Pediatric Corner

Tough time obtaining venous access in a child?

Avoid multiple sticks

Are you able to try sticking your patient more than once or twice? Can you wait for the best possible nurse to be free? Do you need to consider alternative access immediately?

You need to consider all of these areas when attempting difficult intravenous (IV) access on a child, says Denise Langley, RN, BSN, CPEN, CEN, ED nurse manager at Doernbecher Children's Hospital in Portland, OR. Langley gives these three tips:

  • Use a vein-finder light, warm water, or warm washcloths to help veins become more visible and palpable.
  • Allow the child to get comfortable, in his or her position of choice.
  • Know which veins are easiest to access, depending on the age of the child.

"Hand veins are easiest, up until the 7- to 11-month range when extra padding can make it more difficult. Then hand veins become more pronounced again in the preschool to school-aged child," says Langley. "Feet and ankle veins are good places to start the search in the smallest infants, as well as scalp veins."

Antecubital veins can be more difficult in a child that is moving a lot, due to the difficulty of holding and securing the site, adds Langley.

Lee Ann Wurster, RN, an ED nurse at Nationwide Children's Hospital in Columbus, OH, says, "The most difficult patient to obtain venous access on are the chronic children who have had multiple IVs in the past." Wurster says that the best strategy is to "recruit the best nurse to attempt IV access, right from the first stick."

Use other options

When the situation or the patient's condition requires alternative access, the intraosseous (IO) drill is effective and is quicker and easier to use than hand-placed IO needles, says Langley.

While nurses at Nationwide Children's are not permitted to place IOs, Wurster says, they are trained on the use of the EZ-IO Intraosseous Infusion system, manufactured by the Shavano Park, TX-based Vidacare Corp. "This system is used for critically ill or injured patients where urgent access is needed," she says. (See resource box for more information on the system, below, a story on training ED nurses on use of the IO drill, below, and a tip to help ED nurses practice, below.)

If peripheral intravenous (PIV) insertion is needed due to a patient's history, illness, or injury, "our physicians will not hesitate to turn to the 'EZ-IO,' says Wurster. "PIV access will continue to be attempted. However, the IO can be used for fluid resuscitation or medication while PIV attempts are being made.

When using the drill, remember that the torsion of the drill allows for the ease of drilling through the bone, rather than amount of pressure applied to the drill, says Heather Smyers, BSN, RN, CEN, CPEN, ED education specialist at Cincinnati (OH) Children's Hospital Medical Center.

At in-service with a pediatric intensivist, nurses at Mount Desert Island Hospital in Bar Harbor, ME, were complimented on their quick use of the IO access drill for a child seizing. Chris Costello, RN, CEN, director of emergency and obstetrical services, says, "IV access was not immediately successful. One of our ED nurses was the champion to obtain the IO drill last year. If we did not have the drill, we would have had to stick this child potentially many more times before getting access."

An IO drill is typically used when IV attempts have failed or immediate venous access is needed. (See the ED's policy, p. 57.) When the IO drill was first used, demo equipment was made available to ED nurses. "Everyone has as much opportunity to practice with it as they need. The equipment is kept where anyone with down time can access it to refresh," says Costello.

Sources/Resource

For more information on difficult venous access in pediatric patients, contact:

  • Chris Costello, RN, CEN, Director of Emergency and Obstetrical Services, Mount Desert Island Hospital, Bar Harbor, ME. Phone: (207) 288-5081 Ext. 1313. E-mail: chris.costello@mdihospital.org.
  • Denise Langley, RN, BSN, CEN, Emergency Department, Doernbecher Children's Hospital, Portland, OR. Phone: (503) 494-7521. Fax: (503) 494-6954. E-mail: langleyd@ohsu.edu.
  • Heather Smyers, BSN, RN, CEN, CPEN, Emergency Department, Education Specialist, Cincinnati (OH) Children's Hospital Medical Center. Phone: (513) 803-9327. E-mail: heather.smyers@cchmc.org.
  • Lee Ann Wurster, RN, Nationwide Children's Hospital, Columbus, OH. Phone: (614) 722-4333. E-mail: LeeAnn.Wurster@nationwidechildrens.org.

The EZ-IO Intraosseous Infusion system's power driver retails for $295, and needles retail for $99 to $115. For more information, contact:

Hesitant to use IO drill on a child? Practice!

Repetition is key

When ED nurses were learning to use the intraosseous (IO) drill for pediatric patients, they found it hard to "get over the mental barrier of using it on someone who is not coding," says Chris Costello, RN, CEN, director of emergency and obstetrical services at Mount Desert Island Hospital in Bar Harbor, ME.

"It is incredibly difficult to get over the mental block of using a drill on a patient, especially if it is a child and the parents are standing right there," Costello says. However, after repetitive education, "folks have become increasingly more comfortable with the IO drill," says Costello. "It has become a valuable piece of equipment for our ED."

ED nurses at Doernbecher Children's Hospital in Portland, OR, who place IO lines must complete a competency for the procedure. This competency includes correct placement in a practice model leg and a supervised placement in a patient, says Denise Langley, RN, BSN, CPEN, CEN, ED nurse manager.

Heather Smyers, BSN, RN, CEN, CPEN, ED education specialist at Cincinnati (OH) Children's Hospital Medical Center, says some staff might need more time to practice, as they have never used a drill before, so "allowing them ample time to become comfortable with the drill is key." Because IO drill use is a "low-volume, high-risk" skill, Smyers' ED offers nurses a practice kit to use, including a drill and bones.

"Staff will often get out the training kit in times of low volume," she says. "We also run simulations with manikins that allow for IO insertion."


Clinical Tips

Are you new to IO drill? Practice with raw eggs

Heather Smyers, BSN, RN, CEN, CPEN, ED education specialist at Cincinnati (OH) Children's Hospital Medical Center, says that an effective method for ED nurses to become comfortable using an intraosseous drill is training with raw eggs.

The torsion of the drill allows the user to puncture the eggshell without damaging around the insertion site, as long as the user does not apply too much pressure, Smyers explains.

"If the user is applying too much pressure, the eggshell will crack," she says. "This mimics what will happen when applying to much pressure to the bone: a fracture."


Here is ED's policy for use of IO drill

Below is the policy used for an intraosseous (IO) drill on pediatric patients by ED nurses at Mount Desert Island (MDI) Hospital, Bar Harbor, ME.

Policy: After four attempts to establish vascular access by two separate licensed medical providers, intravenous (IV) access is unable to be established in 90 seconds, or IO is deemed the most appropriate avenue for vascular access by the practitioner, and access is rapidly required, the licensed medical provider with documented competency and privileges at MDI Hospital may establish an IO in the adult patient.

After two attempts on a pediatric patient, age 8 and under, unable to establish IV access in 90 seconds, IO is deemed the most appropriate avenue for vascular access by the practitioner; and access is required, the licensed medical provider with documented competency and privileges at MDI Hospital may establish an IO.

Indications include but are not limited to: cardiac arrest, status epilepticus, all shock states, arrhythmias, dehydration, burns, drug overdose, diabetic ketoacidosis, renal failure, stroke, acute myocardial infarction (AMI), coma, obstetric complications, thyroid crisis, trauma, anaphylaxis, congestive heart failure, emphysema, respiratory arrest, hemophiliac crisis, altered level of consciousness, respiratory compromise, and hemodynamic instability.