Chapter 47: Venous Access: Peripheral Intravenous Catheterization

I. INDICATIONS

Peripheral intravenous (IV) catheterization involves inserting an IV catheter into a peripheral vein.

1. Vascular access in nonemergent and emergent situations for the administration of IV fluids and medications.

2. Administration of parenteral nutrition.

3. Administration of blood and blood products.

4. Blood sampling only if associated with initial intravenous placement.

II. EQUIPMENT

1. Basic. Armboard, adhesive tape, tourniquet, alcohol swabs, normal saline for flush (0.5% normal saline if hypernatremia is a concern), povidone-iodine solution/swabs, transparent dressing material, appropriate IV fluid, and connecting tubing. For difficult venous access, transillumination, near-infrared light, or ultrasound can be used, and these are considered optional. In-line filters are sometimes used; however, a Cochrane review (2015) found that there was insufficient evidence to recommend the use of IV in-line filters to prevent morbidity and mortality in neonates.

2. Intravenous catheter. Safety-engineered/self-shielding devices preferred: 23- to 25-gauge scalp vein (“butterfly”) needle or a 22- to 24-gauge catheter-over-needle. Use at least 24 gauge for blood transfusion.

III. PROCEDURE

1. Catheter-over-needle assembly

   1. Select the vein. Common neonatal IV insertion sites are shown in Figure 47–1. Several techniques have been described based on personal preference.

      1. The vessel can be entered directly after puncture of the skin on the top of the vein.

      2. Enter the vein at the “crotch” or “Y region,” the location where 2 veins join together (Figure 47–2A).

      3. Insert alongside the vein and advance approximately 0.5 cm before entry into the side of the vessel (Figure 47–2B).

   2. To help identify the vein, use visualization, palpation, near infrared spectroscopy imaging, transillumination, or point-of-care ultrasound using static technique (see Chapters 25 and 44). The dorsum of the hand is the best choice to preserve the sites for potential central venous catheters (cephalic, brachial, greater saphenous veins) if needed. Avoid areas of flexion.

      1. Scalp. Supratrochlear (frontal), superficial temporal, or posterior auricular vein (last resort).

      2. Back of the hand. Preferred site using the dorsal venous network.

      3. Forearm. At the wrist area is the cephalic and basilic vein. Median antebrachial vein and accessory cephalic vein are higher up on the forearm.

      4. Foot. Dorsal venous arch.

      5. Antecubital fossa. Basilic or cubital veins.

      6. Ankle. Greater and small saphenous veins.

   3. Use of point-of-care ultrasound for peripheral intravenous catheterization. One can use real time imaging to help guide the peripheral IV placement. Benefits include less time for placement, better success, decreased attempts and needle redirections, and less complications. See Chapter 44 for technique.

   4. Shave the area if a scalp vein is to be used. Try to place needle behind the hair line in the event of cosmetic scarring.

   5. Restrain the extremity on an armboard or have an assistant help hold the extremity or the head.

   6. Pain management. Oral sucrose/glucose, pacifier, swaddling, and other nonpharmacologic methods can be used for pain reduction. The American Academy of Pediatrics recommends eutectic mixture of lidocaine and prilocaine (EMLA) applied 30 minutes before ...