Overview
Definition:
Ultrasound-guided peripheral intravenous (IV) access in toddlers is a technique that utilizes real-time ultrasound imaging to visualize veins and facilitate accurate placement of peripheral IV catheters in young children, particularly when peripheral venous access is challenging through traditional methods.
Epidemiology:
Toddlers (1-3 years) frequently present with dehydration, infections, or injuries requiring IV access
Studies indicate a success rate of over 90% for ultrasound-guided PIV insertion in pediatric populations with difficult venous access, significantly reducing the number of attempts and patient distress compared to landmark-based techniques.
Clinical Significance:
Difficult venous access in toddlers can lead to prolonged procedural times, increased pain, patient and parental anxiety, and potential complications like hematomas or nerve injury from multiple failed attempts
Ultrasound guidance improves first-attempt success rates, shortens procedure duration, and enhances patient comfort, which is critical in pediatric care.
Indications
When To Use:
Inability to obtain peripheral IV access after 2-3 attempts using standard techniques
Toddlers with dark skin pigmentation or obesity, where veins are difficult to visualize
Conditions requiring rapid IV fluid resuscitation or medication administration
Patients with previous difficult venous access history
Presence of edema or scarring over superficial veins.
Contraindications:
Local skin infection or cellulitis over the intended insertion site
Lack of skilled personnel trained in ultrasound-guided vascular access
Absence of a suitable vein identifiable by ultrasound
Patient refusal or parental dissent without clear medical necessity.
Benefits:
Increased first-attempt success rate
Reduced number of venipuncture attempts
Decreased patient pain and anxiety
Shorter procedure time
Preservation of peripheral veins for future access
Improved diagnostic and therapeutic capabilities due to timely IV access.
Equipment And Preparation
Equipment Needed:
High-frequency linear ultrasound transducer (e.g., 10-13 MHz)
Ultrasound gel
Sterile gloves
Sterile drapes
Appropriate sized IV catheter (e.g., 22-24 gauge for toddlers)
Antiseptic solution
Sterile gauze
Tape or stabilization device
Local anesthetic (e.g., topical cream or subcutaneous lidocaine).
Patient Preparation:
Explain the procedure to the parent/guardian and the child, if age-appropriate, using simple language to reduce anxiety
Position the child comfortably and securely, ensuring good exposure of the chosen extremity
Consider mild sedation or distraction techniques if necessary
Clean the insertion site thoroughly with an antiseptic solution and allow it to dry.
Ultrasound Machine Setup:
Select a pediatric vascular preset or a high-frequency preset
Apply generous amounts of ultrasound gel to the transducer and the skin over the target vein
Ensure the machine is set up for optimal visualization of superficial structures.
Procedure Steps
Vein Identification:
Identify a suitable vein, typically the cephalic, basilic, or greater saphenous vein, in the antecubital fossa, forearm, or lower leg
Visualize the vein in a longitudinal (long-axis) view to assess its diameter, depth, and course
Look for a anechoic, compressible vessel
Assess for pulsatility, which may indicate an artery.
Insertion Technique:
Using a sterile technique, hold the ultrasound transducer in one hand and the needle/catheter assembly in the other
Insert the needle-catheter unit at a 30-45 degree angle to the skin, aiming towards the visualized vein
Advance the needle slowly while observing the needle tip in real-time on the ultrasound screen
Observe for flashback of blood into the needle hub or a change in the vein's anechoic appearance.
Catheter Advancement:
Once the needle is within the vein, advance the catheter off the needle into the vein
If using a two-person technique, one person holds the transducer, and the other performs the insertion
If using a one-person technique, position the transducer between the fingers holding the needle
After the catheter is advanced, withdraw the needle completely.
Securing The Iv:
Connect the IV tubing or syringe
Aspirate gently to confirm good blood return and check for patency
Secure the IV catheter with sterile tape or a stabilization device
Dress the site with a sterile dressing
Discard all sharps appropriately.
Challenges And Troubleshooting
Moving Veins:
Veins in toddlers can be mobile and difficult to stabilize
Slow, deliberate movements with the transducer can help
Applying gentle pressure with the transducer can sometimes anchor the vein.
Small Veins:
Use a higher frequency transducer if available
Choose a smaller gauge catheter
Consider using a microintroducer needle if available.
Poor Visualization:
Ensure adequate gel application
Adjust transducer pressure
Try different transducer orientations
Consider alternative insertion sites if visualization remains poor
Ensure the ultrasound machine settings are optimized for pediatric vascular imaging.
Arterial Puncture:
If pulsatile flow is observed or arterial blood is aspirated, withdraw the needle immediately and apply firm pressure to the site for at least 5-10 minutes
Avoid the site and choose an alternative vein, ensuring it is anechoic and compressible.
Complications
Common Complications:
Hematoma formation
Phlebitis
Infiltration
Nerve injury (rare)
Infection at the insertion site
Arterial puncture.
Prevention Strategies:
Proper technique, including real-time visualization and appropriate needle angle
Securement of the IV catheter to prevent dislodgement
Regular monitoring of the IV site for signs of complications
Use of sterile technique throughout the procedure
Diligent vein selection and avoidance of pulsatile structures.
Management Of Complications:
For hematoma: apply pressure, ice, and monitor
For phlebitis/infiltration: discontinue IV, elevate limb, warm compress
For infection: IV antibiotics, wound care
For nerve injury: pain management, physiotherapy referral, observation
For arterial puncture: direct pressure and close monitoring.
Key Points
Exam Focus:
Emphasize the indications for USG-guided PIV in toddlers, the equipment required, and the step-by-step procedural technique
Understand common complications and their management
DNB and NEET SS exams often test practical application and troubleshooting.
Clinical Pearls:
Always use a sterile technique, even for difficult IVs
Real-time visualization is crucial for success and safety
Never advance the catheter if you are unsure of its position within the vein
Have all equipment ready before starting
Communicate with parents/guardians throughout the procedure.
Common Mistakes:
Attempting blind insertion without ultrasound visualization after initial failure
Using an inappropriate transducer or ultrasound settings
Not using sterile technique
Failing to adequately stabilize the vein or transducer
Over-advancing the catheter
Misinterpreting arterial pulsatility as venous flow.