Pediatric Pearls - Tough IV Access

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Nurses Edition Commentary

Mizuho Morrison, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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Christopher W. -

I am a PEM working in Louisiana. I was discouraged to hear the lack of support for US guided peripheral IV's in children. I used US to place peripheral IV's in adults for years before making the switch to peds and have found the US invaluable in starting pediatric peripheral IV's. I think the size of patients makes US guided IV's easier in children because the length of the catheter is so much longer compaired to the size of the patient. Obese adults require extra long catheters but a child you just need a regular 22 guage angiocath to get down to the vessels. I use the inch worm technique or threading the needle down the lumen of the vessel with US guidance before advancing the catheter. This technique works well even in neonates where I use the basilic vein. I have taught many nurses to preform this as well. We don't let a child get stuck very many times before pulling out the US.

ilene c. -

As in many cases (especially with pediatric emergency medicine), the existing literature is small, and doesn't support many of our experience. Overall, ultrasound does not seem to be helpful, but it does seem to help a little with the tough ones. My guess is that those are the ones that you are intervening on! Great tip, thanks for sharing!

Whit F. -

Hey there guys. Great job. I am a huge fan of scalp veins (in adults too) and find that Keurig coffee cup (with the coffee removed) can make the perfect IV shield. One question: at what age is ketamine contraindicated in these sick little ones? It seems like an IM injection could go a long way in removing infant and parent distress, especially if you're doing other painful procedures besides an IV (such as an LP and a straight cath). I've heard you can't give it in anyone younger than 3 months, but is this just a medical myth or is there real evidence?

Thanks so much.

ilene c. -

Love the Kerig cup!

There are a number of antecdotal reports of ketamine causing laryngospasm and apnea in kids 3 months. It is therefor listed as a contraindication in the 2011 ketamine practice guidelines (Green et al. Clinical practice guideline for ED ketamine dissociative sedation: 2011 update. An EM 57(5)). This is actually an improvement- it used to be "banned" before age 12 mo. Not much evidence of adverse events between 3 and 12 mo, though!

Whit F. -

Good to know! Thanks.

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