1. St. Vincent's Medical Center, Bridgeport, CT, United States Ultrasound-Guided Peripheral Intravenous Cannula Placement in Children; A Pictorial Review Mahmoud Zahra, MD; Terence1 Hughes, MD; Ara Karamanian, MD; keni1 Augustin,MD; Anne Marie Cahill, MD; Ganesh Krishnamurthy, MD 1. St. Vincent's Medical Center, Bridgeport, CT, United States 2. Children's Hospital of Philadelphia, Philadelphia, CT, United States

Disclosure The authors have no disclosure

Purpose Describe the indications, technique and complications of ultrasound guided peripheral line placement in children with special attention for technique

Indications Failure to place intravenous cannula by conventional technique This could be secondary to: Severe dehydration Obesity Severe edema Extensive burn, Severe positional contracture due to cerebral palsy History of multiple intravenous catheter placements in the past with obliteration of most peripheral veins

Four Step Technique Step I: Preliminary ultrasound examination Step II: Preparation the equipment Step III: Insertion the peripheral intravenous cannula under ultrasound guidance Step IV: Flushing and securing the line

Step I: Preliminary ultrasound examination Preliminary ultrasound examination is performed to : Evaluate and choose a suitable vein for the cannula insertion Differentiate the artery from the vein

Step I: Preliminary ultrasound examination Evaluate and choose a suitable vein for the cannula insertion : The venous segment should be patent, compressible and long enough to contain the whole cannula Color Doppler may not demonstrate flow in a small vein even it is patent Peripheral line could be inserted in the following locations in order of preference: The forearm, arm, leg and thigh

Step I: Preliminary ultrasound examination Differentiation the artery from the vein depends on that the artery has: Stable anatomic location More echogenic wall More resistance for compression Pulsatile spectral waveform

Transverse US section of the mid–left upper arm showing brachial veins (asterisks) on either side of the brachial artery. The basilic vein is located medially (diamond symbol)

Step II: Preparation The Equipment The equipment needed for ultrasound guided intravenous cannula placement is: Ultrasound machine with hockey-stick probe. Probe cover usually is not needed Traditional Angiocatheter size 18, 20, 22 or 24-gauge with extension tubing Tourniquet Sterile gel Alcohol swabs Normal saline syringes for flushing Tegaderm and tape

Small–Foot Plate High-Frequency (15 MHz) US Probe

Step II: Preparation The Equipment Ultrasound probe and the skin of the insertion are cleansed using alcohol swabs Ultrasound probe cover is not usually required Saline syringe is attached to extension tubing The tourniquet is placed in proper position

Step II: Preparation The Equipment The child should be placed in a supine position and held stable by one or two assistants A topical anesthesia cream can be used for 10 minutes before insertion the line Infiltration local anesthesia is not required and may cause spasm of the vein

Step III: Insertion The Peripheral Intravenous Cannula Under Ultrasound Guidance; Technique Best ultrasound approach for peripheral placement in children is transverse approach A sterile ultrasound gel is used A single wall puncture technique should be always used The target vein is placed in the middle of the ultrasound screen The needle is inserted at an acute angle towards the vein, the angle dependent on the depth of the vein from the skin

Step III: Insertion The Peripheral Intravenous Cannula Under Ultrasound Guidance; Technique: Needle tip visualization Needle tip could be followed using one of these two maneuvers: Angling the probe : This is performed when the vein is superficial The probe is angled towards the needle When the needle tip is visualized, the needle is advanced with continuous angling of the probe to follow the needle tip to the vein Moving the probe:

Step III: Insertion The Peripheral Intravenous Cannula Under Ultrasound Guidance; Technique: Needle Tip Visualization Needle tip should be followed using two maneuvers: Angling the probe : Moving the probe: This is performed when the vein is deep After penetration the skin, the probe is removed and placed overlying the needle tip then the needle and the probe are advanced simultaneously towards the vein

The deeper the vein, the more distance between the needle and the probe and steeper the angle of the needle

Step III: Insertion The Peripheral Intravenous Cannula Under Ultrasound Guidance; Technique: Puncture The Vein: When the needle tip reaches the anterior wall of the vein a gentle pressure over the needle is applied to tent the anterior wall and confirm a proper position of the needle tip Puncture the vein should be done with a quick stick After penetration of the three layers of the vein, the needle should appear free in the lumen Then the needle/cannula combination is advanced all the way inside the vein under ultrasound guidance The needle is then removed

The needle tip is free in the lumen in the vein

Step IV: Flushing And Securing The Line After removing the needle, the cannula is attached to extension tubing and the vein is flushed The cannula and tubing are secured into the skin with a small Tegaderm and tape

Complications The only complication could be seen is arterial puncture Careful ultrasound examination would differentiate between artery and vein The treatment is removing the cannula and applying gentle pressure for 5-10 minutes

Conclusion: Ultrasound-guided peripheral intravenous cannula placement in children is feasible Following appropriate technique, as described above, the success rate can be high in experienced hands