Vascular Access in Pediatric Patients .pdf

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A Quick-Read Review Of Key Points & Clinical Pearls, June 2017

Vascular Access in Pediatric Patients in the Emergency
Department: Types of Access, Indications, and Complications
• Remember Poiseuille’s law when choosing equipment for intravenous (IV) access. For situations
requiring rapid fluid administration, the widest and
shortest equipment should be selected.
• Consider the duration of treatment, indication for
treatment, type of solution, vein availability, and
patient age when selecting the type and location of
• The difficult intravenous access (DIVA) score
can be used to predict which children will have
difficult IV access. A DIVA score ≥ 4 identifies
patients who need extra consideration before IV
catheter placement.
• When placing a peripheral IV catheter, consider
using device-assisted access such as ultrasound or a
VeinViewer® or AccuVein®.
• Solutions with a pH < 5 or > 9 or those with an
osmolarity > 600 mOsm/L can cause damage if not
contained in a peripheral vein.
• If an intraosseous (IO) line cannot be placed in the
proximal tibia, other options include the distal tibia,
the distal femur, the distal end of the radial bone,
the proximal metaphysis of the humerus, the sternum, the calcaneus, the iliac crest, the clavicle, and
the lateral or medial malleolus.
• Do not place an IO needle in newborns weighing
< 1000 g, unless there are no other options for obtaining access.
• Laboratory results from an IO sample may vary
compared to peripheral samples; in particular,
carbon dioxide tension may be lower, white blood
cell counts may be higher, and platelet counts may
be lower.
• An IO line may be left in place up to 96 hours; however,
it is preferable that it be removed within 6 to 12 hours.
• For both internal jugular and subclavian nontunneled
catheter access attempts, the right side of the patient is
preferable, due to a lower complication rate.
• Femoral lines have the highest risk of infection compared with internal jugular and subclavian catheters.
• Although implantable ports have a lower infection
rate compared to other catheters, they are associated with extravasation and thrombosis.
June 2017 • Pediatric Emergency Medicine Practice

For patients with difficult access, an IV nursespecialist or alternative IV access methods
(eg, ultrasound-guidance) should be used (if
available) for the first attempt rather than as a
last resort.
Abandon peripheral IV access placement after
2 failed attempts that last more than a total of
90 seconds.
In patients with peripherally inserted central
catheters, blood cultures should be drawn from
a separate venipuncture site to reduce the rate of
false-positive blood cultures via contamination.
Use of pain control strategies in pediatric patients increases first-attempt success rates and
patient comfort.
• Umbilical vein catheters should be inserted only
to the point of blood return (usually 4-5 cm).
• The saphenous vein is the safest access point for
venous cutdown in a pediatric patient. The incision should be made 2 fingers-breadth cephalad
to the medial malleolus.
• For excessive postdialysis bleeding due to heparin administration in a hemodialysis line, use 1
mg of protamine IV per 100 units of heparin. If
the heparin dose is unknown, administer 10 to 20
mg of protamine IV.
Issue Authors

Rachel Whitney, MD

Clinical Fellow, Department of Pediatrics, Section of Emergency Medicine,
Yale University School of Medicine, New Haven, CT

Melissa Langhan, MD, MHS

Associate Professor of Pediatrics and Emergency Medicine; Fellowship
Director, Director of Education, Pediatric Emergency Medicine, Yale
University School of Medicine, New Haven, CT
Points & Pearls Contributor

Kathryn H. Pade, MD

Pediatric Emergency Medicine Chief Fellow, Emergency & Transport
Medicine, Children’s Hospital Los Angeles, Keck School of Medicine/
University of Southern California, Los Angeles, CA

1 Copyright © 2017 EB Medicine. All rights reserved.

Table 1. Difficult Intravenous Access
Prediction Score10

Point Value

Vein visible after



Not visible


Vein palpable after



Not palpable



≥ 3 years


1-2 years


< 1 year






History of

First Responders
What change(s) do you anticipate making in
your practice as a result of this activity?





The sum of point values of the variables noted is the DIVA score (range,
A DIVA score ≥ 4 indicates that extra consideration may be needed
before placing a peripheral intravenous catheter.
Abbreviation: DIVA, difficult intravenous access.

Access your issue by scanning
the QR code with your
smartphone or tablet

I’m going to calculate DIVA scores for my
patients and use transillumination prior to
attempting peripheral intravenous access.

I will be more careful with my peripheral
infusion considerations.

I’ll use a J-tip when appropriate and reconsider EMLA.

11. Jacobson AF, Winslow EH. Variables influencing intravenous
catheter insertion difficulty and failure: an analysis of 339
intravenous catheter insertions. Heart Lung. 2005;34(5):345359. (Retrospective study; 339 IV insertions by 34 nurses)
13. Riker MW, Kennedy C, Winfrey BS, et al. Validation and
refinement of the difficult intravenous access score: a clinical prediction rule for identifying children with difficult
intravenous access. Acad Emerg Med. 2011;18(11):1129-1134.
(Prospective observational study; 366 patients undergoing IV placement) DOI:
19. Costantino TG, Parikh AK, Satz WA, et al. Ultrasonography- guided peripheral intravenous access versus traditional
approaches in patients with difficult intravenous access.
Ann Emerg Med. 2005;46(5):456-461. (Randomized study; 60
patients with IV placement failure > 3 attempts)
43. Hansen M, Meckler G, Spiro D, et al. Intraosseous line use,
complications, and outcomes among a population-based
cohort of children presenting to California hospitals. Pediatr
Emerg Care. 2011;27(10):928-932. (Retrospective cohort study;
291 pediatric patients with IO placement) DOI: https://doi.
108. Vukovic AA, Frey M, Byczkowski T, et al. Video-based assessment of peripheral intravenous catheter insertion in the
resuscitation area of a pediatric emergency department. Acad
Emerg Med. 2016;23(5):637-644. (Retrospective observational
study; 151 nontrauma patients undergoing PIV placement)

Clinical Pathway for Vascular
Access in Pediatric Patients

Most Important References

I’ll consider alternate means of access earlier.

de Caen AR, Berg MD, Chameides L, et al. Part 12: Pediatric
Advanced Life Support: 2015 American Heart Association
guidelines update for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation. 2015;132(18
Suppl 2):S526-S542. (Guidelines)


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Pediatric Emergency Medicine Practice (ISSN Print: 1549-9650, ISSN Online: 1549-9669, ACID-FREE) is published monthly (12 times per year) by EB Medicine (5550 Triangle Parkway,
Suite 150, Norcross, GA 30092). Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication
is intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used
for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Copyright © 2017 EB Medicine. All rights
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