D I A O T A T I ON

PE R

PERIPHE RAL & UMB IL ICAL

VENOUS ACCESS
ARMMC CLINIC
AL CLERKS
DILLA
ROCHA & RON
 PERIPHERAL
VENOUS ACCESS
 PERIPHERAL VENOUS ACCESS
● Pediatric intravenous (IV) cannulation is an integral part of modern
medicine and is practiced in virtually every healthcare setting.

● Venous access allows the sampling of blood, as well as

administration of fluids, medications, parenteral nutrition,
chemotherapy, and blood products.

● Peripheral venous catheters are typically the easiest and safest

means of achieving vascular access during the initial resuscitation
of patients, particularly for clinicians who do not have experience
with central venous catheterization.
PERIPHERAL VENOUS ACCESS
ANATOMY
Common vascular locations for peripheral
venous access for pediatric patients:
• Frontal vein
• Superficial temporal vein
• Posterior auricular vein
• External jugular vein
• Antecubital vein
• Dorsal venous plexus of hand
• Dorsal venous plexus of foot
• Umbilical vein
PERIPHERAL VENOUS ACCESS
ANATOMY

• Potential sites include the upper

and lower extremities, the scalp,
and the external jugular vein.

• Depending on the length and the

position of the catheter tip,
external jugular venous
cannulation also may provide
central venous access.
PERIPHERAL VENOUS ACCESS
ANATOMY
UPPER EXTREMITY
• Cephalic, basilic, and median cubital
veins in the forearm, and dorsal veins of
the hand offer a route for rapid drug
and fluid delivery in upper extremity
• Cephalic (antecubital) vein is relatively
easy to cannulate
• However, catheters placed in this
location must be well secured with an
arm board to prevent elbow flexion
which can cause kinking of catheter
and infiltration
PERIPHERAL VENOUS ACCESS
ANATOMY
SCALP
• Small superficial veins of the
scalp rarely are useful during
cardiopulmonary resuscitation
(CPR) but may be helpful in less
urgent situations

• Less desirable because the scalp

may have to be shaved to expose
the vein, and doing so may cause
the parents unnecessary concern
about a “needle in the head”
PERIPHERAL VENOUS ACCESS
ANATOMY
EXTERNAL JUGULAR
• EJV is another useful site for
vascular access in young children
because no adjacent arterial or
neural structures are present

• Cannot be used as primary site

during resuscitation of infants or
children with airway compromise,
concern for cervical spine injury
or respiratory failure because
cannulation of EJV requires
extension and rotation of neck
PERIPHERAL VENOUS ACCESS
INDICATION
Indications for pediatric IV cannulation include the following:
• Repeated blood sampling
• IV fluid administration
• IV medication administration
• IV chemotherapy administration
• IV nutritional support
• IV blood or blood products administration
• IV administration of radiologic contrast agents
• Computed tomography [CT]
• Magnetic resonance imaging [MRI]
• Nuclear imaging
PERIPHERAL VENOUS ACCESS
INDICATION
• Most often, intravenous (IV) access is obtained to
provide therapies that cannot be administered or are
less effective if given by alternative routes.

• As examples, IV hydration and nutritional support can be

given to a patient with severe vomiting or abdominal
pain from a surgical condition.

• Certain medications are more effective when given

intravenously due to rapid onset or increased
bioavailability.
PERIPHERAL VENOUS ACCESS
INDICATION
• Some clinical situations, such as cardiac arrest,
require treatment using IV medications; blood
products must be given intravenously.

• In some instances, IV catheters are left in place

when medications are given intermittently over a
longer period (eg, long-term antibiotic therapy) or
in case of a potential emergency.
PERIPHERAL VENOUS ACCESS
INDICATION
PERIPHERAL VENOUS ACCESS
CONTRAINDICATIONS
• No absolute contraindications exist for pediatric IV 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 central venous
access is not readily available.
PERIPHERAL VENOUS ACCESS
CONTRAINDICATIONS
OTHER CONTRAINDICATIONS INCLUDE:
• Extremity with significant edema
• Extremity with burns
• Extremity with phlebitis
• Extremity with thrombosis
• Overlying cellulitis
PERIPHERAL VENOUS ACCESS
PROCEDURE

CATHETER SELECTION
• Most common type of peripheral
venous catheter used in children
is the over-the-needle catheter
• 22 to 24 gauge for
newborns and infants
• 18 to 20 gauge for
older children
PERIPHERAL VENOUS ACCESS
PROCEDURE
PERIPHERAL VENOUS ACCESS
PROCEDURE

CATHETER SELECTION
• Size of the cannula used in
resuscitation should be the
largest that can be inserted
reliably

• In shock or severe
hypovolemia, a smaller cannula
may be used for initial fluid
resuscitation until a larger vein
can be cannulated
PERIPHERAL VENOUS ACCESS
PROCEDURE

• Step 1: The chosen extremity or site to be used is

immobilized and/or isolated. The vein is located and
stretched gently. If the antecubital fossa vein is to be
cannulated, a soft roll of gauze can be placed behind the
elbow to fully extend it. If the dorsal hand veins are to be
cannulated, the hand is held firmly with the wrist flexed. If the
dorsal foot veins are to be cannulated, the foot is held firmly
with the ankle extended (foot in plantarflexion).

• Step 2: A tourniquet is applied proximal to the vein, and the

skin over the vein is cleansed with an antiseptic solution.
PERIPHERAL VENOUS ACCESS
PROCEDURE
• Step 3: The needle/catheter is inserted with the bevel of the
needle facing up. It is advanced slowly into the vein until a
flash of blood is seen in the hub.

• Step 4: The needle/catheter is advanced a few millimeters to

ensure that the catheter is in the vein. The catheter is then
advanced over the needle into the vein, which activates a
safety feature in which the needle is withdrawn into a
protective sheath.

• Step 5: Free backflow of blood through the catheter suggests

that the vein has been successfully cannulated.
PERIPHERAL VENOUS ACCESS
PROCEDURE

• Step 6: The tourniquet is removed.

• Step 7: The ability to easily flush saline through the catheter

with no swelling at the insertion site confirms IV placement.

• Step 8: The catheter is taped firmly in place, and any air in

the connecting tubing is evacuated. An infusion set is
attached, and a sterile dressing is applied to the insertion
site. In a resuscitation situation, fluid boluses may be
pushed directly through the connecting tubing by using a
three-way stopcock and a large syringe.
PERIPHERAL VENOUS ACCESS
PROCEDURE: VIDEO
PERIPHERAL VENOUS ACCESS
COMPLICATIONS
• The complication rate associated with peripheral venous catheters
is relatively low, and severe complications are infrequent

• Complications include hematoma formation, cellulitis, osteomyelitis,

thrombosis, phlebitis, pulmonary thromboembolism, infiltration, and
skin slough

• Medications that are irritating to the veins, such as calcium,

dopamine, potassium, or epinephrine, should be diluted and
administered through the largest peripheral vein possible to avoid
the development of phlebitis

• Vesicant or irritant fluids (pH <5 or >9, osmolarity >600 mOsm)

should not be administered through a peripheral IV access site
PERIPHERAL VENOUS ACCESS
COMPLICATIONS
• EARLY COMPLICATIONS
– occur during placement and can be avoided by following
safe placement techniques
• Bleeding
• Hematoma

• LATE COMPLICATIONS
– could be infective and mechanical; aseptic precautions
during placement, hand hygiene, and non-touch techniques
during maintenance care help to reduce infective complications
• Thrombophlebitis
• Extravasation