1. 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

2. Disclosure
The authors have no disclosure

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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)

10. 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

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

12. 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

13. 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

14. 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

15. 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:

16. 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

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

18. 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

19. The needle tip is free in the lumen in the vein

20. 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

21. 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

22. 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