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Vascular Access in Pediatric Patients in the Emergency Department: Types of Access, Indications, and Complications

June 2017

Inside This Issue

It is a mainstay of any ED practice, and often a life-saving procedure: vascular access. But it is challenging to obtain and maintain in pediatric patients, especially in life-threatening cases when every second is critical. While peripheral intravascular (PIV) access is the most common method, failed attempts to place a PIV catheter can be painful and frightening, especially for children. Using the difficult intravenous access (DIVA) score helps predict which children will have difficult IV access, and allows the ED team to prepare before placement, instead of reacting after several attempts. For critically ill patients with difficult access, intraosseous (IO)access or a central venous catheter (CVC) may be a better option. Although CVC is not usually the next step, it is the only device with no contraindications for use or placement, and using ultrasound to guide placement typically leads to a higher success rate. This article helps emergency clinicians quickly assess and treat difficult-access patients by reviewing the types of vascular access, including indications, methods of placement, complications, and troubleshooting. It also suggests techniques to boost chances of first-attempt placement, and which pain control and distraction methods benefit patients and improve success.

Keywords: vascular access, intravenous access, peripheral intravenous access, difficult intravenous access, DIVA, difficult intravenous access score, DIVA score, difficult intravenous access prediction, difficult intravenous access prediction score, DIVA prediction score, intravenous placement, intraosseous access, central venous access, central venous catheter, peripherally inserted central catheter, PICC, nontunneled catheter, skin-tunneled catheter, implantable port, port-a-cath, umbilical catheter, arterial access, device-assisted access, VeinViewer, AccuVein, transillumination, Veinlite, Veinoscope, infusion, needle-free lidocaine injection, saphenous vein, venous cutdown, pediatric, child

Points

  • 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 access.

Pearl

  • 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.
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