Peripheral
For anyone that has struggled getting IV access in children, we will discuss using the ultrasound to assist in peripheral venous access. “Blind” locations are discussed on a separate page. The use of ultrasound may be especially fruitful in specific patient populations, such as ex-premies with prolonged NICU stays or patients with congenital cardiac disease—they have had multiple needle sticks with consequent loss of the superficial veins. Another patient population that requires special consideration are children with Epidermolysis Bullosa, where even the use of a tourniquet may be contraindicated. One may also consider Trisomy 21 patients, as these patients anecdotally never seem to have veins in the expected locations. While this is not meant to be an exhaustive list, one can easily see how beneficial this skill is to learn.
Dynamic Needle Tip Positioning
One of the first trials to show the efficacy of real time ultrasound-guidance in pediatric peripheral IV access was by Doniger et al in the ED of a Level 1 pediatric trauma center. This prospective, randomized study included 50 pediatric patients less than 10 years of age who had either had a history of difficult IV access or at least two unsuccessful traditional attempts. They found an overall success rate of 80% in the US group versus 64% in the traditional group, along with decreased cannulation times, fewer attempts and fewer needle redirections. A more recent meta-analysis by Heinrichs et al suggests that ultrasound-guided may decrease PIV attempts and procedure time in children in both emergency room and operating room settings. Unless our health system is an anomaly, I imagine quite a few of you have also used the ultrasound on the wards after everyone who can put in IV’s have been exhausted and someone finally says, “call anesthesia.” If you haven’t considered using the ultrasound in that situation, perhaps you should.
The most common cannulation sites in the pediatric population include: cephalic, brachial, antecubital, saphenous. Securing the limb to an arm board or having a second pair of hands to secure the limb during the procedure (or both!) can be extraordinarily helpful. One should also pre-scan to identify which side and which vessels seem most promising for cannulation.
Once you have identified the vessel you would like to cannulate, some people will advance the needle out-of-plane until they see blood in the hub of the needle, and then rotate to an in-plane view to ensure that the needle or catheter is advanced intraluminally. Still others will start in the short-axis, out-of-plane and maintain that orientation throughout the procedure, incrementally “walking it in” under direct visualization (aka Dynamic Needle Tip Positioning). This technique has been studied in both peripheral and central venous cannulation, as well as arterial cannulation.
Finally, another unwritten perk of using the ultrasound for PIV placement is that it may help in determining adequate catheter diameter and length based on vessel cross-sectional area and depth from the skin. With many needle manufacturers offering a variety of different sizes and lengths, for example, one may able to choose a long length PIV catheter in a child who one may anticipate needing IV access for more than a few days. This may reduce how quickly the IV wiggles itself out and infiltrates.
Doniger, S.J., Ishimine, P., Fox, J.C. and Kanegaye, J.T., 2009. Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients. Pediatric emergency care, 25(3), pp.154-159.
Heinrichs, J., Fritze, Z., Vandermeer, B., Klassen, T. and Curtis, S., 2013. Ultrasonographically guided peripheral intravenous cannulation of children and adults: a systematic review and meta-analysis. Annals of emergency medicine, 61(4), pp.444-454.
Tobias, J.D., Martin, D.P. and Bhalla, T., 2015. Ultrasound-guided peripheral venous and arterial cannulation in the pediatric population. Anaesthesia, Pain & Intensive Care, 19(3).
Clemmesen, L., Knudsen, L., Sloth, E. and Bendtsen, T., 2012. Dynamic needle tip positioning–ultrasound guidance for peripheral vascular access. A randomized, controlled and blinded study in phantoms performed by ultrasound novices. Ultraschall in der Medizin-European Journal of Ultrasound, 33(07), pp.E321-E325.