What are the recommended IV access techniques for pediatric patients?

IV Access Techniques in Pediatric Patients

Primary Recommendation

Intraosseous (IO) access should be the first-line vascular access method in pediatric cardiac arrest or critically ill children when peripheral IV cannot be rapidly established, as it provides fast, safe, and effective drug delivery comparable to intravenous routes. 1

Hierarchical Approach to Pediatric Vascular Access

Emergency/Resuscitation Settings

For cardiac arrest or critically ill children:

• Attempt peripheral IV access first, but limit attempts to avoid delays 1
• If peripheral access fails or cannot be obtained within 90 seconds, immediately proceed to IO access 1
• IO access is Class I recommendation (highest level) for pediatric cardiac arrest 1
• All medications (epinephrine, adenosine, fluids, blood products, catecholamines) can be administered via IO route with comparable onset and drug levels to IV 1
• Central venous access is NOT recommended as initial route during emergencies due to time requirements and technical difficulty 1

IO Technique Specifics:

• Use manual pressure or infusion pump for viscous drugs or rapid boluses 1
• Follow each medication with saline flush to promote central circulation entry 1
• Can obtain blood samples for analysis including type/cross-match and blood gases (though acid-base analysis is inaccurate after sodium bicarbonate administration) 1

Non-Emergency Settings

Peripheral IV remains standard for routine care:

• Preferred for routine fluid administration, medications, and short-term therapy 2
• Antecubital fossa is the preferred site over hand or lower extremity (hand has 3-fold increased odds of difficult access, lower extremity has 8-fold increased odds) 3
• Ultrasound guidance significantly improves success rates - 78% vs 66% first-pass success compared to landmark technique 4
• Single-operator, dynamic, short-axis ultrasound technique shows best results 4

When to escalate beyond peripheral IV:

• PICCs (Peripherally Inserted Central Catheters): Use when access needed >3-5 days 2, 5
• Average PICC life is 13 days with 69% therapy completion rate 5
• Only 2% documented catheter-associated sepsis rate 5
• Safe for home IV therapy with similar complication rates as hospital use 5

Long-term access (>14-21 days):

• Tunneled, cuffed central catheters (Broviac/Hickman) recommended over prolonged PICC use 2
• Better fixation and decreased infection risk compared to non-tunneled devices 2

Identifying Difficult Access Patients

High-risk characteristics requiring early ultrasound or alternative strategy:

• Age <1 year (younger age increases difficulty) 3
• History of 2+ failed traditional attempts 6
• Non-black/non-white race (2.4-fold increased odds of difficulty) 3
• Previous difficult access history 6

For these patients, ultrasound-guided technique reduces:

• Overall time (6.3 vs 14.4 minutes) 6
• Number of attempts (median 1 vs 3) 6
• Needle redirections (median 2 vs 10) 6

Catheter Size Selection

Match catheter to patient size: 1

• Infants 4-5 kg: 8 Fr dual-lumen catheters tolerated
• Neonates: Catheters available down to 28G 2
• Larger children: Progressively larger catheters as size permits
• "Adult" size (8-10 cm) for children >10 kg (>1 year) 1
• "Infant" size for infants <10 kg 1

Site Selection Algorithm

Peripheral IV site preference order:

1. Antecubital fossa (lowest failure rate) 3
2. Forearm
3. Hand (avoid if possible - 3× failure risk) 3
4. Lower extremity (avoid - 8× failure risk) 3

Central access site selection when needed:

• Internal jugular preferred over subclavian (subclavian causes >80% stenosis rate in pediatrics) 1
• Femoral access when upper anatomy unavailable 1
• Right atrial tip placement prevents occlusion and allows high flow rates 1

Critical Pitfalls to Avoid

Do not:

• Spend >90 seconds attempting peripheral IV in critically ill children before moving to IO 1
• Use subclavian access routinely (>80% develop stenosis - preserve vessels for future dialysis access if needed) 1
• Use multi-lumen catheters when single-lumen suffices (infection rates increase from 0-5% to 10-20%) 2
• Attempt central line as first-line in emergencies 1
• Use endotracheal drug administration if vascular access (IV/IO) is achievable - effects are less uniform 1

Special precautions:

• Use 0.5% chlorhexidine (not 2%) in premature infants to avoid skin burns 2
• Monitor extravasation risk carefully in premature infants 2
• Avoid arm vein cutdown in patients with eGFR <45 mL/min to preserve future dialysis access 7

Endotracheal Route (Last Resort Only)

If vascular access impossible, lipid-soluble drugs can be given via endotracheal tube (mnemonic "LEAN": Lidocaine, Epinephrine, Atropine, Naloxone), though effects are less predictable than IV/IO routes 1