Vascular Access in Pediatric Patients in the Emergency Department

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

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Table of Contents
About 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.

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Types of Intravenous Access
    1. Peripheral Intravenous Access
      1. Indications for Peripheral Intravenous Access
        • Administration of Intravenous Fluids
        • Administration of Medication
      2. Difficult Peripheral Intravenous Access
      3. Peripheral Infusion Considerations
    2. Intraosseous Access
      1. Indications
      2. Devices and Insertion
      3. Contraindications
    3. Central Venous Access
      1. Central Venous Catheter Devices
        • Peripherally Inserted Central Catheters
        • Nontunneled Catheters
        • Skin-tunneled Catheters
        • Implantable Ports
        • Umbilical Catheters
        • Arterial Access
    4. Device-Assisted Access
      1. Infrared Technology
      2. Transillumination
  6. Pain Control
    1. Topical Creams
    2. Needle-free Lidocaine Injection
    3. Vapocoolant
    4. Nonpharmacologic Options
  7. Complications
    1. Peripheral Intravenous Access
    2. Intraosseous Access
    3. Central Venous Catheter Access
  8. Special Circumstances
    1. Venous Cutdown
    2. Hemodialysis
  9. Disposition
  10. Summary
  11. Risk Management Pitfalls in Pediatric Patients Who Need Vascular Access
  12. Time- And Cost-Effective Strategies
  13. Case Conclusions
  14. Clinical Pathway for Vascular Access in Pediatric Patients
  15. Tables and Figures
    1. Table 1. Difficult Intravenous Access Prediction Score
    2. Table 2. Central Venous Catheter Size Recommendations by Patient Age and Body Weight
    3. Figure 1. Intraosseous Placement in the Tibia
    4. Figure 2. Intraosseous Devices
    5. Figure 3. Skin-tunneled Central Venous Catheter
    6. Figure 4. VeinViewer® Imaging of Blood Vessels
    7. Figure 5. Transillumination to Identify Blood Vessels
    8. Figure 6. Venous Cutdown
  16. References


Vascular access is a potentially life-saving procedure that is a mainstay of emergency medicine practice. There are a number of challenges associated with obtaining and maintaining vascular access, and the choice of the route of access and equipment used will depend on patient- and provider-specific factors. In this issue, the indications and complications of peripheral intravenous access, intraosseous access, and central venous access are reviewed. Timely and effective assessment and management of difficult-access patients, pain control techniques that can assist vascular access, and contraindications to each type of vascular access are also discussed.

Case Presentations

A 16-year-old adolescent boy with a history of acute lymphoblastic leukemia presents to the ED with fever and a headache. He is undergoing induction chemotherapy with vincristine and doxorubicin. His last medication administration was 2 weeks ago. His vital signs are: temperature, 39°C (102.2°F); heart rate, 160 beats/min; blood pressure, 80/40 mm Hg; and oxygen saturation, 98% on room air. The nursing staff immediately places him in a room. You recognize signs of shock and the need for rapid fluid resuscitation. Given his condition, he is likely to have difficult peripheral access. The nurse asks whether it would it be better to administer fluids by placing a large-bore peripheral IV line or by accessing his Broviac® catheter...

A 9-day-old girl who was born in Mexico and just moved to the United States is brought to the ED with vomiting and lethargy that have been increasing for the past 3 days. Her mother is no longer able to wake the baby. The baby is afebrile and unresponsive to voice. She has cool, mottled extremities with a capillary refill time of 5 seconds. Her heart rate is 180 beats/min and her systolic blood pressure is reported as 60 mm Hg by palpation. The nurses have been unsuccessful in obtaining access after multiple attempts. The resident who is working with you asks if an intraosseous needle can be placed in a 9-day-old baby. If so, can blood samples for laboratory tests be obtained from the site? Are there medications that are contraindicated through an intraosseous line?

A 2-year-old girl presented to her pediatrician’s office after 3 days of nonbilious vomiting. She has been unable to eat or drink anything without vomiting. Her parents state that her last urine output was the prior evening. Although her doctor gave her oral ondansetron and attempted to rehydrate her orally in the office, the patient continued to vomit and she was transferred to the ED for further management. At triage, she is afebrile, her heart rate is 130 beats/min, and her blood pressure is 80/50 mm Hg. You discuss intravenous fluid hydration with the family. Her parents are nervous about the pain associated with the procedure and the possible need for multiple attempts. Can you predict whether or not it will be difficult to obtain intravenous access on this patient? How can you address their concerns about pain?


Intravenous (IV) access is commonly required in the emergency department (ED) and is a critical life-saving procedure. Since the development of early techniques in the 1830s, there have been significant advancements in obtaining IV access. Advancements in vascular access include devices such as central-line bundles to help decrease infection and technology to assist in difficult IV placement and decrease the pain and anxiety often associated with access procedures.1

When choosing the equipment to use, it is important to consider the reason why vascular access is needed for that patient. Fluid flow through an IV catheter is determined by Poiseuille’s law, which states that the viscosity of the fluid, the pressure gradient across the tubing, and the length and diameter of the tubing all affect the rate of flow. Therefore, for situations requiring rapid fluid administration, the shortest length and widest diameter equipment should be selected. This includes the catheter as well as the IV tubing.2

The ability to obtain vascular access is a paramount skill for the emergency clinician, as it is often a necessity for ill or injured patients. Obtaining vascular access can often be challenging, especially in the pediatric population. This issue of Pediatric Emergency Medicine Practice reviews the indications for obtaining vascular access, different types of access procedures, contraindications for each type of access, and methods for troubleshooting difficult cases.

Critical Appraisal of the Literature

The literature on vascular access was reviewed in PubMed using the search terms pediatric intravenous accesssuccessful intravenous placementintraosseous accesscentral venous cathetersintravenous catheter complicationsdifficult intravenous access, and related terms. The date range for the search was from 1950 to 2016. Nearly 10,000 articles were found using these parameters, and 108 were selected for review. Abstracts were reviewed for relevance to the topic, and articles cited within the search results were also considered for inclusion. The primary focus was on articles that involved vascular access in the ED setting. Where applicable, articles that reviewed vascular access techniques and complications from the pediatric and neonatal intensive care units were included. The available literature on the most recent technologies for assisting with difficult access and on techniques and medications for alleviating pain and anxiety around placement of an IV line was also reviewed. Citations ranged from informational review articles to randomized controlled trials, though the majority of articles were observational studies.

Risk Management Pitfalls in Pediatric Patients Who Need Vascular Access

1. “I need to place an IV catheter in a 13-year-old boy; he’s old enough to handle the pain.”

Age-appropriate relaxation techniques and analgesia should be provided for every patient undergoing a vascular access procedure. Guided imagery, watching a movie, or listening to music, as well as the use of a Buzzy® or needle-free injection of lidocaine would be appropriate for this patient. These techniques may improve patient and family satisfaction with the experience.

2. “My patient has lost a lot of blood, and I only have access to an IO line placed in the field. I need to place a central line in order to give her blood products.”

If the IO line is infusing well, blood products for the patient may be given through the established IO line without need for separate venipuncture. Any fluid, blood product, or medication that can be given intravenously may also be given intraosseously.

3. “I placed a 24-gauge PIV catheter in a 4-day-old patient’s hand; I taped it well, so it shouldn’t cause any problems.”

Both 24-gauge PIV catheters and placement in the wrist area are risk factors for thrombosis. The patient’s arm should be splinted to avoid bending the wrist.

4. “My patient needs a CT scan with contrast, but the radiologist will not administer contrast through the 24-gauge catheter in the patient's antecubital fossa. Even the most experienced staff are unable to place a larger-gauged PIV catheter, so I guess I need to place a central line.”

Despite evidence showing that location and small catheter size are not related to the risk of contrast extravasation, hospital protocol can still dictate the placement of specific PIV catheters before contrast is given. Even in younger children, the saphenous vein is often overlooked, and is consequently pristine, allowing for more successful placement of a larger catheter.

5. “My 5-year-old patient needs a central line. Since we’re in the pediatric ED, I don’t need to worry about catheter size, as all of the catheters should be child-sized.”

CVC selection requires careful consideration, not only for the type of catheter for the needs of the patient, but also the length and diameter of the catheter based on the patient’s age and weight. (See Table 2.) Correct catheter size should always be double-checked before preparing for placement.

6. “The CBC drawn from an IO needle from my septic patient shows a WBC count of 25 x 109/L and platelets at 75 x 109/L. I’m worried about impending disseminated intravascular coagulation.”

Abnormal blood test results can be alarming, but before making decisions about treatment, the source of the sample should always be questioned. Blood tested from the marrow, such as blood from an IO aspirate (as in this case) will have leukocytosis and thrombocytopenia as compared with a venous sample. Blood from a venous or arterial sample should be sent off for the most accurate interpretation of a complete blood cell count.

7. “The patient has a DIVA score of 1, but I keep missing the vein. I know I can get it on the next try.”

Even if a patient is not identified as having potentially difficult IV access, the first provider should relinquish attempts to a more experienced provider after a failed first or second attempt. If available and appropriate, techniques such as transillumination, an infrared device, or ultrasound should be used.

8. “The chest x-ray of my patient with an umbilical catheter confirms my placement, so I can’t understand why I’m not able to aspirate blood or infuse saline.”

Chest x-ray is neither sensitive nor specific for umbilical catheter line placement; difficulty with infusion through the catheter could indicate incorrect placement or even creation of a false tract during placement. The catheter should be removed and alternate access should be obtained.

9. “My patient has a DIVA score of 5, but I could really use the practice.”

The chances of first-attempt success are much higher with an experienced provider. If available, an IV nurse-specialist should attempt first access on a patient like this.

10. “My patient is coding, and I have no vascular access. Since it’s an emergency, I can just drill an IO line anywhere in the leg.”

Taking the time to review correct IO placement, even in a stressful emergency, is best for the patient and the care team. Finding the correct spot 2 cm below and 2 cm medial from the tibial tuberosity, avoiding the epiphysis, will increase the chance of fast, successful

Tables and Figures

Table 1. Difficult Intravenous Access Prediction Score


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.

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Publication Information

Rachel Whitney, MD; Melissa Langhan, MD, MHS

Publication Date

June 2, 2017

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