Peds IV access

[caligas]

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peds folks, give me some tips:

Just did a peds Mri. Pudgy 2 year old, took forever to get an IV. Got me thinking more about back up plans for this. Just keep hammering away, ultrasound etc.? What about a small femoral line? For femoral, use a kit or just place a long Angiocath? Give ED A a call and ask them a call for an IO?

Other thoughts?

 

[d9sccr]

Not a pedi expert by any means but knowing how to do a saphenous is a huge saver. Also, I tend to find veins between the 3rd and 4th digits just proximal to the knuckle

Vein finders can be useful but have a learning curve IMO

 

[drmwvr]

Not a pedi expert by any means but knowing how to do a saphenous is a huge saver.

🙂

 

[oldguy55]

Not a pedi expert by any means but knowing how to do a saphenous is a huge saver. Also, I tend to find veins between the 3rd and 4th digits just proximal to the knuckle

Vein finders can be useful but have a learning curve IMO

This. I have to assume the OP tried it, but that vein is always there, even when I can't see it or feel it. That doesn't mean you will always get it, but it seems to be pretty big, even if it is buried.

 

[btbam]

Saphenous although in the chunky toddlers you usually can't even feel it. There's a vein that runs on the outside of the foot that's usually good as well as the aforementioned 3rd and 4th digit. I'd place an ultrasound guided axillary before going femoral. We run into this problem most often in urology in the 8-9 month olds who haven't started crawling and are just massive.

 

[cowbydoc]

I love my wee sight.
Amazon product ASIN B006R7Z61SIt takes a little bit of a learning curve but once you get it you can get any vein. Works best two years and under.
I agree with the others, when they hit that 9-15 month age range they can get really pudgy. The blind saphenous is possible but it’s prety hard hitting it on a Michelin man.

 

[camkiss]

I flip the wrist over and place a 22 or 24g in one of the veins there. They’re usually fairly superficial even in pudgy kids. If that doesn’t work, saphenous.

 

[drmwvr]

I love my wee sight.
Amazon product ASIN B006R7Z61SThe blind saphenous is possible but it’s prety hard hitting it on a Michelin man.

For such a sewer pipe of a vein, it's worth dragging in the u/s to get it when the problem is evident on PE.

 

[deleted162650]

@camkiss , Thank you for that avatar. I will be taking a blade home to try that.

 

[dhb]

I've done a 22g to the IJ under US.

 

[pocafx]

@camkiss , Thank you for that avatar. I will be taking a blade home to try that.

University Hospitals in cleveland gave them out during interviews.

 

[IlDestriero]

You can get a blind saphenous in almost everyone, unless the NICU jacked it up in some previous admission. It’s also an easy one for the US. The inner wrist is also usually good for a 24. It’s a crappy vein and it won’t last long when the kid is awake and doing stuff, but it will get you through the case and rehydrated if that is an issue. Sometimes I take the chronically dehydrated Dev Delayed kids and give them a 20/kg LR bolus through some crappy 24, then I place a real IV while they prep.
I’ve placed a femoral before for urgent surgery. It’s fine in a pinch, but it’s not going to stay clean and you should place something somewhere else.
I’ve also placed an EzIO in a dire emergency when the kid had no access and wouldn’t be getting any soon. We did the case with it, then placed an IV and a PICC at the end.


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Il Destriero

 

[kidthor]

Like others said a landmarked based saphenous approach is always worth a try. US is also always worth a try (often you can see that the saphenous is nice and patent, at least). Don't forget to look for scalp veins in case there's a winner there...

 

[Iso4ane]

@camkiss , Thank you for that avatar. I will be taking a blade home to try that.

I've tried with a normal miller blade, it kinda works, I just need to wait for another airway emergency before i can get my hand on a Macintosh Blade. (My institution has emergency airway kits with disposable handles and blades, and the blades are fairly sturdy.)

 

[deleted9493]

If the point of vein puncture is deep because of trajectory or insertion site/habitus, consider utilizing an arterial line kit for a catheter of greater length. These kits include catheters that are “tight to wire” ensuring successful Seldinger exchange. 3Fr 5cm or 4Fr 8cm Cook arterial line kits are what I most commonly use for this purpose.