Overview
Definition:
Intravenous (IV) cannulation in infants involves the insertion of a small, flexible catheter into a peripheral vein to establish venous access for fluid, medication, or blood product administration
It is a critical skill in pediatric care, often challenging due to the small size and mobility of infants.
Epidemiology:
Virtually all hospitalized infants require IV access at some point during their admission
The incidence of difficult IV access varies widely based on infant age, condition, and the experience of the clinician, with studies suggesting difficulty in up to 30-50% of cases in neonates and young infants.
Clinical Significance:
Effective IV cannulation is paramount for timely and accurate delivery of life-saving therapies, including hydration, antibiotics, analgesics, chemotherapy, and blood products
Failure to secure adequate venous access can lead to delays in treatment, increased patient distress, and potential complications
Mastering this skill is essential for pediatric residents preparing for DNB and NEET SS examinations.
Techniques For Infants
Vein Selection:
Preferred sites include the superficial veins of the scalp (anterior fontanelle veins), dorsal hand and forearm, antecubital fossa, and dorsum of the foot
Use a vein that is visible, palpable, and well-distended
Avoid areas of infection or previous venipuncture.
Cannula Selection:
Use the smallest gauge catheter appropriate for the intended use
For infants, 24G or 22G catheters are commonly used
Consider color-coded catheters for easy identification of gauge size.
Insertion Technique:
Prepare the site with antiseptic solution and allow it to dry
Stabilize the vein with gentle traction
Insert the cannula at a 15-30 degree angle, bevel up, until a flashback of blood is seen
Lower the angle and advance the cannula slightly before threading it into the vein while simultaneously withdrawing the needle
Secure the cannula with tape or a sterile dressing.
Site Preparation:
Thorough cleaning of the insertion site is crucial to minimize infection risk
Use an alcohol swab or chlorhexidine-based antiseptic
Allow the site to air dry completely before insertion.
Securing The Cannula:
Properly secure the cannula with a transparent semipermeable dressing and tape to prevent dislodgement and monitor the insertion site for signs of infiltration or infection.
Challenges In Infants
Small Vein Size:
Infants have delicate and small veins, making them prone to collapse or rupture during insertion
Gentle technique and appropriate equipment are vital.
Patient Movement:
Infants are prone to spontaneous movements, which can dislodge the cannula or make insertion difficult
Adequate restraint and assistance are often required.
Limited Access Sites:
Certain areas may be compromised due to underlying medical conditions, surgery, or previous attempts, necessitating creative vein selection.
Anxiety And Pain:
The procedure is inherently painful and can cause significant distress to the infant and family, impacting subsequent attempts and overall care.
Distraction And Comfort Measures
Pharmacological Methods:
Topical anesthetics like EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied 30-60 minutes prior can reduce superficial pain
Oral sucrose (12.5-24%) given 2 minutes before the procedure has proven analgesic effects
Intranasal fentanyl or midazolam may be considered for more anxious infants under strict medical supervision.
Non Pharmacological Methods:
Skin-to-skin contact with a parent, swaddling, pacifiers, and dim lighting can provide comfort and reduce crying
For older infants, playing with toys or watching a video can be effective.
Involving Parents:
Parents can be instrumental in comforting the infant
Allow them to hold the child, speak reassuringly, and participate in distraction techniques
Explain the procedure clearly to alleviate their anxiety.
Environmental Factors:
A calm and quiet environment can significantly reduce infant distress
Minimize noise and unnecessary personnel in the room.
Positioning:
Position the infant comfortably and securely
Having an assistant to hold the infant gently can improve stability and reduce movement.
Complications And Prevention
Infiltration And Extravasation:
Occurs when IV fluid leaks into surrounding tissues
Signs include swelling, coolness, and pain at the site
Prevention: secure cannula well, monitor site frequently, use appropriate gauge cannula
Management: stop infusion, remove cannula, elevate limb, apply warm or cool compress as indicated.
Phlebitis:
Inflammation of the vein
Signs: redness, warmth, tenderness along the vein
Prevention: aseptic technique, change cannula site regularly (typically every 72-96 hours), use smallest effective gauge
Management: remove cannula, apply warm compress.
Infection:
Local or systemic infection at the insertion site
Prevention: meticulous aseptic technique, proper skin antisepsis, regular site monitoring
Management: remove cannula, obtain wound cultures if indicated, administer antibiotics if systemic infection is suspected.
Nerve Damage:
Rare but serious complication
Prevention: avoid cannulating over major nerve pathways, be gentle during insertion
Management: depends on severity, may require neurological consultation.
Hematoma:
Bleeding under the skin
Prevention: avoid puncturing the posterior wall of the vein, apply firm pressure after removal
Management: apply pressure, cool compress initially.
Key Points
Exam Focus:
DNB/NEET SS exams will test understanding of appropriate cannula size, vein selection in infants, effective distraction methods (pharmacological and non-pharmacological), and management of common complications
Be prepared for case-based scenarios requiring decision-making on venous access in critically ill infants.
Clinical Pearls:
Always have your equipment ready before starting
If a vein is not immediately visible, try warming the limb or having the infant cry, as this can distend veins
Never be afraid to ask for help from experienced colleagues, especially in challenging cases.
Common Mistakes:
Using too large a cannula, inadequate vein stabilization, insufficient antisepsis, failing to adequately secure the cannula, and not employing distraction techniques leading to increased infant distress and procedural failure.