superficial veins of the upper extremities are preferred to those of the lower extremities for peripheral venous access because they interfere less with patient mobility and pose a lower risk for phlebitis.[3] It is easier to insert a venous

Release the tourniquet and then reapply it to help engorge the vein. If blood stops flowing into the flashback chamber. Observation of a developing hematoma will necessitate removal of the catheter. It also is recommended to choose a straight portion of a vein to minimize the chance of hitting valves. encountering a venous valve. Finally. The scalp veins are easily accessed in infants. needle hub position against a venous valve. vein collapse. Connect a . incorrect positioning. or penetration of the posterior wall of the vein might be the cause. failure to release the catheter from the needle before insertion. attempt to withdraw the needle a few millimeters to move it away from a valve. They can be engorged by placing a rubber band around the patient’s head at the forehead level. or venous collapse can all be the cause. If there is difficulty advancing the catheter over the needle and into the vein. and incorrect angle of penetration can all lead to a failed attempt. removing the needle too far with the catheter being too soft to advance into the vein. Collapse of the vein.catheter where two tributaries merge and form a Y-shape. poor skin traction. venospasm. Release and then reapply the venous tourniquet and attempt to gently stroke the vein to engorge it with blood and release venospasm. Complication Prevention Use of an anesthetic cream 30 minutes prior to insertion attempt and/or subcutaneous infiltration of an anesthetic solution should be used prior to peripheral intravenous insertion whenever possible. if you believe that the selected vein should be accessible. Either attempt insertion at a different site or. withdraw the venous access device to just beneath the skin and reattempt to insert. inadequate skin traction.

or piercing of the venous wall might be the cause. drainage from the skin puncture site. whereas others suggest that proper antiseptic technique and at least daily monitoring of the insertion sites may allow for safe less frequent replacement as long as no signs of phlebitis are present.9%) solution to the hub. blood clot. Observation of a hematoma will necessitate removal of the catheter. Pain to the intravenous site of along the path of the catheter. swelling. Other peripheral nerves might be accidentally punctured. . Some sources recommend the routine replacement of peripherally inserted intravenous catheters every 3-4 days. or presence of a palpable venous cord are the signs of thrombophlebitis. Regularly and at least daily inspect the site of insertion for signs of infections. catheter tip position against a venous wall or a valve.[4] Accidental puncture of the median nerve is rare but possible as it is located just posterior to the basilic vein in the antecubital fossa. Thrombophlebitis can be caused by either thrombus formation with subsequent inflammation and/or infection. If an accidental arterial puncture did occur. If there is difficulty flushing after the catheter was placed in a vein.syringe with normal saline (0. skin erythema and/or induration. as evidenced by arterial pulsation of blood out of the catheter. then attempt to “float” the device in place by flushing the catheter and advancing it at the same time. Withdraw the catheter slightly to release it from a wall/valve and attempt to flush it back in. causing pain and rarely paralysis when other veins are selected. Palpate the vein carefully before attempting to insert a venous access device to ensure that there is no palpable pulse in the vessel. remove the catheter and apply direct pressure using gauze for at least 10 minutes. Remove the catheter and treat with appropriate antibiotics if you suspect an infectious etiology.

Some vesicant and irritant solutions may cause severe soft tissue damage if they extravasate outside of the vein and into the surrounding tissue.Continuous infusion of solutions into a venous access device that extravasated into the surrounding tissue might result in a compartment syndrome. as shown in the image below. in which the catheter is mounted on the needle. Make sure to monitor the site while the transfusion is taking place and use extra caution in patients who are unable to communicate pain or discomfort. Some infusion pumps are preset to stop the infusion and sound an audible alert with any increase in resistance to flow. . Periprocedural Care Patient Education & Consent Explain the procedure to the patient and/or the patient’s representative and obtain verbal consent. Equipment This topic describes the use of the “over-the-needle” type of intravenous catheter. Various sizes of "over-the-needle" intravenous catheters.

An "over-the-needle" intravenous catheter. and designs. compositions.This device is available in various gauges. the smallest gauge of catheter should be selected for the prescribed therapy to prevent damage to the vessel intima and ensure adequate blood flow around the catheter in order to reduce the risk of phlebitis. In general. Necessary equipment includes the following:         Nonsterile gloves Tourniquet Antiseptic solution (2% chlorhexidine in 70% isopropyl alcohol) Local anesthetic solution 1-mL syringe with a 30-G needle 2 × 2 gauze Venous access device Vacuum collection tubes and adaptor . Gauges range from 16-24 G and lengths range from 25-45 mm (see the image below). lengths.

Some of the equipment required for intravenous cannulation .      Saline or heparin lock Saline or heparin solution Transparent dressing Paper tape Padded arm board 1/2-inch gauze bandage roll Equipment is shown in the images below.

. Adjust the height or position of the bed or chair to make sure you are comfortable and to prevent unnecessary bending. Some of the equipment required for intravenous cannulation. Patient Preparation Anesthesia Both intradermal injection of a topical anesthetic agent just prior to intravenous insertion as well as topical application of a local anesthetic cream about 30 minutes prior to intravenous insertion have been shown to significantly reduce the pain associated with intravenous catheterization. . They should be used unless in emergent situation. Positioning Make sure there is adequate light and that the room is warm enough to encourage vasodilation.

The veins of choice for catheterization include the cephalic or basilic veins. it is recommended that an assistant aids in stabilizing the extremity during the procedure.Make sure the patient is in a comfortable position and place a pillow or a rolled towel under the patient’s extended arm. although not always practical. Technique Approach Considerations Use properly fitted nonsterile gloves and eye protection device to prevent exposure via accidental blood splashes. it is recommended. Because infants and young children are unlikely to cooperate. Vein palpation for pediatric intravenous cannulation. followed by the dorsal hand venous network. Intravenous Catheter Insertion Place a venous tourniquet over the patient’s nondominant arm and select a site for intravenous catheter insertion (see the image below). The patient’s skin should be washed with soap and water if visibly dirty. to start distally and move . For prolonged courses of therapy.

flush the saline or heparin lock with the appropriate solution. one of the following techniques may be used: inspection of the opposite extremity. Application of antiseptic solution for pediatric intravenous cannulation. Once cleaned. While the skin is allowed to dry. If blood . or applying heat (warm towel/pack). the dorsal hand and dorsal foot veins are usually easier to access than the antecubital vein. If difficulty is encountered in finding an appropriate vein. Apply an antiseptic solution such as 2% chlorhexidine solution or 70% alcohol with friction for 30-60 seconds and allow to air dry for up to 1 minute to ensure disinfection of the site and to prevent stinging as the needle pierces the skin (see the image below). The syringe may be left attached to the tubing. opening and closing the fist. gravity (holding the arm down). Ultrasound guidance has been shown to facilitate peripheral venous placement in emergency department patients with difficult intravenous access and should be used when appropriate veins are not readily visualized or palpable Transillumination is another technique that can be used in patients with difficult intravenous access. gentle tapping or stroking of the site. do not touch or repalpate the skin.proximally as distal catheters are replaced. In infants.

See the image below. Unless in an emergent situation and if the patient is interested in local anesthesia. Deeper veins should be accessed with a larger catheter at a 30. This will prevent superficial veins from rolling away from the needle.or 30-G needle to raise a wheal at the site of catheter insertion. Release the needle from the catheter and replace it ensuring the catheter was not damaged or fragmented. Hold the venous access device in your dominant hand bevel up. infiltrate 0. . you should not flush the saline/heparin 25-degree angle. Angle of insertion with bevel up for pediatric intravenous cannulation. This will ensure smoother catheterization because the sharpest part of the needle will penetrate the skin first.sampling via a syringe is planned (as in this illustrated case). Stabilization should be maintained throughout the procedure. Stabilize the vein using your nondominant hand (thumb) applying traction to the skin distal to the chosen site of insertion. The angle of the needle entry into the skin will vary according to the device used and the depth of the vein.5-1 mL of a local anesthetic using a 25. This will ensure smooth advancement once the venous access device is inside the vein. but you may connect an empty syringe to 45-degree angle. Small superficial veins are best accessed using a small catheter (22-24 G) placed at a 10.

Flashback may stop if the device punctured the posterior wall of the vein or in extremely hypotensive patients. the needle should never be reintroduced into the catheter.Upon entry into the vein. If no blood is observed in the flashback chamber. If swelling develops. The angle of the venous access device should be reduced to prevent puncturing the posterior wall of the vein. This could result in catheter fragmentation and embolism. release the tourniquet. It should be advanced gently and smoothly an additional 2-3 mm into the vein. See the image below. Flashback of blood into the venous access device for pediatric intravenous cannulation. the practitioner might feel a “giving way” sensation and blood should appear in the chamber of the venous access device (ie. withdraw the device. If venous catheterization is unsuccessful. and apply direct pressure for 5 minutes as a hematoma developed. the device should be withdrawn to just beneath the skin level and another attempt to recatheterize the vein should take place. hold the needle grip portion . flashback). While maintaining skin traction with your nondominant hand after the hub of the venous access device was dropped to the skin.

See the image below. Securing a venous access device in place using a transparent dressing in pediatric intravenous cannulation.of the venous access device in place between your dominant thumb and middle finger. You may apply a transparent dressing to the hub at this time in order to stabilize the venous access device in the vein (see image below). use your dominant hand to withdraw the . Sliding the hub of the catheter over the needle and into the vein in pediatric intravenous cannulation. While using your nondominant middle finger to apply pressure over the catheter to prevent blood spill and using holding the hub in place using your nondominant index and thumb fingers. while using your dominant index finger to slide the hub of the catheter over the needle and into the vein.

. while using the dominant hand to remove and secure the needle. Release the tourniquet once the blood sample obtained. Using the nondominant hand to secure the venous access device in the vein. See the image below. See the image below.needle and secure it in either its safety cover and/or a dedicated biohazard sharps container. use a syringe attached to the saline lock and obtain the required samples. While applying pressure to the catheter to prevent blood spillage and while continuously stabilizing the hub and wings to the skin as described before. Blood sampling in pediatric intravenous cannulation. If blood sampling is needed. A Vacutainer adaptor or a syringe can also be directly attached to the venous access device. disconnect the blood sampling adaptor or syringe and securely attach the pre flushed saline or heparin lock to the hub of the venous access device.

See the image below. Securing a pediatric venous access device . Keeping an intravenous line from being pulled out by pediatric patient can be challenging. Place a label indicating date. Flushing the venous access device in pediatric intravenous cannulation. and other facility-required information over the transparent dressing. The images below show some of the methods for securing such lines. Slide the plastic tubing lock and continue to lock the tubing. Finish securing the tubing to the skin using tape. time.Using the saline or heparin flush syringe. withdraw a small amount of blood to verify that the catheter is still inside the vein and immediately flush the tubing with the remainder solution. if such a lock is available.

 Withdraw the catheter outside of the vein and apply direct pressure with gauze for at least 5 minutes.. The video below demonstrates an example of pediatric intravenous cannulation Intravenous Catheter Removal  Stop the infusion solution and disconnect tubing leaving just the saline/heparin lock tubing connected to the venous access device.  Release the adhesive tape and transparent dressing from the skin. . Securing a pediatric venous access device . Securing a pediatric venous access device.

injections with repeatedboluses requested by the patient.g. It is generally used intravenously. arterial and epidural infusions are occasionally used. in patient-controlled analgesia). Inspect the catheter for fragmentation and document in the patient’s chart the date. they can administer as little as 0. medication or nutrients into a patient's circulatory system. although subcutaneous. For example. Infusion pumps can administer fluids in ways that would be impractically expensive or unreliable if performed manually by nursing staff. or fluids whose volumes vary by the time of day Because they can also produce quite high but controlled pressures.1 mL per hour injections (too small for a drip).a very popular local spinal anesthesia forchildbirth). Types of infusion The user interface of pumps usually requests details on the type of infusion from the technician or nurse that sets them up: . they can inject controlled amounts of fluids subcutaneously (beneath the skin). time.  Place a 2 × 2 gauze pad or a cotton ball with a paper tape over the intravenous insertion site and instruct the patient to continue manual pressure for 10 more minutes in order to minimize hematoma formation. An infusion pump infuses fluids. injections every minute. or epidurally (just within the surface of the central nervous system. and reason for catheter removal and the integrity of the catheter as inspected. up to maximum number per hour (e.

in which repeated small doses of opioid analgesics are delivered. Continuous infusion usually consists of small pulses of infusion. usually with a preprogrammed ceiling to avoid intoxication. with the rate of these pulses depending on the programmed infusion speed.  Intermittent infusion has a "high" infusion rate. with the device coded to stop administration before a dose that may cause hazardous respiratory depression is reached. Types of pump There are two basic classes of pumps. Some pumps offer modes in which the amounts can be scaled or controlled based on the time of day. . The timings are programmable. depending on the pump's design. This allows for circadian cycles which may be required for certain types of medication.  Patient-controlled is infusion on-demand. Within these classes. others are designed to be used in a hospital. Small-volume pumps infuse hormones.  Total parenteral nutrition usually requires an infusion curve similar to normal mealtimes. This mode is often used to administer antibiotics. Large volume pumps can pump nutrient solutions large enough to feed a patient. such as opiates. It is the method of choice for patientcontrolled analgesia (PCA). The rate is controlled by a pressure pad or button that can be activated by the patient. or other medicines. and there are special systems for charity and battlefield use. some pumps are designed to be portable. or other drugs that can irritate a blood vessel. usually between 500 nanoliters and 10 milliliters. alternating with a low programmable infusion rate to keep the cannula open. such as insulin.

nurses are often volunteers. The classic medical improvisation for an infusion pump is to place a blood pressure cuff around a bag of fluid. In the areas where these are used. A pressure bottle. One common system has a purpose-designed plastic "pressure bottle" pressurized with a large disposable plastic syringe. Small-volume pumps usually use a computer-controlled motor turning a screw that pushes the plunger on a syringe. Places that must provide the least-expensive care often use pressurized infusion systems. potentially causing risk when attempted by an individual not trained in this method. mass-produced sterile plastic. The battlefield equivalent is to place the bag under the patient. Classically. and the needed pressure varies with the administration route.Large-volume pumps usually use some form of peristaltic pump. air filter and drip chamber helps a nurse set the flow. they use computer-controlled rollers compressing a silicone-rubber tube through which the medicine flows. . A combined flow restrictor. The pressure on the bag sets the infusion pressure. The pressure can actually be read-out at the cuff's indicator. restrictor and chamber requires more nursing attention than electronically controlled pumps. Another common form is a set of fingers that press on the tube in sequence. or very inexpensive. The problem is that the flow varies dramatically with the patient's blood pressure (or weight). The parts are reusable. and can be produced by the same machines that make plastic soft-drink bottles and caps. The restrictor and high pressure helps control the flow better than the improvised schemes because the high pressure through the small restrictor orifice reduces the variation of flow caused by patients' blood pressures.

The rate is precisely controlled by the salt concentrations and pump volume. They are carefully designed so that no single cause of failure can harm the patient. a bag of salt solution absorbs water through a membrane. with dramatically changing blood pressures and patient condition. most have batteries in case the wall-socket power fails. They generally have one spring to power the infusion. Some of the smallest infusion pumps use osmotic power. When a large air bubble reaches it. Spring-powered clockwork infusion pumps have been developed. but in the veins they pass through the heart and leave in the patients' lungs. to keep air out of the patients' veins: doctors estimate that 0. Basically. and air in the line. The bag presses medicine out. it bleeds off.55 cm³ of air per kilogram of body weight is enough to kill (200–300 cm³ for adults) by filling the patient's heart. The air filter is just a membrane that passes gas but not fluid or pathogens. which can cause an air embolism. Small bubbles could cause harm in arteries. Battlefields often have a need to perfuse large amounts of fluid quickly. For example.An air filter is an essential safety device in a pressure infusor. Additional hazards are uncontrolled flow causing an overdose. . swelling its volume. Osmotic pumps are usually recharged with a syringe. Many infusion pumps are controlled by a small embedded system. causing an underdose. although they have not been deployed. uncontrolled lack of flow. which can siphon blood from a patient. Specialized infusion pumps have been designed for this purpose. reverse flow. and another for the alarm bell when the infusion completes. and are sometimes still used in veterinary work and for ambulatory small-volume pumps.

This is a minimum requirement on all human-rated infusion pumps of whatever age. A state of the art pump in 2003 may have the following safety features:  Certified to have no single point of failure. or the line to the patient is kinked.  An "air-in-line" detector. Some pumps actually measure the volume.  An "up pressure" sensor can detect when the bag or syringe is empty. It should at least stop pumping and make at least an audible error indication. It is not required for veterinary infusion pumps. but sometimes the air can interfere with the infusion of a low-dose medicine.  A "down pressure" sensor will detect when the patient's vein is blocked. so the pump can operate if the power fails or is unplugged. from 0. when the infusion pump is being set up. .Safety features available on some pumps The range of safety features varies widely with the age and make of the pump. That is. A typical detector will use an ultrasonic transmitter and receiver to detect when air is being pumped.1 to 2 ml of air. or even if the bag or syringe is being squeezed. and may even have configurable volumes.  Anti-free-flow devices prevent blood from draining from the patient. or infusate from freely entering the patient.  Batteries. no single cause of failure should cause the pump to silently fail to operate correctly.  A drug library with customizable programmable limits for individual drugs that helps to avoid medication errors. This may be configurable for high (subcutaneous and epidural) or low (venous) applications. None of these amounts can cause harm.

Food and Drug Administration (FDA) has launched a comprehensive initiative to improve their safety.  Usually. Safety issues Infusion pumps have been a source of multiple patient safety concerns. It cited software defects.  Many makes of infusion pump can be configured to display only a small subset of features while they are operating. and problems with such pumps have been linked to more than 56. erasing the log is a feature protected by a security code. Mechanisms to avoid uncontrolled flow of drugs in large volume pumps (often in combination with a giving st based free flow clamp) and increasingly also in syringe pumps (piston-brake)  Many pumps include an internal electronic log of the last several thousand therapy events. the U. user interface issues.S. [1] As a result. and mechanical or electrical failures as the main causes of adverse events. These are usually tagged with the time and date from the pump's clock. called the Infusion Pump Improvement Initiative. [2] The initiative proposed stricter regulation of infusion pumps. including at least 500 deaths. in order to prevent tampering by patients. . untrained staff and visitors.000 adverse event reports from 2005 to 2009. specifically to detect staff abuse of the pump or patient.