Tips and tricks for pediatric I.V. insertion

Nursing, Dec 2000 by Frey, Anne Marie

LET'S FACE IT. Children and nurses alike dread the insertion of an intravenous (I.V.) device. In the following questions and answers, I'll share some tips and tricks that experienced pediatric nurses rely on to make the procedure less traumatic for you both.

Get special pediatric IN. training before trying to access sites that you wouldn't use in an adult, such as the foot or scalp. Placing an umbilical line is usually limited to advanced practice nurses and physicians.

Should parents be present?

Keep in mind that most children up to age 7 are less apprehensive if a parent is present. Ask an older child if she wants her parent present. Encourage the parent to calm and comfort the child, but don't ask her to help restrain her; let another nurse take on this role.

Now can I minimize the child's pain and anxiety?

The best way to prepare a child for venipuncture depends on her age and developmental level. In general, the younger the child, the less time you should allow before the procedure and the simpler your explanation should be. Try these tricks to promote cooperation:

Administer a local anesthetic before venipuncture, according to policy.

Perform I.V. insertion outside of the child's hospital room. Allow her room to be a safe haven.

Give an age-appropriate explanation when the time is right. With toddlers, wait until immediately before you start to say, "We're going to do your I.V. line now." With school-age or adolescent children, explain the procedure and, if possible, allow them to choose the arm.

Always be honest. Tell the child that the venipuncture will hurt, but only for a short time. Don't promise "only one stick" or say that it won't hurt.

Provide as much privacy as possible and give her permission to cry.

Allow her to have items that calm her, such as her pacifier, bear, or blanket.

Let older children participate, which will help distract them, by ripping tape, opening alcohol swabs, and holding tubing. Older children may also want to listen to music with headphones.

What size device should I use?

Choose the smallest-gauge catheter (24 or 22) in the shortest length to allow hemodilution of infusates by blood flow around the catheter. In neonates, administer I.V. fluids and medications, blood, and blood products via a 24-gauge I.V. device. In older children, a 24- or 22-gauge catheter works without increasing the risk of hemolysis.

How do I choose a suitable site?

Selecting a site depends on the type and duration of I.V. therapy and the child's developmental level. A child's veins are located in the same areas as an adult's, but subcutaneous fat may make finding them difficult. Brush up on your knowledge of vein anatomy and anatomic landmarks.

Start by looking at various veins before choosing one. Here are a few common sites and some guidelines for using them.

Scalp veins are easy to access and most appropriate in neonates; an older infant might dislodge a device placed there.

Hand and foot veins are appropriate for children of all ages, but try to use foot veins only in children who aren't walking yet. If possible, try not to choose a vein in a child's dominant hand or the hand she favors for thumb sucking.

Digital veins are useful in toddlers and older children if other sites aren't accessible, but they infiltrate easily because the site is difficult to immobilize in an active child.

The forearm or upper arm is suitable for all children, but veins there may be harder to access, especially in infants and toddlers, where veins may hide under subcutaneous fat. Arm sites allow for larger-sized catheters and hand mobility.

Antecubital sites (cephalic, basilic, or median cubital vein) are suitable for all children and are easy to locate in infants. But these sites are uncomfortable and require immobilizing the elbow. Because this site is also used for phlebotomy and peripherally inserted central catheter placement, it shouldn't be your first choice.

Now do I distend a child's vein?

To dilate veins in children, use a tourniquet appropriate for the size of your patient and position it several inches above the intended site. To place a device in a scalp vein, a rubber band with a tape tab, placed above the eyes and ears, is an easily removable tourniquet. Make sure the tourniquet isn't too tight or on too long, indicated by red or purplish skin. You should be able to distend veins but still feel a pulse. To ease the discomfort of the tourniquet, you can tie it over a sleeve or a gauze 4x4. In some cases, especially with premature neonates, you'll be able to see or feel veins well enough to access them without using a tourniquet.

To encourage vein dilation, place warm packs on the site for 10 minutes, according to the manufacturer's instructions, before venipuncture. After you locate the most suitable site, remove the tourniquet.

How do I keep a child still during venipuncture?

Comfortably position the child as needed before the procedure using gentle restraint. It's better to restrain the child and obtain IN. access in one attempt than to make multiple attempts in a flailing, distressed child.