Overview
Definition:
Scalp vein intravenous (IV) cannulation is a procedure where an IV catheter is inserted into a vein on the scalp of an infant to administer fluids, medications, or draw blood samples
It is particularly useful in neonates and young infants when peripheral IV access in the limbs is difficult to obtain or maintain.
Epidemiology:
Scalp vein IVs are frequently utilized in neonatal intensive care units (NICUs) and pediatric emergency departments for patients weighing less than 10 kg or those with poor peripheral venous access
The incidence varies based on the acuity of the patient population and institutional protocols.
Clinical Significance:
Effective vascular access is critical for the management of critically ill infants, enabling timely administration of life-saving fluids and medications, monitoring of hemodynamic status, and nutritional support
Scalp vein IVs offer a viable alternative when other sites fail, preventing delays in treatment and reducing patient distress.
Indications
Indications For Use:
Need for rapid fluid resuscitation in dehydrated or hypovolemic infants
Administration of essential medications (antibiotics, vasopressors, anticonvulsants) requiring reliable IV access
Requirement for prolonged IV therapy or parenteral nutrition
Inability to secure peripheral IV access in the extremities due to anatomical challenges, edema, or previous venipuncture attempts
Neonatal resuscitation or transport situations where immediate IV access is paramount.
Contraindications:
Scalp infection or skin breakdown at the proposed insertion site
Presence of a skull fracture or head trauma that may interfere with insertion or increase the risk of complications
Significant coagulopathy if invasive procedures are to follow
Routine elective procedures where peripheral access is easily achievable
History of significant scalp vein abnormalities.
Age Considerations:
Primarily indicated in neonates and infants up to approximately 12 months of age
Vein size and fragility increase with age, potentially making scalp veins less ideal or more challenging for older infants
Specific anatomical landmarks and vein selection may vary with gestational age and postnatal age.
Equipment And Preparation
Required Equipment:
Sterile gloves
Antiseptic solution (e.g., chlorhexidine or povidone-iodine)
Sterile gauze pads
Appropriate size IV catheter (e.g., 22-24 gauge for neonates, potentially 20 gauge for larger infants)
Transparent dressing or Steri-Strips
Arm board or padding to immobilize the head
Syringe with sterile saline for flushing
Tourniquet (optional, may use finger pressure)
Head protector or net to prevent dislodgement
Patient Preparation:
Explain the procedure to the parents or guardians, if present, and obtain informed consent
Ensure adequate lighting and a calm environment
Position the infant appropriately, often supine with the head slightly elevated
Gentle restraint may be necessary to prevent movement of the head
Secure the infant's head using padding or an arm board to minimize movement during insertion.
Aseptic Technique:
Perform thorough hand hygiene before starting the procedure
Cleanse the selected scalp area with an antiseptic solution using concentric circles, allowing it to dry completely
Avoid touching the prepared site after cleansing
Use sterile equipment throughout the procedure.
Procedure Steps
Vein Identification:
Identify prominent superficial scalp veins, typically in the temporal, parietal, or frontal regions
Palpate the vein to assess its fullness and direction
A slight head tilt away from the insertion side can sometimes distend the veins.
Cannulation Technique:
Gently apply traction to the skin below the insertion site to stabilize the vein
Insert the catheter bevel-up at a 15-30 degree angle to the skin, aiming for the center of the vein
Observe for a "flashback" of blood in the catheter hub, indicating entry into the vein
Advance the catheter slightly while simultaneously withdrawing the needle introducer
Release traction and smoothly advance the catheter off the needle into the vein.
Securing The Cannula:
Once the catheter is fully advanced into the vein, withdraw the needle completely
Apply digital pressure proximal to the insertion site to prevent blood leakage
Immediately connect a syringe with sterile saline for flushing or the administration set
Secure the catheter with a transparent dressing, ensuring the insertion site is visible and the catheter is well-anchored to prevent dislodgement
Consider using Steri-Strips for additional support.
Flushing And Confirmation:
Gently flush the catheter with sterile saline to confirm patency and ensure no infiltration
Observe the insertion site for any signs of swelling or leakage
If patent, connect the IV infusion or medication as prescribed
Document the procedure, including the catheter size, insertion site, time, and the name of the person performing the cannulation.
Troubleshooting And Alternatives
Difficulty Locating Veins:
Try gentle warming of the scalp, applying a mild downward traction on the skin, or using a different lighting source
Consider using a Doppler if available to locate deeper veins
If scalp veins are consistently problematic, explore alternative sites like the dorsal hand or foot veins.
Failed Insertion:
If flashback is not obtained or the vein is perforated, withdraw the catheter and apply pressure
Do not attempt reinsertion through the same site
Choose a different vein and repeat the procedure
Consider using a smaller gauge catheter if veins are very small or fragile.
Alternative Sites:
If scalp vein access is not feasible or unsuccessful, consider peripheral veins in the dorsal hand, antecubital fossa, dorsal foot, or posterior auricular veins
Intraosseous (IO) access is a crucial alternative in emergencies when IV access cannot be obtained rapidly
Umbilical venous catheters (UVCs) are used in neonates but are typically placed by experienced personnel.
Complications
Common Complications:
Infiltration of IV fluids into the subcutaneous tissue, leading to swelling and discomfort
Phlebitis (inflammation of the vein) may occur with prolonged dwell time or irritant medications
Localized infection at the insertion site, characterized by redness, warmth, and purulent discharge
Hemorrhage or hematoma formation during or after insertion.
Less Common Complications:
Arterial puncture if the catheter is inserted into an artery instead of a vein
Air embolism, though rare with scalp veins
Nerve irritation or damage, causing pain or paresthesia
Dislodgement of the catheter leading to loss of access and potential for wound contamination.
Prevention Strategies:
Strict adherence to aseptic technique during insertion and dressing changes
Regular monitoring of the insertion site for signs of complications
Using the smallest effective catheter size
Securing the catheter properly to prevent dislodgement
Avoiding insertion over bony prominences or joints
Prompt removal of the catheter once it is no longer needed or if complications arise.
Key Points
Exam Focus:
Recognize indications and contraindications for scalp vein IVs in infants
Understand the steps of sterile preparation and cannulation technique
Identify common complications and their management
Be aware of alternative vascular access methods like IO infusion.
Clinical Pearls:
Scalp veins are often the most accessible in neonates and young infants
Immobilization of the infant's head is crucial for successful insertion
Always confirm vein patency with a saline flush before starting infusion
Secure the dressing meticulously to prevent accidental dislodgement, especially in restless infants
Consider using an arm board or head protector.
Common Mistakes:
Failure to maintain aseptic technique, leading to infection
Using a catheter that is too large for the vein, increasing the risk of phlebitis and infiltration
Inadequate immobilization of the infant's head, causing repeated failed attempts and patient distress
Not adequately securing the catheter, leading to dislodgement
Ignoring early signs of infiltration or infection.