• Many children require IV access for the administration of fluids and/or medication during their hospitalisation.
• Many complications associated with IV cannulation are preventable. If observed closely the development of major complications can be prevented.
• Cannulation is often the most feared painful procedure for children and their family members.

• Intravenous cannulation will be undertaken by medical officers or competent Emergency Department clinician for patients less than 10 years of age.

• The peripheral venous catheter will be inserted safely and in an appropriate site for the administration of IV fluids and/or medications.

• There will be no significant compromise to circulation distal to the site.

• The peripheral venous catheter will be inserted using aseptic techniques.

• All measures to minimise pain during the procedure will be undertaken.

• The cannula site will be observed regularly for redness, swelling, blanching, heat or pain and subsequently documented

• There will be reduced morbidity and mortality associated with intravenous peripheral cannulation.

PIVC - insertion of cannula into a peripheral vein.

Phlebitis - swelling, redness, heat, pain related to local inflammation of the vein at or near the cannula site.

Pump - refers to Alaris pumps or syringe pumps.

RCH - Royal Children's Hospital.

V.I.P Score - Visual Infusion Phlebitis Score.

PIG - Paediatric Injectable Guidelines.

AT- Aseptic Technique.

Drug Line - 0.9% sodium chloride run at 2-10ml/hr to keep vein open between doses of medication.

• Always justify and explain the need for the procedure to the child and carers.

• Whenever possible, painful procedures should be performed AWAY from the bedside (i.e. in treatment room).

• Use play therapy, distraction, relaxation and guided imagery (refer Royal Children's Hospital Comfort Kids Guidelines, appendix 1).

• Staff required will be medical officer and at least one nurse. Two nurses may be required to help with taping and distraction therapy even if a family member is present with the child.

• Consider nitrous oxide for anxious children.

• Consider utilising 'smileyscope', 'buzzy bee' or 'exocool' as method of distraction

• Some children may need sedation (as per paediatrician).

Ballarat Health Services acknowledges, and supports, that best clinical practice is to minimize the disconnection of all intravenous (access) closed systems. In some cases disconnection will be assessed as necessary by the nurse (or clinician) if clinically indicated. The disconnected intravenous end point must be managed aseptically so as not to compromise reconnection. On reconnection of the intravenous system the connection points will be cleaned (using 70% alcohol / 2%chlorhexidine swab) by scrubbing the hub for 30seconds and allowing to air dry completely. (Reference: Infection Control Guidelines, 2010, updated 2019).

• IV Trolley.

• One (1) 3M Tegaderm IV Starter 1610K (containing 2% Chlorhexidine /70% Alcohol swab, 3M Tegaderm 1610K, Latex free tourniquet, non woven gauze and dressing towel).

• Solu IV 2% Chlorhexidine / 70% Alcohol (tinted pink), as required.

• Disposable gloves, protective eyewear.

• 22g or 24g (or larger as required) cannula.

• One (1) needle free valve port (Smartsite) access device or Carefusion extension set.

• In-line filter (PALL) primed with normal saline.

• Sterile steri strips.

• Leukoplast and Transpore for taping.

• IV line and fluid, as required.

• One (1) 10 ml syringe and 10 ml 0.9% sodium chloride.

• One (1) drawing up needle.

• If taking blood - syringe and blood tubes.

• Sharps container.

• Appropriate sized arm board for splint.

• Tubifast bandage.

PREPARATION
Neonates/Infants less than 3 months:

• Oral sucrose and/or a pacifier should be used.

• Give parent or carer option to assist with holding infant during procedure.

Older infants and children:

• Apply topical anaesthetic creams in advance of procedure whenever possible:

• Local AnGel (Tetracaine (amethocaine) 4% in methylcellulose base): 45 mins.

• EMLA (Lignocaine 25mg/g & Prilocaine 25mg/g - 5% cream) : 60 mins.

Have equipment ready before the child enters the room:

IV Site Selection

• Look carefully for the most suitable vein and remember that in paediatric patients the best vein may not necessarily be palpable.

• Dorsum of the non-dominant hand is preferred - the vein running between the 4th and 5th metacarpals is most frequently used.

• In addition to the usual sites in adults, commonly used sites in children include the volar aspect of the forearm, dorsum of the foot and the great saphenous vein of the ankle.

• Consider the practicalities of splinting (e.g. elbow, foot in a mobile child, site that crosses a joint).

• The presence of a bruise does not necessarily preclude that vein from use, simply cannulate ABOVE the bruised area.

Holding:

• Ask assistant to stabilise limb by holding joint above and joint below if necessary.

• If applying tourniquet, be careful of pinching skin or compressing artery.

• When accessing the hand of neonates / infants, grasp as shown; this achieves both immobilisation and tourniquet (Fig.1).

Inserting the Cannula:

• Use an aseptic technique (AT) for peripheral intravenous insertions and access.

• Explain procedure to patient/parents/carer and ensure patient comfort and privacy.

• Place the protective towel under the patient's arm.

• Prepare the equipment.

• Apply the tourniquet.

• Put on protective eyewear

• Perform hand hygiene using either soap and water or Alcohol Chlorhexidine Hand Rub (ACHR).

• Put on the non sterile gloves

• Locate the vein and prepare the selected venepuncture site using 2% Chlorhexidine/70%

• Alcohol swab and ALLOW TO DRY for 30 seconds or alternatively use Solu IV 2% Chlorhexidine/70% alcohol swab stick (Pink Tinted).

• Maintain asepsis by using Sterile Gloves if re palpation required FOLLOWING cleaning site.

• Insert cannula just distal to and along the line of the vein at an angle of 10-15 degrees. (Fig.2).

• Advance needle and cannula slowly, checking for blood in the hub of the cannula. A 'flash-back' may not occur for small veins.

• Once in vein, advance the needle and cannula SLOWLY a further 1-2mm along the line of the vein before advancing cannula off needle until resistance is felt or the hub of cannula reaches the skin.

• DO NOT RE USE THE SAME CANNULA IF ATTEMPT IS UNSUCCESSFUL

• Discard needle (sharp) into yellow sharps container following use

Ensure that hand hygiene is performed after re-preparation of the equipment

Figure 1: Holding an Infants Hand

Figure 2: Shallow Angle of Insertion

Taking blood samples:
For some cannulae, it may be possible to let blood drip passively into collection tubes (Fig.3).

• When taking blood for culture or gas from small cannulae, aspirate blood from the hub of the cannula using a blunt 'drawing up' needle and syringe (Fig.4).

• For larger cannulae, a syringe can be used to aspirate blood.

Figure 3: Passive Blood Collection for Infants

Figure 4: Aspirating Blood for Culture or Gas

Gently flush the cannula to ensure patency.

Secure cannula as follows:

• Place a steri-strip under the cannula hub and cross over the hub to secure (Fig 5).

• Repeat with second steri-strip (Fig 5).

• A third steri-strip can be placed across the top of the hub if necessary (Fig 5).

• Attach primed Smartsite.

• Attach primed In-line filter (PALL).

• Flush with 0.9% Sodium Chloride to confirm intravenous placement.

• Place a small piece of gauze underneath the hub to prevent pressure injuries (Fig 6).

• Place a transparent Tegaderm dressing over top of insertion site and hub (Fig 6).

• Remove gloves and perform hand hygiene.

• Write the date of insertion on the Tegaderm dressing using the adhesive label contained in the dressing pack.

• Tegaderm IV Starter Pack; Remove the bright green sticker and place in patient progress notes for easy identification.

Strapping:

• Tapes should secure the limb proximal and distal to the cannula (keeping thumb free) without compromising circulation (Fig 7).

• Leukoplast to stablilise fingers and arm to armboard.

• If tape is needed directly over IV site, use transparent tape as this is will enable better site observation.

• Secure the whole distal extremity in a tubifast bandage if necessary. In very young children, give consideration to bandaging the other hand as well to prevent removal of the cannula.

• When securing the IV ensure there is a clear window where the cannula enters the skin so that the site can be viewed at all times. Tubifast is the recommended product for securing.

Figure 5: Cannula taping technique -
inverted cross-over.

Figure 6: Secure with Tegaderm. Pad under cannula to prevent pressure areas.

Figure 7: Strap so that joint is immobilised, but avoid tapes being too tight.

IV Fluid Management

• All Paediatric Patient infusions MUST be run through a Burette or via Syringe Driver.

• Running a 'drug and flush' (2- 10ml 0.9% sodium chloride) through the cannula may keep it patent for longer.

• IV lines should not be disconnected in line with BHS policy.

• Medical permission required for IV lines to be disconnected between doses of medication if fluids are not being given.

• Disconnect the line from the Smartsite and connect red 'combi stopper' to detached line to maintain asepsis.

• IV lines should be changed every 72 hours in accordance with BHS policy.

Changing IV cannulas:

• There is no evidence to recommend regularly resiting IV cannulas in children as is the practice in adults.

• Cannulas need only be replaced when they fall out, show signs of phlebitis or become blocked.

Ordering IV fluids and medications:
Orders for IV fluids and infusions are ordered by medical staff and should:

• Be written on the VICTOR 24hr Fluid Management Chart Paediatrics (VPFM001).

• Be legible and understandable.

• Complete all relevant fields on the IV order.

• IV orders are only valid for a maximum of 24 hours.

• Be checked by 2 RN Div 1 nurses / medication endorsed enrolled nurses at commencement of EACH new bag/syringe.

• IV medicines in paediatrics are to be prepared and administered as per RCH PIG.

• Consider IV compatibilities when administering multiple IV medicines & fluids via the same line, consult with pharmacy if unsure.

• Ensure minimal volumes for dilution of medicines, especially in small neonates and infants as per RCH PIG.

Documentation
On insertion or removal of each PIVC, the medical officer or RN or medication endorsed enrolled nurse documents the following in the care plan and the progress notes:

• Insertion (Remove the bright green sticker from the outside of the Tegaderm Starter pack and place into patient progress notes for easy identification).

• Removal date/time.

• Site.

• Size of cannula inserted.

• VIP Score (Appendix 2).

• Date of in-line filter attached (change on day 5).

• A sticker should be attached to the line to indicate required day of change.

Check and document the following on the fluid balance chart HOURLY: (unless otherwise documented by Medical dr, ie consideration of transmission based precautions).

• VIP Score - report any signs of phlebitis, infiltration, leakage or infection.

• Pump pressure for each IV line.

• Infused volume.

Alaris pumps and Medication Administration:

• Use Alaris pump 'neonatal' or 'paediatric' profile for neonates, infants and children, respectively.

• Default pressure limits are set at 200mmHg. Ensure ALL limits are manually set to 100mmHg before commencing infusion.

• Flucloxacillin should be infused using only a syringe driver and the pressure limit changed to 50mmHg.

• Observe pressure TREND and record/report increase.

• If using syringe pump, record numerical pressure value hourly and report any increase.

• If occlusion alarm occurs, observe site and if unsure, flush cannula with 0.9% sodium chloride to assess patency. This is particularly relevant prior to infusing medications.

• Be especially cautious when infusing known irritant medications - observe site frequently DURING infusion.

• Extreme caution should be taken with IV administration of Flucloxacillin, Erythromycin, Chemotherapy, Calcium and Phenytoin.

• Cease infusion immediately if any signs of extravasation are observed.

In-line Filters (PALL):

• A filter should be used on all paediatric patients requiring IV therapy greater than 24 hours.

• Prime with 0.9% sodium chloride as per instructions in filter pack.

• Filters should be attached directly onto Smartsite at time of insertion. If patient arrives on ward from another area (ED or Theatre) without a filter, add primed filter to IV line.

• Attach filter to line as close as possible to cannula using aseptic technique minimising risk of contamination through breaking the line.

• Be aware of filter fluid / drug incompatibilities (see appendix 3).

• Filter requires changing every 72 hours.