Venous Access in Children

Intravenous Cannulation
 Most of us are skilled at gaining IV access in adults, but get a bit more concerned when we need to bleed or cannulate a small child. Here's a few tips I've picked up on the way...

Preparation and Distraction

• Get all your stuff ready and open before you start. This means the rustling isn't off putting.
• If the child is big enough, sit them on a parent's knee, and position the hand behind them, so they can't see what is going on. 
• Distraction is really important - parents are excellent at this. They might use an iphone, Where's Wally, or singing of Nursery Rhymes.
• Go in to the room feeling positive and as though you WILL succeed - children pick up on the vibes.
  
• Ametop or Emla cream is very helpful if you have time.
• Babies still feel pain - sucrose can be helpful. 
• If you don't have time for Ametop to work, remember cold spray can be helpful. 
• Analgesic gas can also be very useful - using it also distracts the child!

Technique
There are plenty of excellent resources demonstrating a good technique.

• Medscape
• Royal Children's Hospital
• You Tube

From personal practice, I think the most important steps are distraction (otherwise you have a wriggling child), confidence, and holding the skin really really taut before attempting the cannulation.
What are your tips?

Intraosseous Cannulation
IO is a new idea in adult trauma, but has been used in children for a while. There's a great article on IO in trauma here. There are many methods of gaining IO access in children and despite them all seeming as good as each other in adults,  EZ-IO seems better and quicker in children, with low complications... Whether your department uses a Cook needle or a gun type device like the EZ IO make sure you know how to use it, and which needle to use. Most devices use a pink needle for children.

Although it doesn't alter flow rates, the site you chose for IO access is really important in children, as you don't want to damage their growth plates. These guidelines have clear location pictures reminding us of where the growth plates are. EZ - IO have a clear powerpoint with guidelines too. 

1. Tibia
   Find the flat anteromedial surface of the tibia one- to two-finger breadths below the level of the tibial tuberosity is the preferred site.
   Position the leg with the knee slightly bent and semi-externally rotated. Place a sandbag or towel roll under the leg for support.
2. Ankle
   One- to two-finger breadths proximal to the medial malleolus, sufficiently posterior to avoid the saphenous vein.
   Externally rotate the leg.
   Use only as last choice in young children
3. Humerus
   1 cm above the surgical neck (where the bone juts out)

• Clean the area
• Insert the IO
• After you have inserted the IO, you need to unscrew the needle from the stylet, and dispose of the needle. If you forget to unscrew the needle your IO won't work!
• Secure the IO 
• Consider  flushing with local anaesthetic.
• Aspirate bone marrow for analysis (and remember to let the lab know).
• Attach extension tubing to the IO. This means you can easily access the IO without repeatedly moving the IO.

Keep practicing when ever you can on the non-poorlies, and then when you need to gain IV or IO access in a poorly patient, you'll have no problems.