26FLARES
Placing peripheral IV cannulas (PIVC) is THE paediatric procedure. Rather than including every single step towards being a 100% sharpshooting cannula guru (I’m not!), the emphasis for this post is securing a cannula. That is, making it last long enough to investigate & treat the child, and hopefully for several days of an admission if required. The need for repeated cannula placement isn’t just “annoying” for ward staff – they’re genuinely traumatising experiences for children and their families. A good reason to aspire to keep that first PIVC as secure as possible. Bear in mind, this is not a post about access in a resus situation; there are IOs for that. This post emphasises some key tips for securing a PIVC that will last the distance.
You are caring for Roman, a severe pre-school wheezer who is vomiting and moderately dry. He needs IV hydration in addition to IV steroids & you’d like a venous blood gas for your troubles, too, as you think he’s getting worse. But, he’s not so sick that he won’t fight you off; his hypoxic agitation mandates that rather than a gentle cuddle and songs, he’s a raging ball of fear. So, with the help of four others, you have him suitably positioned and calm for a few minutes. You find a vein in his plump wee hand, and…Zip, your 24g IV goes in first attempt. Boom! Flashback, gas taken, bloods off. Okay. Flush please.Now he’s getting cranky. And squirming. And screaming. You’re holding his sweaty hand firmly, plus the cannula as the extension set is attached. The assistant hurriedly puts on the first layer of tapes. Within seconds the ends are curling. The tension rises. The assistant whacks on the next layer of dressing. And the next. You ask them to try to flush the line; it’s ‘stiff’. You know it’s in the vein; now it’s kinked!? The dressing is beginning to lift. Roman is losing it, crying, trying to escape. Mum says “It’s almost done, honey.” nervously. (She’s squished up against the railing on the far side of the bed, holding Roman still and looking a bit pale herself.) Someone says “No more needles!” Roman doesn’t care, he wants it all to stop and is getting sweatier and more upset. Your team tries to retape, but Roman wriggles. You can see the entire cannula just sitting on the skin in a mess of sweaty, blood-stained tape. Roman’s Dad groans loudly.
It’s fair to say this is going badly. How did we get here? How can we avoid it? Just like all the simulation training we talk about, this is one you need to go over a few times, both in your head and in practice (with ‘smoother’ cannulations). Here’s one framework:
1. Decide
Decide that the cannula is genuinely indicated. A line you don’t believe in is more likely to fail. I will say in my head (or out loud) why the cannula is required; investigation or access. The main caveat is that if it’s for access in the resus setting, know your backup and your threshold to use it. For any cannulation attempt, consider the alternative. What if you fail? Most departments have a strict “three strikes and you’re out” policy. Stick to it, and make sure your colleagues, irrespective of seniority, do too.
2. Plan
“Plan” is the key word throughout this post. In truth, every aspect of success for this procedure comes down to planning. Here are a few things to consider
Where (patient): When you have a bit of time to plan the cannula, do exactly that! Plan your first pass site & a couple of backups. Look everywhere that’s appropriate for each child. In the neonate, hands or feet are preferred. Generally, I use the rule that until a child is walking, feet are just “upside down hands” from the point of view of access. I also apply this rule to children who can walk but are likely to be too sick to do so for the duration IV access is required.
In school age children whom are ambulatory, this usually means both hands, before both cubital fossae before other sites. IVs around joints, particularly the elbows can be a source of immense frustration to the patient, ultimately limiting the cannula’s life.
Aim to cannulate the best vessel, in general, don’t “save them” for someone better; give yourself the best chance of first time success!
Cream them! If you’ve picked the target vein and backups, use LMX4 or AnGel and allow it time to work.
Where (physical space): Are you happy with the current location for the child? On the ward, it may be more appropriate to use a treatment room. Get your equipment ready. Make sure as much as possible you do this outside the line of sight for the child; seeing blunt needles and syringes waved around in the air make anyone anxious, least of all the reflected anxiety from the patient and their family. Be discrete, but not secretive.
Further to this end, if you’re on the ward and the child can be moved, use the treatment room. The child’s bed should, as much as possible, be a place of safety. Likewise, you’re more likely to have all the things you need for a successful line in the treatment room, not just spares, but the distractors too!
In your preparation, be systematic (I lay things out left to right in order of usage.) To trim things up or down for different ages, acuity or breadth of investigations, it pays to set up yourself, if you have time. Use an appropriate sized cannula; in the words of one experienced paediatrician, “Yellows (24g) are only for babies.” Knowing your tools and environment puts you at ease and hence improves your likelihood of success.
Specifically, get the gear you want. A surgeon friend told me once “No one minds or really remembers if you wait for a particular piece of kit if the procedure goes seamlessly. But everyone remembers the mess & scrambling when you need that one piece of kit you thought you could go without at a key point of the procedure.” If there’s a big kerfuffle over not having the right tools for the job, it will be on you, the cannulator. In the same way you wouldn’t “just have a crack” at an airway, a major bowel operation or a lumbar puncture, placing an IV is a procedure that deserves respect and preparation.
3. Prepare your team
Find the staff who will assist you. Cannulating kids is at least a two person gig, often more once you adjust for age and acuity. Check they are comfortable assisting and state what the plan is, with specific mention of ‘high risk times’, specifically, immediately after skin breakage prior to securing the IV and whilst obtaining blood from the cannula.
For a child that you suspect will fight, or particularly kick, it’s good to specifically mention needlestick. If you believe the situation is becoming unsafe from a needlestick point of view, pause the procedure, deescalate and start again, with more pairs of hands available.
At the bedside, explain to the parents. If they are to be assisting/comforting the child, explain what is required and offer an out (timeout etc). After a couple of syncopal parents, I’ve recently included a bit about feeling faint / lying down on the ground.
So, we can pretty comfortably describe roles for five people in addition to the patient;
- Cuddler (parent)
- Distractor (parent or staff)
- Stabiliser & tourniquet control
- Cannulator
- Cannulator’s assistant & taper
- Plus, someone to run a blood gas (who will be of no help in the ~5 minutes thereafter)
Generally, get at least one more person than you think you need. Consider the experience level of your colleagues. If you are being assisted by four staff who’ve been paediatric nursing this since you were in nappies, listen to their advice.
4. Positioning for the team
Get a comfortable position for everyone; you will work better if you are comfortable.
For children or in the emergency department, I generally kneel on a pillow, as I find it offers a broader, more stable base, allows others to sit on the bed, and enables access for taping from a broad range of angles.
In neonates, I set the resuscitaire at my waist, and ensure there’s a step for my more diminutive colleagues.
Optimise the lighting – often shining the brightest light source at shiny skin recently doused with liquid will make veins evaporate. You can experiment with aiming procedure lights about 10cm away from the target and using the ‘shadows’ for contrast. Just like a wiley instagram filter, it often makes the unexpected stand out!
5. Position the child
If the child is too young to sit but too large for a resuscitaire, have them supine.
Pre-schoolers and school aged children seem to prefer a Koala cuddle. In this position, the parent sits on the side of the bed. Child faces in for a cuddle, with legs to one side. To the other side, the arm of choice is placed under the parents armpit, with an assistant further stabilising & on tourniquet control. Alternatively, a toddler can be cannulated in a similar way, with leg in the same position as the arm just described. This is an excellent position for distraction therapy, either by a parent or one of your assistants. you can cannulate from the same side, or reaching across the bed whilst kneeling.
School-aged children may be able to receive IV cannulation whilst sitting up, perhaps in the lap of a parent. You may have already established this when the the child was wholly compliant with a look in their throat and ears on examination, but be careful not to underestimate how fearful a child might be.
Sheet restraint is certainly not the first way to go, but if you deem this as the most appropriate way to cannulate a particular patient, wrap a sheet around & under the child with the desired access point free. This wrapping will utilise some of their own body weight in keeping them still. Do not restrain the child longer than necessary. If you need multiple attempts, release the wrap and have a ‘cool down’ time between attempts.
Do not say “this won’t hurt” – it’s lying to the child and erodes their trust.Do not say “just a little stab” – it primes them for pain.Distract, distract, distract.And, Don’t Forget The Bubbles.
In addition to topical & systemic analgesia (make sure you’ve listened to Andy Tagg’s talk on Paediatric Pain Management), adjuncts such as nitrous oxide can be considered. If you’ve come to this point, please reconsider the indication, level of distress, timeliness of access & duration of therapy; will this child need a PICC or Long-line instead of this PIVC?
Some phrases to use when the child is already distressed;
“You can be as loud as you like, so long as you are as still as a stone.”“Brave doesn’t mean that you’re not scared. Brave is being a bit scared and doing it anyway.”“We are going to look after you & help you feel better.”
If the situation has deteriorated and you are confronted with a screaming, sweaty, distressed child who clearly has some fight and the cannula is indicated, just get it done. Identify when you’re past a point of reassurance and distraction, secure the access and allow for cuddle, reconciliation and care afterwards.
6. Place the cannula
You’re in! You felt the pop, saw a red streak of flashback. (Or the saline you’ve put in the hub changed, thanks Andy W!)
Now’s the time to remember why you’re doing this; if it’s for bloods, get the IV to a point that’s relatively stable and drag them out via a 3mL syringe on a blunt needle. If you need more blood, use more syringes. If everyone (especially the child) is calm at this point, it might be possible for an initially slow vein to speed up. I’m not sure why, but sometimes it appears that veins stop bleeding for a period of time (say, a minute or two), even when the IV is in, only to open up and pour out blood a few minutes later. If you need a reasonable volume of blood, and things are stable, take you time and get the amount you need to send the tests. I’m thinking here of say, new diagnosis leukaemia, where the line might be for transfusion and hence pre-transfusion investigations are essential. Remember, the only ‘common’ tests you need from the vein are a blood culture and coagulation profile. A Capillary blood gas, FBC, Gp & hold, CRP, UEG can all be scraped off the skin from a heel/finger prick. Don’t compromise a difficult “access-oriented” cannula waiting for tests you can get somewhere else.
If the line is primarily for access, whilst the flow might not be impressive, ensure you have the cursory investigations you need and secure & flush.
Keep hold of the limb & cannula until you are happy it is secure. The scenario at the outset of this post emphasises the importance of everything but ‘getting the IV in’, in kids & here’s where it really, really counts.
If you miss, take a breath! All is not lost! Keep positive! Decide if you’ll start from scratch or if your next best attempt can be undertaken with minimal fuss in changing positions. Visualise the cannula’s tip into the vein. Visualise the cannula passing along the length of the vein. If you’re out, say so. Verbalise your backup plan & action it.
Rightio, let’s secure this line properly.
7. Site
You’ve already considered the location of the PIVC & how best to stabilise & secure once you’re in. It’s good form to think about your plan to secure the line at the same time you’re placing the LMX4 at the outset, and explain the plan to your team in advance of the attempt. Remember, elbows are wriggly, ankles are strong, and foot stabilisation can be a bit more challenging to maintain for a usually active toddler. These considerations may alter your choice of target vein.
8. Sweat
Children who are febrile sweat, as do kids in respiratory distress or heart failure. If you’ve spotted these things from the end of the bed, prepare for a sweaty cannula. Expect most of the usual ‘gentle’ adhesive glues to melt off prior to stabilisation. I rely on Cavilon (3M), which acts like a glue. I’ve found it better than SkinPrep and others, and will use it with the first run of taping. (It’s also good for sticking your glasses to your nasal bridge, if they have a habit of sliding off during this kind of procedure!)
In the scenario above, the cannula kinked during taping. This is never an easy situation, but all the more worse because the child was so sweaty. If things are ‘not right’, and you know the cannula is in the right spot in vivo, keep things calm and go back to the start of securing. Visualise the cannula & the entry point, it’s where it’s most likely kinked. Feed it to the hilt & give it a small flush. Meantime, use your skin preparation/glue to clean around the cannula and methodically step through each set of tape/dressing, with a small flush at each point. Keep talking in a low calming voice to your colleagues, and direct them to what you want. If you’re not sure ask. If you’re not satisfied with something, firmly but gently redirect things until you are convinced of the cannula’s security.
9. Taping
There are a myriad of ways to ‘best’ secure a PIVC, and to my knowledge, not much in the way of evidence. Here we’ll give one way to do things, but firstly, think about what you’ll be using to secure the line.
Good choices include hypafix and brown tape or similar. There’s a trend away from brown tape as it is pretty harsh on the skin. Don’t waste time/energy/resources with micropore & paper tapes as they are useless at this point. In total, you’ll need;
- two thin pieces to secure the cannula to the skin
- a windowed dressing (“the teddy bears”)
- another piece of wider tape to further attach the cannula’s hub to the teddybears.
- Three pieces to secure the armboard
- One or two armboard, depending on location
- In addition to the tapes mentioned, a longitudinally divided piece of the accessory tapes that come with the ‘Teddy bear” type dressing will do the trick.
The most important part of taping is securing the cannula to the skin, with either
- a) two “figure 8” or “awareness ribbons”, or
- b) a “figure 8” (#1) and another piece across the hub horizontally (#2).
Typically these pieces need to be quite narrow; say, 0.5-0.8cm wide, and are placed to prevent the PIVC just walking its way out of the vein. These are placed as shown in the diagram below.
Once the cannula is at least attached to the skin, give it a flush; if the line is hard to flush at this stage, either the cannula is kinked, is walking out or has blown. Visualise the very base of the cannula, and restart the taping from the beginning. If you’re happy at this point, proceed to placing the teddy-bear style dressing. Wrap it around the base and have the bulk of the dressing proximal to the PIVC insertion point. In some situations, it can be useful to do a “double teddy bear”, with one aiming proximally & one aiming distally from the entry point. It’s also good to put some kind of barrier between the cannula’s hub and the skin. A small piece of microfoam or a small piece of foam that comes with the arm boards reduces the chance of a pressure sore at this spot. Lastly, “put the teddies to bed”, with a further piece horizontally across the hub.
Throughout the taping, above, the cannulator will not have let go of the hand/foot/limb, so we’d better crack on and get the board placed.
10. Board/splint & bandages
I’ve used the terms armboard & splint interchangeably below. I will use a splint for every PIVC I place in a child under about 10yo, with three points of contact to the board.
Hands: Aim to splint the wrist. The commercial arm boards were designed for this, so make use of the many options. This means that the board finishes at either the MCP joint or at the finger tips, usually depending on the location of the cannula & age of the child. For neonates, I’ll leave the fingers free if I can help it, likewise kids over five. For infants & toddlers, I’ll tend toward strapping the board at the proximal phalanges, wrist and forearm. Leave the thumb frees. Ensure all fingers are pink and visible to be checked.
Feet: If you have a bendable splint, it’s good to have it pre-fitted before things get started. In a pinch, they usually conform pretty easily. Again, three points of contact – distal foot, ankle, lower leg. If, however, your unit has hard, breakable boards, you’ll need two of them. The first you break and place as above. Use the second board to brace the first like a splint at 90deg and affixed with two additional pieces of tape. For best results, place the bracing board on the same side (medial v lateral) as the cannula; this has an added role of protecting the PIVC from direct trauma, and means there’s a handy place to tuck the extension tubing.
Elbows: With my background heavily in paediatrics, I’m loathe to use cubital fossa veins, but sometimes they’re what you can get. I advocate for the two rigid splints in this location too (without breaking either!). The perpendicular splints reduce the chances of the child rotating and squirming out of the dressing.
For all the above, attach the trailing extension set to the splint/board.
Scalp: Scalp veins are becoming less utilised. I’m mentioning them here more as an item of curiosity, with a focus on securing the cannula once it’s in a scalp vein. After the tape & “double teddies” as above, find a small foam cup and cut a 3cm wide, 1.5cm high portion of of the edge for the extension line. Affix three points of tape to the scalp and bandage with lightweight crepe bandage. It should look like a cross between an Ancient Egyptian Mummy and a Fez.
Likewise, the endpoint of bandages vs large tapes vs tubigrip vs minimal outer dressing is controversial between practitioners & units. There is no ‘standard’ in this; I personally like thin tube bandages, as they don’t catch aren’t too bulky and are easy to check.
11. Yankers and biters
For kids like Roman in the scenario, it’s worth asking the parents if the child is ‘a biter’; in addition to being a risk to staff safety, biting out cannulas is not uncommon. Some kids will yank out their IVs with a free hand, in fear or rage. This is never an easy situation. In some cases, the child’s free hand is bandaged up to protect against removal of a cannula from the contralateral limb. A similar “boxing glove” style of wrapping around both the cannulated hand and non-cannulated hand can be utilised to at least delay removal via biting. Aside from this, it’s all down to lots of parental cuddles and astute observation.
Feeling confident about the plans I’ve described above, I set out to take a few illustrative photos with my toddler. I prepared all the tapes, the boards (no actual IV insertion, of course) and dressings. A couple of each for a few different plans. The results were impressive; not a single successfully taped splint in sight. Why? It was just me; and I was no match for a well squirmy, enthusiastic child, who rapidly pulled off boards & tape even as I reached for another. I implore you to ensure you have more people than you need!
12. Post-procedure care
In the immediate aftermath, it might be good for you to leave the room whilst the child settles. Often though, it’s best to take a bit of extra time to calmly explain with the family what you’ve done, why it’s important, as well as some of the key points about caring for the PIVC. Yes, it’s important to send of the investigations, but likewise, this is a key point for good, clear communication & empathy.
We’d love you to share your tips for securing lines in the comments below!
In summary:
- Placing an IV is a procedure that deserves respect and preparation.
- Decide and Believe the indication for a cannula.
- Aim to make the PIVC last.
- Plan & Prepare equipment, staff, parents & the child. Get at least one more person than you think you need.
- Positions need to be comfortable, and Distract, distract, distract.
- Plan securing the line; personnel, site, sweat, taping, protection.
- Securing the line can be harder than accessing the vein. Plan and prepare for it!
References:
Additionally, although I’d initially planned to write a ‘how to guide’ from scratch, the RCH Melbourne team have already done a great job here; http://www.rch.org.au/clinicalguide/guideline_index/Intravenous_access_Peripheral/
No comments:
Post a Comment