Emergency and elective venous access in children

INTRODUCTION — This topic will discuss the approach to emergency and elective venous access, techniques for peripheral and umbilical venous access in children, and pediatric considerations.

The techniques for central line placement, including principles of ultrasound-guided venous access, and intraosseous (IO) cannulation are discussed separately:

●(See "Basic principles of ultrasound-guided venous access".)

●(See "Placement of femoral venous catheters".)

●(See "Placement of jugular venous catheters".)

●(See "Placement of subclavian venous catheters".)

●(See "Intraosseous infusion".)

EMERGENCY VENOUS ACCESS — Emergency venous access is essential to timely delivery of medications and fluid resuscitation during pediatric resuscitation and is often challenging in infants and young children.

Infants and children — For infants (other than newborns) and children who require immediate access because of cardiac arrest, hypotensive shock, or other critical illness, the approach is as follows (algorithm 1) [1]:

●First-line (peripheral IV or IO) – Simultaneously attempt peripheral intravenous (IV) and intraosseous (IO) access; IO access can often be obtained in less than one minute [2-4]. During cardiopulmonary resuscitation (CPR), avoid scalp or external jugular sites. For neonates with a patent umbilical vein presenting to the emergency department, emergency umbilical vein catheterization (UVC) by a trained and experienced clinician is an alternative route for venous access (figure 1 and algorithm 2). (See 'Emergency umbilical vein catheterization' below.)

The preferred peripheral IV site during pediatric resuscitation is the largest, most accessible vein that does not require interruption of the resuscitation. The use of a protocol that sets a time limit for peripheral IV access attempts can aid in the rapid establishment of IO access [5,6]. For patients with hypotensive shock, fluid boluses may be pushed directly through the connecting tubing by using a three-way stopcock and a large syringe.

During CPR, if no access is achieved after one minute and an endotracheal tube is in place, epinephrine can be administered endotracheally, as indicated, while continuing efforts to establish venous access. (See "Primary drugs in pediatric resuscitation", section on 'Endotracheal drug administration'.)

●Second-line (central venous access) – If peripheral IV or IO access is not rapidly achieved, have an experienced clinician place a central venous line (femoral line preferred); whenever available, use ultrasound guidance. (See 'Central venous catheter placement' below and "Placement of femoral venous catheters".)

For the patient in whom peripheral, IO, or central venous access cannot be established, consult a trained and experienced clinician (eg, surgeon with pediatric expertise) to perform a venous cutdown. The saphenous vein is the preferred site [7]. With the advent of routine use of IO cannulation during pediatric resuscitation, venous cutdown is rarely necessary in resource-abundant settings [8].

●Post-resuscitation access – Critically ill infants and children require at least two peripheral IV lines or an IO and IV line to permit simultaneous administration of medications and fluid resuscitation. The clinician should follow drug administration with a bolus of 5 to 10 mL of normal saline [5]. Although animal models have suggested that central venous drug administration can produce more rapid onset of action and higher peak drug levels than peripheral venous or IO administration, these differences are not clinically important, especially in pediatric models [9-12].

For the rapid delivery of isotonic solutions in patients with shock, short peripheral IV lines are preferred to central lines because they take less time to place. The shorter peripheral IV line also permits a faster flow rate that is about twice the rate of a similar gauge, longer central line [13].

For patients receiving rapid fluid administration through an IO, there is higher resistance to fluid administration in patients with an IO compared with a peripheral IV that requires manual or high-pressure mechanical administration. Once the patient is stabilized, individuals who need ongoing monitoring of central venous pressure, central venous oxygen saturation, frequent blood sampling, or administration of irritating medications or solutions, require central venous line placement if not already in place [14,15]. (See 'Central venous catheter placement' below.)

Newborn infants (delivery room) — For newborn infants who need emergency access in the delivery suite, the approach differs because peripheral IV access is unlikely to be successful, and the umbilical vein presents an alternative site [14]:

●Place an emergency (low) UVC (figure 1 and algorithm 2) (see 'Emergency umbilical vein catheterization' below).

●In the rare patient in whom a UVC cannot be placed or when the clinician does not have experience with UVC placement, obtain IO access.

URGENT OR ELECTIVE VENOUS ACCESS

Indications — Indications for venous access in children include:

●Intravenous (IV) fluid therapy (eg, children with dehydration, shock, or who cannot tolerate or must avoid oral intake)

●Administration of medications more effective for the condition by the IV route or only available in the IV form

●Blood administration

●Need for frequent blood sampling

●Anticipatory access for patients with potential for decompensation

●Parenteral nutrition

In infants and children, central venous catheters are a reliable means for administering large volumes of fluids or potentially irritating solutions or medications (eg, vasoactive agents, chemotherapy, parenteral nutrition, or other sclerosing medications). Peripheral IV access may be used for administration of vasoactive agents until central access can be established. (See "Children at risk for sepsis and septic shock in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Central versus peripheral venous access'.)

For critically ill children, central line placement typically occurs after the initial stabilization under sterile conditions in the pediatric intensive care unit. Central venous access permits collection of blood samples and monitoring or hemodynamic variables, such as central venous pressure or mixed venous hemoglobin-oxygen saturation. Peripherally inserted central catheters (PICC lines) provide reliable access for patients who require intermittent or prolonged medication administration and are also appropriate for initial administration of vasoactive agents.

Contraindications — Site-specific contraindications to venous access common to peripheral and central venous access include:

●Placement through infected skin or tissue

●Proximal disruption in venous flow (eg, in children with proximal venous obstruction or injury, avoid lower extremity access)

●Placement through a burn (unless extensive burns make it necessary)

In addition, phlebitis or thrombosis of the vein exclude peripheral or central access in that vein. Additional contraindications for placement of intraosseous and central lines are discussed separately. (See "Intraosseous infusion", section on 'Contraindications' and "Central venous access in adults: General principles", section on 'Precautions'.)

PERIPHERAL IV LINE — Peripheral intravenous (IV) lines are the primary means of venous access during the initial resuscitation of children, particularly for clinicians who do not have experience with central venous catheterization.

Patients with difficult access — The difficult intravenous access (DIVA) score is a validated clinical prediction tool that identifies children at risk for difficulty with peripheral IV placement (table 1) [16-18]. Children with a DIVA score ≥4 have a predicted first-attempt success rate of ≤50 percent for standard peripheral IV placement; ultrasound guidance or, to a lesser extent, devices to improve vein visualization may increase the likelihood of successful peripheral IV placement in patients with difficult IV access. (See 'Vein visualization devices' below and 'Ultrasound guidance' below.)

Preparation

Consent — During emergency care, consent for treatment, including peripheral IV placement, is implied (presumed). However, the clinician or their designee should still inform the parents or primary caregivers of the need to perform the procedure and the reason (eg, to give medications, intravenous fluids, or blood).

For routine IV placement, verbal consent from the parents or primary caregivers is usually sufficient. Verbal children also benefit from an age-appropriate explanation; child-life specialists are an invaluable resource when time allows. It is best to inform the child as close as possible to the time of the procedure to avoid escalating fear and anxiety caused by prolonged anticipation. (See "Procedural sedation in children: Selection of medications", section on 'Nonpharmacologic interventions'.)

Topical analgesia — The approach to analgesia in awake children undergoing peripheral IV placement depends upon how soon venous access is needed (algorithm 3) (see "Clinical use of topical anesthetics in children"):

●Urgent access – For urgent access:

•Local infiltration of 1 percent buffered lidocaine

•Needle-free lidocaine delivery

•Vapocoolant spray

●Nonurgent access – For nonurgent access:

•Topical anesthetics (eg, liposomal lidocaine, tetracaine gel, or lidocaine-prilocaine cream)

•Needle-free lidocaine delivery

Standing orders promote appropriate use of these agents for pain management in emergency department and hospital unit settings. Behavioral methods complement local analgesia (table 2). A combination vibration and cooling device provides decreased pain compared with no intervention in children undergoing venipuncture or intramuscular injections and may have some efficacy in children undergoing peripheral IV access if the above topical analgesics are not available [19].

Some uncooperative or anxious patients may benefit from mild sedation such as inhaled nitrous oxide, intranasal midazolam, or dexmedetomidine as described separately. (See "Procedural sedation in children: Selection of medications", section on 'Minimally painful procedures'.)

Equipment — Prior to peripheral IV catheter placement assemble the following equipment:

●Tourniquet

●Antiseptic swab or pad (eg, 70 percent isopropyl alcohol or, when sterile preparation of the site is necessary, povidone-iodine solution or similar antiseptic)

●Over-the-needle peripheral IV catheter

●Luer lock T-connector with safety cap

●IV tubing

●Small volume (eg, 3 to 6 mL) sterile syringe filled with nonbacteriostatic sterile saline

●If blood sampling will occur with line placement, small volume sterile syringe with large bore (eg, 18 gauge) transfer needle, and blood collection tubes

●Medical tape and transparent adhesive dressing

●Arm board (extremity IV site) with gauze for padding as needed

Peripheral catheter size — IV catheter sizes range from 14 (larger) to 24 (smaller) gauge. Our approach to catheter sizing considers the age of the child, degree of illness, and purpose for venous access:

●Emergency fluid resuscitation or blood administration – For critically ill children in shock who require rapid administration of balanced crystalloid solutions or blood, the peripheral IV catheter should be the largest that can be reliably inserted:

•Infants and pre-school children – 22 to 24 gauge

•School age children – 20 to 22 gauge

•Adolescents – 18 to 20 gauge

●Routine medication and fluid administration – For stable children receiving nonirritating IV medications or maintenance fluids, a small-bore peripheral IV catheter is a good choice because it is less painful to place:

•Infants and preschool children – 24 gauge

•School age children – 22 or 24 gauge

•Adolescent – 22 gauge

Site selection — Sites for peripheral IV placement in children in order of preference include [20]:

●Upper extremity — The cephalic, basilic, and median cubital (also called antecubital) veins in the forearm (figure 2) and the dorsal veins of the hand offer upper extremity routes for rapid drug and fluid delivery.

The antecubital vein is relatively easy to cannulate. However, catheters placed in this location must be well secured with an armboard to prevent elbow flexion, which can cause kinking of the catheter as well as infiltration [21]. In severe hypovolemia or shock, unintentional cannulation of the brachial artery is a rare but potentially serious complication that could cause limb ischemia, especially if it is unrecognized. Use of ultrasound helps prevent this complication.

Any of these IV sites may be difficult to locate in a well-nourished infant. For children outside of the neonatal period who are expected to have difficult IV access (DIVA score ≥4), point-of-care ultrasound guidance during IV placement is recommended. (See 'Ultrasound guidance' below.)

●Lower extremity — In children, the great saphenous vein at the ankle is the most accessible vein in the lower extremity because of its large size and consistent anatomy. The veins of the dorsal arch of the foot are optional sites (figure 3).

●External jugular — The external jugular vein (figure 4) is another useful site for vascular access in young children because no adjacent arterial or neural structures are present. However, it cannot be used as a primary site during initial resuscitation of infants or children with airway compromise, concern for cervical spine injury, or respiratory failure because cannulation of the external jugular vein requires extension and rotation of the neck.

Cannulation of the external jugular vein usually requires that the infant or child be placed in a 30-degree head-down (Trendelenburg) position. The right external jugular vein is preferred for access because it provides a more direct path to the superior vena cava (SVC). Cannulation of this vessel is difficult because of its tendency to roll. In addition, short external jugular catheters are easily dislodged and difficult to immobilize, particularly in infants [22,23].

●Scalp — Avoid IV placement in scalp veins during cardiopulmonary resuscitation (CPR) or other pediatric emergencies because the IV catheter is easily dislodged, and IV catheter infiltration may result in scarring near the face and/or permanent alopecia [23].

Scalp vein access may be helpful in less urgent situations, especially in young infants with difficult access. However, this location is less desirable than other sites because the scalp may have to be shaved to expose the vein, the IV catheter is easily dislodged, and IV catheter infiltration may result in scarring near the face and cause permanent alopecia [23].

A circumferential tourniquet, such as a rubber band, is placed around the forehead to make the veins visible (figure 5). Boluses of fluid may be given via a scalp IV in an attempt to improve circulating volume, making other peripheral venous sites more visible and accessible. Caution must be used when accessing the temporal scalp vein because the temporal artery or its branches can be cannulated inadvertently. Cannulation of an artery is indicated by blanching of the scalp distal to the catheter when the saline flush is introduced [24].

Vein visualization devices — Measures to better visualize veins during peripheral IV placement include vein transillumination with a cold light source (white fiberoptic light or light-emitting diode) and near infrared (NIR) light devices. Utility of these devices depends upon patient age:

●Preterm infants - In preterm infants, NIR light devices have increased first attempt success rate for peripheral IV placement by less experienced nurses and decreased procedure time by an experienced nurse [25,26]. In a nonrandomized trial in almost 170 preterm infants, first attempt success rate was similar when IVs were placed with a NIR light device versus the landmark technique (60 versus 56 percent, respectively) [25]. Among nurses with <1 year of experience, first attempt success rate was markedly increased in the NIR group compared with the landmark technique (73 versus 23 percent). In a randomized trial of 90 preterm infants undergoing peripheral IV placement by an experienced research nurse, first attempt success rate was similar for the NIR light device and the standard technique (80 versus 87 percent, respectively), but the time of the procedure was significantly shorter with the NIR light device [26].

By contrast, transillumination in preterm infants appears to hamper performance of the procedure. In the previously mentioned trial, first attempt success by an experienced nurse was worse with transillumination compared with controls (60 versus 87 percent, respectively) and the procedure time was significantly longer (45 versus 17 seconds) [26].

●Infants and children – For most infants and children, transillumination or use of a NIR light device is not helpful during peripheral IV placement [27-30]. For children with predicted difficult venous access (DIVA score ≥4 (table 1)), these devices may increase first attempt success rate, although evidence is inconsistent. Instead, we suggest point of care (bedside) ultrasound guidance, if available. (See 'Ultrasound guidance' below.)

Ultrasound guidance — For children, other than preterm infants and neonates, who are likely to have difficult peripheral intravenous access (eg, DIVA score ≥4 (table 1)) or in whom previous attempts have failed (eg, no peripheral access after three attempts by an experienced clinician), we suggest point-of-care (bedside) ultrasound guidance (POCUS) during IV placement, if possible [31,32]. The preferred POCUS technique uses dynamic US guidance with short axis out-of-plane and/or long axis in-plane approaches. (See "Basic principles of ultrasound-guided venous access", section on 'Dynamic ultrasound techniques'.)

In children without difficult access, POCUS improves first-pass and overall IV placement success, especially when performed by a physician in the operating room (OR) setting with the child sedated [31]. However, when IV placement is performed in awake children in the emergency department, results have been inconsistent although supportive of POCUS for children predicted to have difficult access. Furthermore, POCUS for all IV placements in awake children requires equipment and training that is not available in all settings.

For IV placement in neonates and preterm infants, POCUS has been less reliably helpful because of the size differential between the ultrasound (US) probe and the extremity as well as the proximity of the vessel to the skin surface and underlying structures which makes vein visualization difficulty. These obstacles may be overcome by using a hockey stick probe in these patients (picture 1).

In a meta-analysis of eight randomized trials (nearly 1300 children) that compared the landmark technique with US guidance, clinicians assigned to US guidance during peripheral IV placement had higher first attempt (78 versus 66 percent) and overall success (93 versus 78 percent) [31]. On post hoc subgroup analysis, first pass success rate for POCUS was higher than the landmark technique for children younger than three years, physician operators, performance with sedation (OR setting, saphenous vein site), and dynamic US technique. First pass success rate for POCUS and the landmark technique was similar in the ED setting but had high heterogeneity. In a subsequent randomized trial not included in the meta-analysis, 110 children (median age 4 to 5 years) with difficult access (DIVA score ≥4) were randomized to IV placement with POCUS or the landmark technique [32]. Patients assigned to POCUS had a higher first attempt and overall success rate. Clinicians assigned to POCUS also had shorter procedure times and number of attempts.

Technique — The clinician should use over-the-needle catheters for peripheral venous access, regardless of the site, and employ standard infection control precautions prior to and during the procedure (table 3). (See "Infection prevention: Precautions for preventing transmission of infection", section on 'Standard precautions'.)

Although not usually possible during emergency access procedures, for routine peripheral IV placement, we offer topical analgesia and behavioral methods for elective IV placement in children (table 2). (See 'Topical analgesia' above and "Clinical use of topical anesthetics in children".)

Prior to attempting IV placement, ensure that all supplies are ready to be used, including premeasured tape strips and a transparent dressing.

The steps for peripheral IV catheter insertion are as follows [33,34]:

●Choose the insertion site (upper extremity preferred) (see 'Site selection' above):

•During pediatric resuscitation, use the veins of the antecubital fossa or greater saphenous vein (figure 2 and figure 3).

•For elective insertion, attempt insertion in more distal sites (eg, dorsal hand or foot) so that more proximal sites are saved for later access. Avoid saphenous and dorsal pedal veins in ambulatory patients whenever possible.

●Immobilization – Immobilize the patient, the chosen extremity, and site (use an assistant as needed) in a way that gently stretches the vein and makes it less likely to roll away from the needle during catheter insertion:

•Dorsal hand vein – Hold the fingers in a fist and flex the wrist

•Antecubital vein – Place a soft gauze roll underneath the elbow to slightly hyperextend the joint

•Dorsal foot vein – Hold the toes and plantar flex the foot

•Posterior tibial vein – Hold as for the dorsal foot vein and slightly externally rotate the foot

●Make the vein more visible:

•Place a tourniquet.

•Keep the site in a dependent position (for external jugular vein or scalp, position the patient supine with the head below the feet).

•Tap on the vein.

•In cooperative children undergoing upper extremity vein cannulation, have them open and close their hand and then make a fist.

•Apply alcohol or povidone-iodine antiseptic.

•If the above methods do not result in a visible vein:

-Remove the tourniquet. Have an assistant milk the vein from proximal to distal, then reapply the tourniquet.

-Use transillumination with a cold light source or near-infrared spectrum light.

-If the vein is still not evident, look for veins at other sites.

•If vein is still not visible or if DIVA score ≥4:

-Children (not preterm or neonates) – Use ultrasound (US) guidance (see 'Ultrasound guidance' above).

-Neonates and preterm infants or US guidance not available - Use of a near infrared may be helpful; transillumination may hamper IV access attempts. (See 'Vein visualization devices' above.)

●IV placement:

•Hold the catheter with your thumb and middle finger; keep the pointer finger free to advance the catheter off the needle.

•Use your ring and pinky fingers to steady your hand against the patient just distal to the insertion site.

•Insert the needle and the IV catheter bevel up into the vein (if the vein is small or collapsed, bevel down is also acceptable):

-Advance the needle through the skin at a 10- to 30-degree angle to the skin surface until blood is seen in the IV catheter flash chamber.

-Decrease the angle of the IV catheter relative to the skin surface and advance the catheter and needle a short distance (1 to 2 mm) to ensure that the catheter is in the vein.

-With the pointer finger, advance the catheter over the needle and farther into the vein until the hub is at the skin surface (advancing the catheter will activate a safety feature that will withdraw the needle into a protective sheath). Continued back flow of blood to the hub of the catheter indicates that it is in the vein.

-Secure the IV with tape, a transparent sterile dressing, or integrated securement dressing with or without tissue adhesive [35].

-Attach a Luer lock T-connector to the catheter hub. Obtain blood for testing if needed.

-Remove the tourniquet.

-Flush the tubing and IV catheter with nonbacteriostatic sterile normal saline. Easy flushing without the development of swelling proximal to the IV site indicates successful placement.

●Prevent IV dislodgement:

•For extremity IV sites, use an arm board to further immobilize the IV site.

•To prevent the child from pulling out the IV, cover it. For example:

-Wrap the IV site, arm board, and extremity with a gauze roll or clean wash cloth and tape into place but ensure that the IV tubing and clamp are external and accessible. To assist with assessment of IV patency, keep as much of the skin proximal to the IV site visible as possible.

-Cover with loose stockinette.

-Check the IV site frequently to assure patency, especially if the child reports more pain or the IV pump registers increased pressure.

Complications — The complication rate associated with peripheral venous catheters is low; severe complications such as cellulitis, skin slough requiring skin graft, osteomyelitis, phlebitis, thrombosis, or pulmonary embolus are rare [23,36]. Common complications include hematoma formation, premature loss of IV access, and infiltration.

Medications that are irritating to the veins, such as calcium, dopamine, potassium, or epinephrine, require dilution and administration through the largest peripheral vein possible to avoid the development of phlebitis. Vesicant or irritant fluids (pH <5 or >9, osmolarity >600 mOsm) require administration through a central venous line. (See "Central venous access: Device and site selection in adults", section on 'Nature of infusate'.)

INTRAOSSEOUS ACCESS — Intraosseous (IO) cannulation is the recommended form of access in infants and children with cardiopulmonary arrest, hypotensive shock, or severe multiple trauma who do not have readily available venous access (algorithm 1). IO is also an option for children who need urgent venous access (eg, dehydration, burns, multiple trauma) and in whom peripheral IV placement is unsuccessful despite multiple attempts. The technique for IO placement is discussed separately. (See "Intraosseous infusion".)

CENTRAL VENOUS CATHETER PLACEMENT — Central venous catheter (CVC) placement in children follows the same principles and steps as in adults. A well-trained and experienced provider should perform CVC placement in children or provide direct supervision. Important considerations include:

●Catheter selection — When choosing a CVC in infants and children, the length must be sufficient to permit secure placement within the vessel and the bore large enough to achieve high flow rates. The table provides suggested size and length by the age and weight of the child (table 4) [37].

●Site selection — In infants and children, the three primary sites for CVC placement are the femoral vein, subclavian vein, and the internal jugular vein (figure 6). There are no significant differences in risk of infection between sites, although femoral lines may carry a higher risk of thrombus [38,39]. In newborns, the umbilical vein is preferred. (See 'Emergency umbilical vein catheterization' below.)

•Femoral vein – The femoral vein is the most commonly accessed central line site in pediatric resuscitation (figure 7) because it is relatively easy to access and emergency placement does not interrupt airway procedures or cardiac compressions. (See "Placement of femoral venous catheters".)

•Internal jugular vein – The internal jugular vein is another common sited for infants and children. Only individuals specifically trained in the procedure should perform internal jugular vein cannulation in children because the complication rate is significantly increased when cannulation in children is attempted by inexperienced clinicians [40]. (See "Placement of jugular venous catheters", section on 'Internal jugular vein cannulation'.)

•Subclavian vein – The subclavian vein is a common site for placement of tunneled catheters and ports by surgeons. It is less commonly used during pediatric resuscitation. (See "Placement of subclavian venous catheters".)

●Point of care ultrasound guidance (POCUS) — For children undergoing CVC placement at any site, we recommend POCUS guidance rather than using landmark techniques [41-44]. The basic principles and techniques for ultrasound-guided venous access are discussed separately. (See "Basic principles of ultrasound-guided venous access".)

In a meta-analysis of eight randomized trials (760 children), POCUS during central line placement increased success rates (RR 1.32, 95% CI 1.10 to 1.58) and reduced the number of attempts compared with using landmark techniques [41]. Although not statistically significant, unintentional arterial puncture also occurred less commonly with POCUS during CVC placement (relative risk [RR] 0.36, 95% CI 0.12 to 1.09). However, indirect evidence from CVC placement in adults has shown significantly lower rates of complications with POCUS. (See "Central venous access in adults: General principles", section on 'Real-time ultrasound guidance'.)

●Technique by site — The technique of central venous access in children follows the same approach as in adults, as discussed separately by site:

•Femoral vein – (See "Placement of femoral venous catheters".)

•Internal jugular – (See "Placement of jugular venous catheters", section on 'Internal jugular vein cannulation'.)

•Subclavian vein – (See "Placement of subclavian venous catheters".)

●Catheter tip positioning — The clinician should estimate the depth of insertion according to site selection and external measurements prior to inserting the line. After placement and before administration of potentially harmful (sclerosing) medications, the clinician should ensure correct position of CVCs with imaging such as a chest and/or abdominal radiograph or ultrasound:

•Superior vena cava (internal jugular or subclavian lines) – For CVCs placed in the superior vena cava, a safe position is at the junction of the superior vena cava (SVC) and the right atrium junction [45]. The carina may be a reliable landmark for proper catheter tip placement on a chest radiograph [46,47]. (See "Placement of jugular venous catheters", section on 'Positioning the catheter' and "Placement of subclavian venous catheters", section on 'Positioning the catheter'.)

•Inferior vena cava (femoral lines) – For femoral vein sites, the catheter should be located just below the diaphragm between T9 to T11 (high line placement) [45].

●Complications — The site, experience of the clinician, and the clinical condition of the patient affect the incidence of complications. Complications of central venous catheterization are more common in the pediatric age group than in adult patients [22,38,39,42,48-59]. For example, in one study of nearly 370 central venous catheterizations in children in a pediatric intensive care unit, there was a 1.3 percent overall rate of serious complications [59]. Insertion-related complications included 9 percent arterial punctures, 7 percent malposition, 5 percent hematomas, 3 percent minor bleeding, and 0.8 percent with pneumothorax. Complications were less common after access in femoral and internal jugular veins than the subclavian vein. Pneumothorax is more likely to occur after cannulation on the left jugular or subclavian vein because the cupula of the lung is higher on the left side than on the right side [22].

Catheter sepsis, either isolated or associated with thrombus formation, is a common and serious problem with long-term central venous access, especially in immunosuppressed children [56]. A prospective study of children in a pediatric intensive care unit reported blood stream infections in 5 percent of the 155 children with central lines and catheter thrombus in one femoral and two internal jugular veins [42]. (See "Intravascular catheter-related infection: Epidemiology, pathogenesis, and microbiology".)

EMERGENCY UMBILICAL VEIN CATHETERIZATION — During the resuscitation of newborns and neonates with a patent umbilical vein, emergency umbilical venous access can provide a reliable route for medication and fluid administration during resuscitation [60,61]. The umbilical vein can remain patent for up to 10 to 14 days after birth, but emergency umbilical vein access is most commonly used during delivery room resuscitation.

Umbilical vein catheterization is contraindicated in neonates with anatomic wall defects (eg, omphalocele, gastroschisis, omphalitis, or peritonitis).

Studies of intraosseous (IO) versus placement of umbilical vein catheters (UVC) using simulated neonatal models suggest that an IO may be placed about 45 to 80 seconds faster than an umbilical venous line [62,63]. Thus, outside of the delivery room, we prefer IO placement for emergency access, although UVC placement is a reasonable alternative for providers with training and experience. UVC placement also permits blood sampling for laboratory testing. Standard trays for umbilical vein cannulation are commercially available. Essential equipment for the procedure includes:

●Antiseptic solution (eg, povidone-iodine solution) or iodine swabs

●Sterile gloves

●Umbilical vein catheter (UVC; 5 French for infants <3.5 kg, 8 French for infants ≥3.5 kg) flushed with nonbacteriostatic normal saline and attached to a 10-cc syringe using a three-way stopcock

●Clothe umbilical tie

●Scalpel (No. 11 or 15 blade)

●Small, curved hemostats

●Adhesive tape

Emergency UVC placement does not permit time for full sterile precautions [61]. The clinician should don sterile gloves and make every effort to keep the UVC sterile during the procedure. The technique for emergency umbilical vein catheterization is as follows (figure 1) [60,61]:

●Step 1 – With the infant supine, prepare the umbilical stump with antiseptic solution.

●Step 2 – Secure the umbilical tie around the base of the umbilicus using a firm half knot that will provide control of bleeding from the umbilical stump but still permit passage of the UVC.

●Step 3 – Cut the residual umbilical cord approximately 2 cm above the skin or as distally as possible if the stump is shorter than 2 cm.

●Step 4 – Locate the umbilical vein (thin-walled, typically cephalad in the 12 o'clock position, and, in newborns, bleeds after cutting). For patients undergoing resuscitation outside of the delivery room, identify and remove any blood clot from the umbilical vein using a small, curved hemostat.

●Step 5 – While holding the base of the umbilicus with the nondominant hand, insert the preflushed UVC into the vein approximately 3 to 5 cm in a full-term infant (2 to 4 cm in a premature infant) and check for blood return.

●Step 6 – Once blood return is confirmed, secure the catheter manually or with adhesive tape and administer medications. Because emergency UVCs can frequently become misplaced during resuscitation, check for blood return prior to each use.

A clinical video of emergency umbilical venous access is provided in the reference [61].

Complications of emergency UVCs include air embolism, infection, and thromboembolism [60,61]. UVCs that are placed too deeply can lodge in hepatic vessels where medications may cause hepatocellular damage.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Basic and advanced cardiac life support in children" and "Society guideline links: Venous access".)

SUMMARY AND RECOMMENDATIONS

●Emergency venous access – For infants and children who require immediate access because of life-threatening critical illness, the initial approach consists of simultaneous attempts at peripheral intravenous (IV) and intraosseous (IO) placement (algorithm 1). For newborns, emergency umbilical vein catheterization (UVC) by a trained clinician is an alternative route (figure 1 and algorithm 2). (See 'Infants and children' above and 'Newborn infants (delivery room)' above and 'Emergency umbilical vein catheterization' above.)

If IV or IO access is not rapidly achieved, central venous catheter (CVC; or, in newborns, UVC) is indicated. (See 'Central venous catheter placement' above.)

After resuscitation, critically ill patients optimally should have at least two peripheral IV lines or an IO and IV line to permit simultaneous administration of medications and fluid resuscitation. For the rapid delivery of isotonic solutions in patients with shock, short peripheral IV lines are preferred.

●Urgent or elective peripheral IV placement – For peripheral IV placement, the clinician should choose the largest, most easily identified vein, usually in the upper and/or lower extremity (figure 2 and figure 3). (See 'Site selection' above.)

•Analgesia – Prior to IV placement, children should be offered topical analgesia (algorithm 3); behavioral interventions complement local analgesia (table 2). (See 'Topical analgesia' above.)

•Technique – A step-by-step description of IV placement technique in children is provided above. (See 'Technique' above.)

•Difficult access – For children outside of the neonatal period who are likely to have difficult intravenous access (eg, difficult intravenous access [DIVA] score ≥4 (table 1)) or in whom previous attempts have failed (eg, no peripheral access after three attempts by an experienced clinician), we suggest point-of-care ultrasound (POCUS) during peripheral IV placement if available (Grade 2B) (see 'Patients with difficult access' above and 'Ultrasound guidance' above). Dynamic ultrasonography with a short axis out-of-plane or long axis in-plane approach is the preferred technique. (See "Basic principles of ultrasound-guided venous access", section on 'Dynamic ultrasound techniques'.)

●IO cannula placement – IO placement is also an option for children who need urgent venous access (eg, dehydration, burns, multiple trauma) and in whom peripheral IV placement is unsuccessful despite multiple attempts. The technique of IO cannula placement is discussed separately. (See "Intraosseous infusion".)

●Central venous access – If CVC placement is required, the procedure should be performed or supervised by a well-trained and experienced provider. For children undergoing CVC placement at any site, we recommend POCUS guidance rather than using landmark techniques (Grade 1B). The femoral vein is the most commonly accessed central line site in pediatric resuscitation (figure 7). The table provides suggested size and length by the age and weight of the child (table 4). (See 'Central venous catheter placement' above.)

The technique of central venous access in children is the same as in adults and is discussed separately by site:

•Femoral vein — (See "Placement of femoral venous catheters".)

•Internal jugular — (See "Placement of jugular venous catheters", section on 'Internal jugular vein cannulation'.)

•Subclavian vein — (See "Placement of subclavian venous catheters".)

The clinician should estimate the depth of insertion according to site selection and external measurements prior to inserting the line. After placement and before administration of potentially harmful (sclerosing) medications, the clinician should ensure correct position of central line catheters with imaging such as a chest and/or abdominal radiograph or ultrasound.

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Pamela Bailey, MD, who contributed to earlier versions of this topic review.