PIV tips in chunky babies?

[invitro]

Hey so after dealing with two <1 yo babies going for cranioplasties and having a rough time with venous access, I was wondering if any of the pedi guys on this forum could offer some tips for PIVs on chubby babies with not a blue vein in sight. Particularly on getting the saphenous...it you look at the literature many authors seem to think its gettable in 80-90% of patients...my track record is not that great, maybe 50-60%.


thanks guys..

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[IlDestriero]

My success with the saphenous vein is probably >80%. I use a 22 vs 24. You can use the ultrasound if you have a quality one available. In little chubby babies the saphenous is often a blind line. I also have great success with a couple 24s in the palmar wrist.
When all else fails, just put a central line in the femoral vein and take it out the next morning. If you're doing those surgeries, you need good access for blood products.
Practice putting saphenous lines in all of your outpatient peds patients. You'll get up to speed pretty quick.
Good luck.

 

[sevoflurane]

Those michelin kiddo's can be a pain in the arse. I don't routinely do these kids anymore, but I do remember a couple of cases where IV access took a good while to get (with multiple Peds attendings in the room).... one or two ending up with scalp IV's. Getting femoral a-lines poses it's own challanges.

I wish I still did them as I feel I'm loosing my skills if a month goes by and I haven't had to struggle with a 24g. Peds attendings make for the best IV access guru's in the hospital, IMO.

I don't know what IlD uses, but the preference of most of the peds attendings I worked with was the 22/24g jelco's

I think you can actually feel a pop as you enter the vessels with these. My wife carries her own stash of these as our hospital doesn't routinely carry them.

 

[Coastie]

Hey so after dealing with two <1 yo babies going for cranioplasties and having a rough time with venous access, I was wondering if any of the pedi guys on this forum could offer some tips for PIVs on chubby babies with not a blue vein in sight. Particularly on getting the saphenous...it you look at the literature many authors seem to think its gettable in 80-90% of patients...my track record is not that great, maybe 50-60%.


thanks guys..

saphenous....

or, in between the knuckles on these little fatties..

Either of those is a >90% success rate for me, N = hundreds

 

[Gern Blansten]

my favorite go to spot on these kids is between the knuckles of the pinky and ring finger just proximally. Frequently a blind stick, but that vein is always there and I can almost always thread it. Hope I didn't jinx myself.

 

[IlDestriero]

We use some safety needles most of the time, when I'm really in the weeds, it's time to call for a hand and break out the Jelcos. And yes, I feel a pop.

Those michelin kiddo's can be a pain in the arse. I don't routinely do these kids anymore, but I do remember a couple of cases where IV access took a good while to get (with multiple Peds attendings in the room).... one or two ending up with scalp IV's. Getting femoral a-lines poses it's own challanges.

I wish I still did them as I feel I'm loosing my skills if a month goes by and I haven't had to struggle with a 24g. Peds attendings make for the best IV access guru's in the hospital, IMO.

I don't know what IlD uses, but the preference of most of the peds attendings I worked with was the 22/24g jelco's

I think you can actually feel a pop as you enter the vessels with these. My wife carries her own stash of these as our hospital doesn't routinely carry them.

 

[countingdays]

My success with the saphenous vein is probably >80%. I use a 22 vs 24. You can use the ultrasound if you have a quality one available. In little chubby babies the saphenous is often a blind line. I also have great success with a couple 24s in the palmar wrist.
When all else fails, just put a central line in the femoral vein and take it out the next morning. If you're doing those surgeries, you need good access for blood products.
Practice putting saphenous lines in all of your outpatient peds patients. You'll get up to speed pretty quick.
Good luck.

I was going to recommend the bolded options above. Even if you have to hold a fat fold out of the way you can usually see wrist veins. Saphenous is my preferred blind stick so far. Hopefully people mention more good possibilites for blind sticks on this thread. I've heard and done blind sticks in the midhand between the 4th and 5th metacarpals but don't love it so far. I've never done or seen an iv between the knuckles, but I'll try looking for that in the future. Scalp might work too, a lot of our nicu kids show up with them though I don't think I ever had to put one there myself.

 

[jwk]

Would an IO be acceptable, or is that truly for urgent/emergent use only?

 

[Masseter Spasm]

If I don't see veins, I often try to blindly stick the saphenous vein, the "intern vein" (basilic vein?), or the vein between the fourth and fifth metacarpal. Most of the kids coming in for a craniosynostosis repair are otherwise healthy and have a venous system that is intact but hidden.

 

[IlDestriero]

Would an IO be acceptable, or is that truly for urgent/emergent use only?

I would never do an IO for anything not emergent, and only when I didn't have time to drop in a femoral line. If you disrupt a growth plate for anything less than a dire emergency, you will pay dearly.

 

[IlDestriero]

One great go to spot in a pinch is the "thumb vein of Destriero" it is accessed blindly just proximal to the metacarpophalangeal joint. Sometimes there's a faint blue streak. Check it out on your own thumb.