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


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Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. McMullan R, Gordon A. Impact of a central line infection pevention bundle in newborn infants. Infect Control Hosp Epidemiol. 2016:1-8. (Retrospective cohort analysis; 353 CVCs placed in 214 neonates during baseline period, 260 CVCs in 162 neonates during intervention period)
  2. Wilson W. Trauma: Emergency Resuscitation, Perioperative Anesthesia, Surgical Management. Vol 1. New York: Informa Healthcare USA, Inc.; 2007. (Textbook)
  3. PIV catheter gauge selection. Available at: https://infusionnurse.org/2013/03/27/piv-catheter-gauge-selection/. Accessed May 15, 2017. (Online review)
  4. Hoste EA, Maitland K, Brudney CS, et al. Four phases of intravenous fluid therapy: a conceptual model. Br J Anaesth. 2014;113(5):740-747. (Review article)
  5. Silverman A, Wang V. Shock: a common pathway for life-threatening pediatric illnesses and injuries. Pediatr Emerg Med Pract. 2005;2(10):1-22. (Review article)
  6. 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)
  7. Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA. 1991;266(9):1242-1245. (Prospective cohort study; 34 patients analyzed together and in 3 groups)
  8. Kleinman ME, Chameides L, Schexnayder SM, et al. Pediatric Advanced Life Support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Pediatrics. 2010;126(5):e1361-e1399. (Guidelines)
  9. * 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. (Prospective cohort study; 615 patients age 0-21 years)
  10. Larsen P, Eldridge D, Brinkley J, et al. Pediatric peripheral intravenous access: does nursing experience and competence really make a difference? J Infus Nurs. 2010;33(4):226-235. (Prospective observational study; 1135 venipunctures in 592 pediatric patients)
  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):345-359. (Retrospective study; 339 IV insertions by 34 nurses)
  12. Brunette DD, Fischer R. Intravascular access in pediatric cardiac arrest. Am J Emerg Med. 1988;6(6):577 579. (Retrospective review; 33 cases)
  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)
  14. Lininger RA. Pediatric peripheral I.V. insertion success rates. Pediatr Nurs. 2003;29(5):351-354. (Prospective study; 249 IV placements)
  15. Petroski A, Frisch A, Joseph N, et al. Predictors of difficult pediatric intravenous access in a community emergency department. J Vasc Access. 2015;16(6):521-526. (Retrospective cohort; 652 pediatric patients)
  16. Black KJ, Pusic MV, Harmidy D, et al. Pediatric intravenous insertion in the emergency department: bevel up or bevel down? Pediatr Emerg Care. 2005;21(11):707-711. (Randomized crossover study; 396 IV attempts from 63 nurses)
  17. Riera A, Langhan M, Northrup V, et al. Remember the saphenous: ultrasound evaluation and intravenous site selection of peripheral veins in young children. Pediatr Emerg Care. 2011;27(12):1121-1125. (Prospective observational study; 60 children aged 0-3 years)
  18. * Frey AM. Success rates for peripheral I.V. insertion in a children’s hospital. Financial implications. J Intraven Nurs. 1998;21(3):160-165. (Retrospective cohort study and cost-effectiveness analysis)
  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)
  20. Miller JM, Goetz AM, Squier C, et al. Reduction in nosocomial intravenous device-related bacteremias after institution of an intravenous therapy team. J Intraven Nurs. 1996;19(2):103-106. (Retrospective cohort study and cost-effectiveness analysis)
  21. Scalley RD, Van CS, Cochran RS. The impact of an I.V. team on the occurrence of intravenous-related phlebitis. A 30-month study. J Intraven Nurs. 1992;15(2):100-109. (Prospective observational study)
  22. Meier PA, Fredrickson M, Catney M, et al. Impact of a dedicated intravenous therapy team on nosocomial bloodstream infection rates. Am J Infect Control. 1998;26(4):388-392. (Retrospective cohort study; pre- and post-specialized IV team)
  23. Kumar RJ, Pegg SP, Kimble RM. Management of extravasation injuries. ANZ J of Surg. 2001;71(5):285-289. (Retrospective case review; 9 patients)
  24. Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care. 2015;30(3):653.e659-617. (Systematic review; 270 patients with 325 injuries)
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  29. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: Pediatric Advanced Life Support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S876-S908. (Guidelines)
  30. Fisher B, Thomas D, Peterson B. Hypertonic saline lowers raised intracranial pressure in children after head trauma. J Neurosurg Anesthesiol. 1992;4(1):4-10. (Double-blind crossover study; 18 pediatric patients with head trauma)
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  32. Khanna S, Davis D, Peterson B, et al. Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury. Crit Care Med. 2000;28(4):1144-1151. (Prospective cohort; 10 pediatric patients with increased ICP)
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  34. Luu JL, Wendtland CL, Gross MF, et al. Three-percent saline administration during pediatric critical care transport. Pediatr Emerg Care. 2011;27(12):1113-1117. (Retrospective study; 101 pediatric patients)
  35. Amaral JG, Traubici J, BenDavid G, et al. Safety of power injector use in children as measured by incidence of extravasation. AJR Am J Roentgenol. 2006;187(2):580-583. (Prospective observational study; 557 patients receiving contrast through PIV access)
  36. Jacobs JE, Birnbaum BA, Langlotz CP. Contrast media reactions and extravasation: relationship to intravenous injection rates. Radiology. 1998;209(2):411-416. (Prospective observational study; complications of 6660 contrast injections)
  37. * Reuter-Rice K, Patrick D, Kantor E, et al. Characteristics of children who undergo intraosseous needle placement. Adv Emerg Nurs J. 2015;37(4):301-307. (Retrospective descriptive analysis; 143 patients)
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  39. Ellemunter H, Simma B, Trawoger R, et al. Intraosseous lines in preterm and full-term neonates. Arch Dis Child Fetal Neonatal Ed. 1999;80(1):F74-F75. (Prospective cohort; 30 IO lines placed in 27 patients--20 preterm, 7 full-term)
  40. Leidel BA, Kirchhoff C, Bogner V, et al. Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation. 2012;83(1):40-45. (Prospective observational study; 40 adult patients receiving IO and CVC simulataneously)
  41. * Smith R, Davis N, Bouamra O, et al. The utilisation of intraosseous infusion in the resuscitation of paediatric major trauma patients. Injury. 2005;36(9):1034-1038. (Retrospective review)
  42. Ramet J, Clybouw C, Benatar A, et al. Successful use of an intraosseous infusion in an 800 grams preterm infant. Eur J Emerg Med. 1998;5(3):327-328. (Case report)
  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)
  44. Miller LJ, Philbeck TE, Montez D, et al. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010;134(9):1253-1260. (Cross-sectional study; 10 samples of IO and peripheral blood)
  45. Evans RJ, Jewkes F, Owen G, et al. Intraosseous infusion--a technique available for intravascular administration of drugs and fluids in the child with burns. Burns. 1995;21(7):552-553. (Case reports)
  46. Hartholt KA, van Lieshout EM, Thies WC, et al. Intraosseous devices: a randomized controlled trial comparing three intraosseous devices. Prehosp Emerg Care. 2010;14(1):6-13. (Single-blind randomized trial; 65 adult and 22 pediatric patients)
  47. Myers LA, Russi CS, Arteaga GM. Semiautomatic intraosseous devices in pediatric prehospital care. Prehosp Emerg Care. 2011;15(4):473-476. (Retrospective review; semiautomatic vs conventional devices)
  48. Spriggs NM, White LJ, Martin SW, et al. Comparison of two intraosseous infusion techniques in an EMT training program. Acad Emerg Med. 2000;7(10):1168. (Prospective cross-over study; 28 EMT students and 10 paramedics)
  49. Cheung E, Baerlocher MO, Asch M, et al. Venous access: a practical review for 2009. Can Fam Physician. 2009;55(5):494-496. (Review article)
  50. O’Grady NP, Chertow DS. Managing bloodstream infections in patients who have short-term central venous catheters. Cleve Clin J Med. 2011;78(1):10-17. (Review article based on 2009 Infectious Diseases Society of America guidelines)
  51. Miller AH, Roth BA, Mills TJ, et al. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med. 2002;9(8):800-805. (Prospective cohort study; 122 patients with CVC placement)
  52. Leung J, Duffy M, Finckh A. Real-time ultrasonographically guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med. 2006;48(5):540-547. (Prospective randomized study; 130 patients)
  53. Ballard DW, Reed ME, Rauchwerger AS, et al. Emergency physician perspectives on central venous catheterization in the emergency department: a survey-based study. Acad Emerg Med. 2014;21(6):623-630. (Survey study; 365 emergency medicine physicians)
  54. Gallagher RA, Levy J, Vieira RL, et al. Ultrasound assistance for central venous catheter placement in a pediatric emergency department improves placement success rates. Acad Emerg Med. 2014;21(9):981-986. (Retrospective cohort study; 168 patients)
  55. Freeman JJ, Gadepalli SK, Siddiqui SM, et al. Improving central line infection rates in the neonatal intensive care unit: Effect of hospital location, site of insertion, and implementation of catheter-associated bloodstream infection protocols. J Pediatr Surg. 2015;50(5):860-863. (Retrospective chart review; 368 catheters in 285 NICU patients)
  56. Froehlich CD, Rigby MR, Rosenberg ES, et al. Ultrasound-guided central venous catheter placement decreases complications and decreases placement attempts compared with the landmark technique in patients in a pediatric intensive care unit. Crit Care Med. 2009;37(3):1090-1096. (Prospective observational cohort study; 93 patients)
  57. Dougherty L. Central venous access devices. Nurs Stand. 2000;14(43):45-50. (Review article)
  58. Weddle G, Jackson MA, Selvarangan R. Reducing blood culture contamination in a pediatric emergency department. Pediatr Emerg Care. 2011;27(3):179-181. (Retrospective cohort study; pre- and post-phlebotomy policy)
  59. Chiang VW, Baskin MN. Uses and complications of central venous catheters inserted in a pediatric emergency department. Pediatr Emerg Care. 2000;16(4):230-232. (Retrospective chart review; 121 patients)
  60. Parienti JJ, Mongardon N, Megarbane B, et al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015;373(13):1220-1229. (Multicenter randomized trial; 3471 catheters in 3027 adult patients)
  61. Andropoulos DB, Bent ST, Skjonsby B, et al. The optimal length of insertion of central venous catheters for pediatric patients. Anesth Analg. 2001;93(4):883-886. (Prospective observational study; 452 internal jugular and subclavian line placements in pediatric patients)
  62. Galloway S, Bodenham A. Long-term central venous access. Br J Anaesth. 2004;92(5):722-734. (Review article)
  63. Keir A, Giesinger R, Dunn M. How long should umbilical venous catheters remain in place in neonates who require long-term (≥ 5–7 days) central venous access? J Paediatr Child Health. 2014;50(8):649-652. (Evidence-based review)
  64. Hollingsworth C, Clarke P, Sharma A, et al. National survey of umbilical venous catheterisation practices in the wake of two deaths. Arch Dis Child Fetal Neonatal Ed. 2015;100(4):F371-F372. (Survey study)
  65. Guimarães AF, Souza AA, Bouzada MC, et al. Accuracy of chest radiography for positioning of the umbilical venous catheter. J Pediatr (Rio J). 2017;93(2):172-178. (Cross-sectional observational study; 162 newborns with umbilical venous catheter placement)
  66. Jain A, Deshpande P, Shah P. Peripherally inserted central catheter tip position and risk of associated complications in neonates. J Perinatol. 2013;33(4):307-312. (Retrospective cohort study; 336 infants)
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  68. Perry AM, Caviness AC, Hsu DC. Efficacy of a near-infrared light device in pediatric intravenous cannulation: a randomized controlled trial. Pediatr Emerg Care. 2011;27(1):5-10. (Randomized controlled trial; 123 patients)
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  70. Katsogridakis YL, Seshadri R, Sullivan C, et al. Veinlite transillumination in the pediatric emergency department: a therapeutic interventional trial. Pediatr Emerg Care. 2008;24(2):83-88. (Randomized trial; 240 pediatric patients with nonemergent PIV placement)
  71. Goren A, Laufer J, Yativ N, et al. Transillumination of the palm for venipuncture in infants. Pediatr Emerg Care. 2001;17(2):130-131. (Prospective cohort study; 100 infants aged 2-36 months)
  72. Cordoni A, Cordoni LE. Eutectic mixture of local anesthetics reduces pain during intravenous catheter insertion in the pediatric patient. Clin J Pain. 2001;17(2):115-118. (Double-blind placebo-controlled trial; 57 patients aged 4-12 years)
  73. Koh JL, Harrison D, Myers R, et al. A randomized, double-blind comparison study of EMLA and ELA-Max for topical anesthesia in children undergoing intravenous insertion. Paediatr Anaesth. 2004;14(12):977-982. (Double-blind randomized trial; 60 patients aged 8-17 years)
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  82. Waterhouse MR, Liu DR, Wang VJ. Cryotherapeutic topical analgesics for pediatric intravenous catheter placement: ice versus vapocoolant spray. Pediatr Emerg Care. 2013;29(1):8-12. (Cross-sectional cross-over study)
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Rachel Whitney, MD; Melissa Langhan, MD, MHS

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June 2, 2017

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July 1, 2020

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