Technologies in pediatric vascular access: have we improved success rate in peripheral vein cannulation?

Peripheral vein cannulation in children is possibly one of the most challenging routine care issues for healthcare providers. It is certainly one of the most terrifying experiences for nonanesthetized children who may endure multiple attempts. Therefore, first-attempt successful intravenous (IV) cannulation is crucial. In critically ill children, it may have an impact on timely intervention. It is generally difficult to predict the success of the first attempt, although it may be related to patient’s age and skill of the practitioner. Difficult IV access (DIVA) score has been validated for identification of children with difficult IV access. The DIVA score is based on four factors: age, history of prematurity, and if the vein is visible and/or palpable after application of the tourniquet. Patients in cardiac arrest or in hypovolemic or septic shock states may develop into DIVA patients and timely vascular access can be critical. According to the current resuscitation guidelines, intraosseus (IO) access is recommended if IV access cannot be established with in the first minute or in cases where veins are not visible. In children, the proximal tibia is recommended for the site of access. IO access has also been used successfully in the operating room when the IV access has failed. When establishing the IO access in neonates and infants, the relatively small size of the medullary diameter (8 mm) compared to the size of the IO needle must be kept in mind to avoid complications. Ellemunter reported remarkable safety and efficacy. They reported a case series of 30 successful IO access attempts during resuscitation of preterm and term infants, weighting between 670 and 3970 g. We believe complications were minimized, and perhaps avoided, by the regimented monitoring of the IO access site and the replacement of the IO cannula once resuscitation was achieved. New and old technologies have been evolving to make the peripheral IV cannulation more successful. Of these technologies, the near-infrared (NIR) and the ultrasound (US) are the most published (Table 1). Challenges and limitations of most studies related to IV cannulation include variation in type of healthcare providers and their years of practice or experience with the technology. Many studies include relatively small numbers of patients with or without a known difficult IV access history. The most common outcome measured is based on the success of the first IV cannulation attempt and/or frequency of attempts compared to non-assisted method; one adult study reported that success of ultrasound-guided peripheral IV led to reduction in central line placement. The ultrasound-guided firstattempt IV access success rate is commonly report between 53% and 80%. Triffterer et al. specifically studied ultrasound technique for the great saphenous vein and reported a remarkable