If holding the child firmly is not sufficient to keep him or her immobile for a procedure, a wrapping technique can be used. This technique will be needed for many children between 1 and 6 years of age.

Procedure

Use a sheet or blanket to wrap the child as shown in Fig. 2-1. If a limb is required for the procedure (e.g., for IV access), leave it outside the wrapping.

Fig 2-1

Fig. 2-1: Wrapping Technique to Immobilize a Child for a Procedure

Venipuncture

General

For venipuncture, always make your first attempt in the largest, most prominent vein you can find.

It is sometimes easier to feel a vein than to see it.

Sites

Preferred (Upper Extremity)

Forearm veins (e.g., cephalic, median basilic or median antecubital); these are the best choices in all age groups, but can be difficult to find in chubby babies
Veins on the dorsum (back) of the hand
Tributaries of the cephalic and basilic veins, dorsal venous arch

Other (Less Well Known)

Saphenous vein, just anterior to medial malleolus (lower extremity)
Small veins on ventral surface of wrist or larger one on inner aspect of wrist proximal to thumb

Procedure

Immobilize child by either holding or wrapping (see"Restraint," above, this chapter).
Practice universal precautions against contamination with child's body substances (e.g., gloves, possibly goggles, safe disposal of needle).
Apply tourniquet proximal to site; rubbing or warming the skin will help to distend the vein.
Use a 25- or 23-gauge butterfly needle with syringe attached, bevel up.
Stabilize vein by applying traction.
Insert needle just far enough to get "flashback" of blood.
Apply gentle suction to prevent the vein from collapsing.
If flow is very slow, try "pumping," by squeezing the limb above the site of the puncture.

Intravenous Access

Vascular Sites

Best Sites, in Order

Dorsum of hand
Feet
Saphenous vein
Wrist
Scalp: a good site in infants, as veins are close to the surface and are more easily seen than in the extremities; useful for administration of fluid or medication when the child's condition is stable, but rarely useful during full resuscitation efforts
Antecubital vein

Upper Extremity

Forearm veins (e.g., cephalic, median basilic or median antecubital); these veins can be difficult to find in chubby babies
Veins on the dorsum (back) of the hand
Tributaries of the cephalic and basilic veins, dorsal venous arch

Lower Extremity

Saphenous vein, just anterior to medial malleolus
Median marginal vein
Dorsal venous arch

Types of Needles

Over-the-Needle Catheters

Cathilons or IV catheters are the most stable - 24- or 22-gauge needle is usually used in infants
Required for volume resuscitation efforts

Advantages

More comfortable than butterfly needle
Frequency of infiltration into interstitial space is lower

Butterfly

Especially useful for scalp veins - 25- to 23-gauge needles are most commonly used in infants

Advantages

May be used to obtain blood samples
Design (i.e., the wings) facilitates insertion because there is a handle to be gripped
Wings allow the needle to be taped more securely in place

Disadvantages

Butterfly needles tend to be inserted interstitially more frequently and should not be used for primary venous access in volume resuscitation efforts.

Procedure

Practice universal precautions against contamination with child's body substances (e.g., gloves, possibly goggles, safe disposal of needle).
Assemble necessary equipment.
Immobilize the child well, but avoid restraints if at all possible.
Always make first attempt in the largest, most prominent vein you can find - take your time to ensure you have identified the best vein.
If a scalp vein is chosen, you may have to shave the skin around it.
Apply tourniquet, if appropriate.
Cleanse the skin.
Stabilize the vein.
If using a catheter needle, insert it through the skin at an angle of 30° to 45°.
Once the needle is through the skin, adjust the angle of the cannula so that it is parallel to the skin, and advance it slowly into the vein far enough to get "flashback" of blood, then go in another millimeter or so to ensure that the plastic catheter is also in the vein before trying to thread it.
Remove the tourniquet and attach IV infusion set. Make sure there are no air bubbles in the tubing before connecting it.
Run in some IV fluid. If the IV line is patent, tape the needle and catheter securely in place.

These small catheters are fragile. Avoid bending them, and always tape them securely, preferably using an arm board and half a plastic medicine cup to cover the site.

Complications

Local

Cellulitis
Phlebitis
Thrombosis
Hematoma formation

Systemic

Sepsis
Air embolism
Catheter fragment embolism
Pulmonary thromboembolism

Intraosseous Access

General

Purpose

Used to administer IV fluids and medications when attempts at IV access have failed
For use in emergency situations only

Indications

Attempt intraosseous access in the following situations in children 6 years of age, when venous access cannot be achieved within three attempts or 60-90 seconds, whichever comes first:

Multisystem trauma with associated shock or severe hypovolemia (or both)
Severe dehydration associated with vascular collapse or loss of consciousness (or both)
Unresponsive child in need of immediate drug and fluid resuscitation: burns, status asthmaticus, sepsis, near-drowning, cardiac arrest, anaphylaxis

Contraindications

Pelvic fracture
Fracture in the extremity proximal to or in the bone chosen for the intraosseous access

Sites

Preferred

Anterolateral (flat) surface of the proximal tibia, 1-3 cm (one finger's breadth) below and just medial to the tibial tuberosity

Other Possibility

Distal tibia, 1-3 cm above the medial malleolus on the surface of the tibia near the ankle (believed by some to be the best site in older children because of the greater thickness of the proximal tibia relative to the distal tibia)

Procedure

Practice universal precautions against contamination with child's body substances (e.g., gloves, possibly goggles, safe disposal of needle).
Assemble necessary equipment.
Immobilize the child well, but avoid restraints if at all possible.
Place the child in the supine position and externally rotate the leg to display the medial aspect of the extremity.
Identify the landmarks for needle insertion.
Cleanse the puncture site.
If the child is conscious, use local anesthesia (see section on local anesthesia in "Suturing," below, this chapter).
Use an intraosseous needle or, in a small child, an 18-gauge butterfly needle.
Angle the needle away from the joint. Insert the needle at a 60° angle, 2 cm below the tibial tuberosity, through the skin and subcutaneous tissue.
When the needle reaches the bone, exert firm downward pressure, rotating the needle in a clockwise-anticlockwise manner. Be careful not to bend the needle.
When the needle reaches the marrow space, the resistance will drop (indicated by a "pop").
Attach a 10-mL syringe and aspirate some blood and marrow to determine if the needle is correctly positioned (other indicators of correct positioning: the needle will stand upright by itself, IV fluid flows freely, no signs of subcutaneous infiltration are apparent).
Secure needle with tape.
Use as you would a regular IV line. For example, fluids can be infused quickly for resuscitation of a child who is in shock.

Complications

Extravasation
Tibial fracture
Osteomyelitis
Epiphyseal injury
Lower extremity compartment syndrome
Obstruction of needle with marrow, bone
fragments or tissue

Insertion of Nasogastric Tube

General

Tube Size

Estimate length of tube needed by extending the tubing from the tip of the child's nose to the ear lobe and then to the xiphoid process.

Neonates: size 5-8 French
Young children: size 12-16 French

Procedure

Assemble required equipment.
Explain procedure to child (if he or she is able to understand) and parents or caregiver.
Lubricate tip of tube and slide it into the nostril along the base of the nose, advancing the tube slowly. Some pressure may be needed to enter the nasopharynx. Try to have the child assist by swallowing.
Once the tube has been advanced the desired distance, check the position either by aspirating gastric contents or by listening with a stethoscope over the stomach as a small amount of air is instilled into the tube.
Tape the tube in place.
Attach to drainage bag.

Withdraw the tube if choking or coughing occurs during placement.

Suturing

Use of Local Anesthesia

General

Lidocaine (1%, without epinephrine) is the local anesthetic that should be used
To avoid systemic toxic effects, instill no more than 4 mg/kg (0.4 mL/kg of a 1% solution without epinephrine)
Use a 28- or 27-gauge needle (the size found on insulin syringes) and inject slowly

For detailed information on wound management and suturing, see "Skin Wounds," in chapter 9, "The Skin," in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).

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	Last Updated: 2005-03-17		Important Notices