Ultrasound for difficult pediatric IV's

[HalO'Thane]

Anyone have any experience with using ultrasound for difficult pediatric IV placement? Those who do a decent volume of sick kids knows the painful difficult IV scenarios: 10 month old former preemie, veins scarred down, now older and much, much chubbier, congential cardiac disease, multiple previous surgeries, etc. If ultrasound is used, which sites do you go for first? To me, antecubital would be the most logical; but I was also wondering if people have tried other sites, such as saphenous, forearm, or EJ. I have no problem placing central lines, but I do think it is crazy to drop one for a 20 minute outpatient procedure, such as a circ, T&A, fracture reduction, etc. To me this would be a great opportunity for ultrasound.

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[i want out]

Anyone have any experience with using ultrasound for difficult pediatric IV placement? Those who do a decent volume of sick kids knows the painful difficult IV scenarios: 10 month old former preemie, veins scarred down, now older and much, much chubbier, congential cardiac disease, multiple previous surgeries, etc. If ultrasound is used, which sites do you go for first? To me, antecubital would be the most logical; but I was also wondering if people have tried other sites, such as saphenous, forearm, or EJ. I have no problem placing central lines, but I do think it is crazy to drop one for a 20 minute outpatient procedure, such as a circ, T&A, fracture reduction, etc. To me this would be a great opportunity for ultrasound.

I have used it a few times but only after several blind attempts by several people.

I used superficial lower arm or hand veins. The hard part is putting enough pressure on to make contact without collapsing the vein.

 

[Oggg]

i've only tried this on adults and it's pretty hard to do realtime. I end up marking the path of the vein, putting the U/S down, and following the pen marks

 

[HalO'Thane]

For ultrasound peripheral IV placement on adult patients I find it easier to use the in-plane approach: find the vessel, turn the probe 90 degrees so that it is parallel with the vein, and advance the angiocath in-plane so that I can visualize the entire length of the needle in the vessel. For kids, I think their vessels may be too small to do that. If you turn the probe 90 degrees you may end up losing sight of the vessel.

 

[epidural man]

For ultrasound peripheral IV placement on adult patients I find it easier to use the in-plane approach: find the vessel, turn the probe 90 degrees so that it is parallel with the vein, and advance the angiocath in-plane so that I can visualize the entire length of the needle in the vessel. For kids, I think their vessels may be too small to do that. If you turn the probe 90 degrees you may end up losing sight of the vessel.

Like this? I put this video on youtube a few years ago. (I didn't do the stick - just was there when it was done by the US master).

http://www.youtube.com/user/pagerstalker#p/a/u/0/fie9DI8lV3M

 

[B-Bone]

One trick I like to use is to find a big deep vein, usually something you can't see or feel, underneath a fat pad, or whatever. I get a solid short axis view of a nice round target, then I use one of those long Arrow 20 g artline things with a wire you can advance. As soon as I get a flash, I advance the wire and thread the catheter, just like placing an art line. I find I bugger up fewer difficult IVs with this technique. A 20 is usually sufficient on kids, but if you need a big PIV for an adult, just do the whole thing using sterile technique and wire a 14 or 16 using a short guidewire. Or obviously just place a central line if you're that screwed.

 

[HalO'Thane]

Epidural Man: Yes. Cool video

B-Bone: Sounds like a cool trick. I will have to practice that. We also have pediatric 22G art line kits. The guidewire is separate from the catheter so you can use it to threat in 22G IVs if you have to (I've done that a few times). Does it matter if you go in at a shallow angle or steep angle with the angiocath when in the short axis view?

Thanks everyone.

 

[Oggg]

Are you guys using a standard linear probe 38mm long? Or do you use something smaller?

 

[HalO'Thane]

Are you guys using a standard linear probe 38mm long? Or do you use something smaller?

We are currently only using the standard linear probe. As you can imagine, it can be a little cumbersome to maneuver on a very small infant for peripheral IV's. For bigger vessels for central lines I haven't had as much of a problem. Perhaps our group should look into the smaller probes. Getting the hospital to actually buy one for us is a different story...