What type of line should be attempted next in a 2-year-old patient where a peripheral (peripheral intravenous line) line cannot be established?

Intraosseous Access is the Next Step When Peripheral Access Cannot be Obtained in a 2-Year-Old Patient

In a 2-year-old patient where peripheral intravenous access cannot be established, intraosseous (IO) access should be the next line attempted as it provides rapid, safe, and effective vascular access. 1

Rationale for Intraosseous Access

Intraosseous access offers several advantages in pediatric patients with difficult vascular access:

• Can be established quickly (within seconds to minutes)
• Has minimal complications
• Can be performed by providers with varied levels of training
• Allows administration of all intravenous medications, including:
  • Epinephrine
  • Adenosine
  • Fluids
  • Blood products
  • Catecholamines 1

The American Heart Association guidelines specifically state that IO access is "useful as the initial vascular access in cases of cardiac arrest" and is appropriate when peripheral access cannot be rapidly established in critically ill children (Class I, Level of Evidence C). 1

Comparison with Other Access Options

Central Venous Catheters (CVC)

While central venous access is an option, it has significant limitations in emergency situations:

• Requires more training and experience
• Time-consuming procedure
• Not recommended as initial route during emergencies 1
• Often requires general anesthesia in pediatric patients 1

Ultrasound-Guided Peripheral IV

Although ultrasound-guided peripheral IV placement can be considered:

• Success rates vary (56-99% in different studies) 2, 3
• Requires ultrasound equipment and trained personnel
• Higher failure rates in the first 24 hours (47%) 2

Practical Aspects of IO Access

Placement Sites

• Proximal tibia (preferred site in young children)
• Distal femur
• Proximal humerus (in older children)

Medication Administration

• All IV medications can be administered via IO route
• Onset of action and drug levels comparable to venous administration
• Use manual pressure or infusion pump for viscous drugs or rapid fluid boluses
• Follow each medication with a saline flush to promote entry into central circulation 1

Blood Sampling

• IO access can be used to obtain blood samples for analysis
• Suitable for type and cross-match and blood gases during CPR
• Note: acid-base analysis becomes inaccurate after sodium bicarbonate administration via IO 1

Subsequent Vascular Access Options

After stabilization with IO access, consider:

1. Ultrasound-guided peripheral IV placement
2. PICC line for prolonged hospitalization 1
3. Tunneled CVC for long-term access needs 1

Cautions and Considerations

• Limit time spent attempting peripheral venous access in critically ill children 1
• In settings with limited resources, use caution with bolus fluid therapy in children with severe febrile illness 4
• Be vigilant for complications of IO access, though these are rare when properly placed

Following successful resuscitation and stabilization, a more definitive vascular access plan can be implemented based on the child's ongoing needs and clinical condition.