The simple IV?

Pediatrics for Parents, March, 2008 by John E. Monaco

To many it seems like such a simple concept. Admit a sick child, start the IV, administer fluids and medications and wait for the child to get better, right? How hard can it be? Well, one of the great ironies of caring for sick children in the hospitals is that one of the most basic steps in hospital care can be one of the most challenging.

Luckily, most people manage to get through the long and difficult process of raising their children without ever having to go through the trauma of experiencing the hospitalization of their child. Those who have gone through the trauma of seeing their sick child in the hospital will tell you that one of the most harrowing experiences is watching the ER staff or the pediatric floor staff attempt, and hopefully succeed, in drawing blood and starting IVs. It can be long and arduous, and unfortunately painful, process.

Picture this: Your nine-month-old otherwise healthy child has been vomiting for two days, and over the last 24 hours has also developed diarrhea. You have been talking to your pediatrician and she says to give only clear liquids, slowly and frequently. You manage to get a couple ounces in over two or three hours and suddenly your child vomits again. He is more listless than he was earlier in the day. And all the time he continues to have loose, frequent diarrhea stools. You begin to panic. What am I going to do? How long can he go on vomiting and having diarrhea and not drinking? You call the pediatrician. It is late in the evening and the office is closed. She tells you to bring the child to the Emergency Room of your local hospital.

You get to the ER; you wait an hour, maybe two, to be seen. You keep trying to give your child Pedialyte, but he's losing interest as quickly as he is losing energy. Finally, a very nice nurse comes back to you and escorts you to a room. The ER doc comes in and immediately says the your child looks very dehydrated, and we'd better get an IV in right away.

Two nurses come in. They tell you that you can stay, but you might not want to. You decide to stay because you have never left your baby. One of them holds your child and the other starts "to look for a vein." She looks at the back of your baby's hand and grumbles that he is either too chubby or too dry. You take offense but want to stay supportive. She looks at the ankles and again grumbles at the lack of possibilities. Then, in your horror, she looks at your baby's scalp. It turns out that this is one of the best sites in a child under a year. You go along, and amidst the desperate screams of your beloved child, now in the hands of strangers, you watch as a completely focused nurse threads a tiny IV catheter into one of the spidery looking veins in your baby's scalp. You can't believe that she got it in. You can't believe that she seemed to be unaffected by the screams. You can't believe that this seemingly simple procedure stands between life and possibly death for your baby.

But it does. The most valuable person in any pediatric ER, on any pediatric ward, ICU or any other setting where kids get sick, is the nurse, or doctor, who is proficient at getting IVs in kids. Without that skill, or talent, almost nothing else in pediatric hospital care is possible.

IV starting is learned by practice, which means that there will be times when your child is having his IV started by someone who is doing it for the first time. Hopefully, someone who is more experienced and can prevent any mishaps is supervising that individual. A recent wonderful development in medical education is the use of "dummies" or simulators to teach students clinical procedures. These are basically computer-animated patients with veins that need IVs. Much like the concept used in teaching airline pilots, the theory is that a medical student who hones his techniques on a nonliving subject will be much more prepared when the real thing comes along.

Ultrasound technology has developed to the point that veins can actually be visualized at the bedside, making IV starting much easier. Unfortunately, in the case of the tiny veins in pediatrics, this is often impractical. One can only hope the research in adults will eventually trickle down to the more challenging veins of small children.

Obviously, pain is an unwelcome consequence any time a needle pierces the skin, and is an enormous inhibition to trust in the pediatric population. In the last decade, the use of topical anesthetics, like EMLA cream or other lidocaine-containing creams, have been a tremendous help in IV starting in kids. These creams are applied to the skin over the vein to be used for the IV. It takes a few (up to 30) minutes, but the surface skin will eventually become numb. The obvious limitations to this technique are time, in an emergency situation, or when multiple attempts are needed to even "find" the vein. Still, you should not be afraid to ask for your child to receive one of these creams, if time and the severity of illness allow.

Still, there is hope on the horizon. But even with all these techniques designed to make IV insertion easier, less painful and more successful, getting the IV started remains one of the most important first steps in caring for almost any child admitted to the hospital for almost any reason. The IV nurse that tries to find a good vein in your child's body isn't trying to hurt him--or emotionally torture his parents--but help him on his way to recovery.