18-month-old Byron presents to ED with septic arthritis. You know you need to take cultures, so you think you might pop a peripheral intravenous cannula in his antecubital while you’re there – he’ll need intravenous (IV) antibiotics for sure, maybe some fluids. He’s toddler-level chubby, and not exactly compliant.
Time for a deep breath.
Inserting peripheral intravenous catheters (PIVCs) is a core skill in paediatric acute care. We often make a quick decision to insert a PIVC in order to ensure accurate diagnosis and commence important treatments. We often worry about our capacity to insert the PIVC, especially in children like Byron. The vessels can be hard to visualise and palpate, and putting a young child going through a painful procedure can be stressful for all concerned.
But quick decisions have consequences
We know that PIVCs can result in harm. Multiple insertion attempts, extravasations, and infections are all a risk. They often stop working prior to the completion of treatment. PIVCs last only 48 hours, on average, in children and young people. When they fail, we not only pause treatment, but we frequently have to start the process all over again. According to children (and their families) cannulation is the most stressful part of their healthcare experience.
Think carefully about the IV, before it is inserted.
We have an array of IV devices and a variety of places to insert them. In 2020, the Michigan Appropriateness Guide for Intravenous Catheters (miniMAGIC) was published. Its aim was to improve the safe selection of IVs in children across a range of indications. You can read them (open access) here; or download the app for Google or Apple.
In Queensland (Australia) we have developed our first practice targets to improve IV selection, insertion, and securement based on miniMAGIC, and thus reduce IV associated harm. We are currently rolling them out at Queensland Children’s Hospital (Australia). These are:
Improving device selection
Peripheral devices (like PIVC or midline catheters) should only be used for peripherally compatible therapies, outside of an emergency or crisis
To ensure safe administration of ‘at risk’ infusates, we consider:
- Is this PIVC working? Check for good flow prior to administration
- Is this PIVC optimally placed? Ideally, it should be away from a joint?
- Are we giving this medication slowly and with enough dilution? Check the Paediatric Injectable Guidelines (PIG)
- Is this PIVC site visible? It shouldn’t be coverfed up with crepe bandages
We are proactive in our device planning:
- If the child needs >2 days of IV therapy, make sure the PIVC is optimally positioned (e.g., in forearm)
- If the child needs >5 days of IV therapy, consider a midline catheter
STOP and THINK, Make a plan! If this PIVC stops working, do we need to replace it immediately or are there other options? If this child is going to theatre, can we have the device ‘upgraded’?
Peripherally Inserted Central Catheters (PICCs) should not be inserted for antibiotic administration without discussion with the Infectious Diseases team. We use the minimal lumens necessary for treatment (NO just in case PICC/additional lumens).
Improving device insertion
Inserted them away from joints, where possible, looking for visible AND palpable vessels in the forearm. If there is nothing obvious it is time to turn to the trusty ultrasound machine if you have the skills. Even when we place topical anaesthetics, we pop some on the mid-forearm rather than antecubital fossa.
When faced with a child without palpable or visible vessels, don’t have multiple IV insertion attempts. Instead, refer early to an experienced clinician (+/- USG).
Improving device securement
- Keep it visible: Do not use crepe bandages; use tubular bandages.
- Keep it clean: Use sterile products
- Keep it secure: Use two points of securement
Take a look at Henry’s Twelve tips to placing a well secured PIVC.
For Byron, this means we consider the planned duration of intravenous antibiotics, assess his vessels, and our skills. If practical, Byron would have a PIVC inserted in the forearm (most likely via USG) where we can simultaneously take blood cultures. We would also consider an upgrade to midline or PICC, once the cultures and sensitivities are known, providing a better understanding of the actual duration of therapy and targeted antibiotic therapy.
We are evaluating the project, to see its impact on PIVC related morbidity. Based on the impact of MAGIC on adults, this is likely to be considerable (read here).
Another way to make sticking children with sharp needles less painful for everyone.
Want some top tips on paediatric cannulation? Watch our paediatric cannulation video on the DFTB YouTube channel here.