Improving IV Success in Children

I haven’t quite figured why we consistently shortchange children when itchild_iv comes to IV therapy.  I don’t know if it’s because we’re scared, or intimidated or just plain lazy.  But let’s face it—starting IV’s on little kids is hard!  Their veins aren’t always the most accessible, they like to scream, kick and bite, and sometimes parents are the problem.  I’m going to lay out a few suggestions that I’ve found helpful that, hopefully, you can put into your ownpractice.  I’ll acknowledge that some of these suggestions are not practical because of time constraints, but see what you can use:

  1. Preparation.  Preparation.  Preparation.  I can’t overstress this enough—this is without a doubt the single most important step.  I’ve seen it many times, someone goes to poke a little kid and BAM, because of some failure to prepare, and IV site goes to waste.  And with little kiddo’s we don’t always get the luxury of multiple sites.  Get all your equipment set up.  Have your bag hung and tubing primed.  Have several IV catheters opened up and ready.  Have your saline lock primed and ready to go.  Have multiple alcohol wipes open and easily accessible.  Have your securing device—whatever that may be—ready for immediate use (peel the back off!).  Have your help ready.  Have a back up plan (don’t be afraid to drill if indicated!).
  2. Create an environment conducive to starting an IV.  I don’t have any scientific evidence to support this, but I’ve observed that starting an IV in a child’s living room has been far more successful than the back of a moving ambulance.   Remove screaming siblings and other screaming people from the area.  If a parent is going to be a problem politely ask them to stand behind the curtain or outside the ambulance, for a brief moment.
  3. Palpate without a glove.  I know some of those BSI Nazi’s out there will chide me for suggesting this, but it’s far more difficult to palpate small veins wearing gloves.  Mark a suitable site with a sharpie if you need to, then put on gloves before you poke.  Let gravity be your friend.  Use good tourniquet technique; cut a latex tourniquet in half for infants and toddlers.  An appropriately sized BP cuff works great as a tourniquet; inflate until just past the diastolic BP for optimal vein filling.  Some of the best nurses I know use the Weesight or a high-powered flashlight.  Don’t use one that get’s hot—if you burn a child you’ll be in big trouble.
  4. If in doubt, use a smaller catheter.  It’s far better to have an IV that is “too small” than no IV at all.  In fact, I’d take a well placed 22g in the hand over a tenuous 18 that is highly positional in the AC any day.
  5. Use good technique.  Rest the extremity on a solid surface.  If starting an IV in the hand (which I’ve found to be a favorable site in little kids) rest the wrist (catchy!) over a rolled up towel to create a natural angle.
  6. Use an arm board.  You know, those foam covered sticks in the upper cabinet of the ambulance?  They aren’t coasters or door stops—they’re for immobilizing IV’s in kids.  They work wonders!  I’m completely amazed at how often I encounter EMS field crews who choose not to use these.
  7. Have plenty of help.  Don’t expect to be able to stick a needle in the hand of a 4 year old without someone else holding on to the arm.  I avoid using parents as my heavy muscle, but if that’s all you’ve got—make it work.
  8. I’ve been in the habit of telling kids who are of age enough to understand this:  “cry all you want, scream all you want, but just don’t move.”  I’ve found it helpful, but you might not.  Proceed with caution.
  9. Be careful with your insertion angle.  A steeper angle goes much further on small veins.  The inverted bevel technique is complete garbage.  If you’ve ever seen it used, then you know that.  Now if you ever hear of it being used, stomp that crap out like a wildfire.
  10. The last bit of advice I’ll pass along is not a “don’t do that.”  It’s a “do, do that.”  When it comes down to it, don’t be afraid to try.  Hear what I am saying… don’t make a pin cushion out of a child, but don’t be afraid to try.  Rely on landmarks.  So in the end, sometimes the best advice is do, do that.

I could go on all day about reasons to start IV’s and reasons not to, good ways to do it and bad ways, blah, blah, blah.  In the end, I felt like these ten things were of the most value.  Good luck!

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