Myron Yaster MD and Lynne G. Maxwell MD
When we were pediatric interns or “yoots”, the defining ability of a pediatric medicine intern/resident was the ability to place an IV in a screaming, wiggling, frightened, sick child. Obtaining IV access was as challenging and humbling as it is today. Perhaps even more so. The smallest bore plastic IV was 22 gauge, and 25 or 27 gauge butterfly needles were used for smaller veins, and, if you can believe it, as the primary IV in many oncology patients. Why oncology patients? To prevent thrombophlebitis (the needles fell out in 24-48 hours so they were thought to be “safer”). As the people who had to reinsert these needles, we thought this policy was bat-shit crazy. Sedation, topical or local anesthetics, parental presence, child life were not available. To our despair, children were quite literally tied down on a papoose board (look it up) to facilitate performance of painful procedures. Obviously, the more we failed the more agitated and difficult IV placement became.
How times have changed! In modern pediatric practice, the majority of IVs are placed by nurses, IV/phlebotomy teams or technicians and only occasionally by physicians. The need for multiple IV starts has been reduced by the miraculous use of silicone peripherally or centrally placed long lasting IV catheters. As pediatric anesthesiologists, we may be the last dinosaurs who personally practice the essential skill of placing a peripheral IV catheter. Indeed, we are often the “Alamo”, or the last line of defense when all is else fails. Today’s PAAD by Ballard et al. and the accompanying editorial by Simpao and Galvez shed some light on risk factors for difficult pediatric IV access in the operating room.
Original article
Ballard HA, Hajduk J, Cheon EC, King MR, Barsuk JH. Clinical and demographic factors associated with pediatric difficult intravenous access in the operating room. Paediatr Anaesth. 2022 Jul;32(7):792-800. PMID: 35293066
Editorial
Simpao AF, Gálvez JA. Mining large data on small veins to inform pediatric perioperative difficult intravenous access. Paediatr Anaesth. 2022 Jul;32(7):790-791. PMID: 35665569
“Difficult venous access situations humble and frustrate even the most experienced pediatric anesthesiologists and anesthetists, and failed placements of intravenous (IV) catheters are not uncommon in children. Early identification of risk factors for difficult venous access is the first step in optimizing this aspect of perioperative patient care, as the anesthesiologist may be able to adjust their management of IV placement accordingly.”1
Over a one-year period, Ballard et al., working in the operating rooms of the Lurie Children’s Hospital in Chicago, prospectively collected information in EPIC on IV placement in almost 13,000 children. Difficult IV access was defined as IV access requiring more than 2 attempts. “Black non-Hispanic race/ethnicity, younger age, obese/overweight body mass index, American Society of Anesthesiologists physical status III, and ultrasound were all associated with pediatric difficult vascular access in the operating room”.2 “When these factors are identified, clinicians should consider obtaining ahead of time either expert human assistance or assistive technologies such as an ultrasound machine or near-infrared imaging device to minimize attempts”.1
We chose this article (and editorial) for the PAAD because as Simpao and Galvez point out, this “study by Ballard et al. is an excellent example of asking clinically relevant questions, having the expertise and will to analyze a large electronic health record dataset to answer the questions, and then taking a thoughtful approach to translating that analysis while accepting and stating fair limitations”.1
Finally, this article and editorial point out the dramatic impact of ultrasound in today’s pediatric anesthetic practice. Initially used primarily for regional anesthesia or central line placement by “experts”, it is now used by more and more practitioners for arterial and venous catheterization, point of care assessment of heart, lung and other organ systems, and the list goes on. Perhaps like videolaryngoscopy, which initially was used for difficult intubations and is now increasingly replacing conventional, first attempt intubation, the same may be true for IV placement. In many anesthesia training programs, current anesthesiology residents are learning ultrasound intravenous placement and may arrive for their pediatric anesthesia rotations more comfortable with using ultrasound than they are with direct percutaneuous placement. As Simpao and Galvez speculate: “Perhaps, the study by Ballard et al. can serve as a catalyst for a multicenter, randomized trial of ultrasound for first-attempt IV placement that will incorporate yet unexplored factors and address the unanswered questions regarding difficult venous access in anesthetized children”.1
References
1. Simpao AF, Gálvez JA: "Mining large data on small veins to inform pediatric perioperative difficult intravenous access". Paediatr Anaesth 2022; 32: 790-791
2. Ballard HA, Hajduk J, Cheon EC, King MR, Barsuk JH: Clinical and demographic factors associated with pediatric difficult intravenous access in the operating room. Paediatr Anaesth 2022; 32: 792-800