David L. Eldridge

Pediatric peripheral intravenous access: does nursing experience and competence really make a difference?

Placement of peripheral pediatric intravenous (IV) catheters in infants and children is difficult, even in skilled hands. This large, 2-institution prospective study used real-time independent observations to describe the effect of nurse experience and competence on the length of time and the number of attempts to establish a successful IV placement in the hospitalized child. Data from a convenience sample of 592 evaluable patients and 1135 venipunctures showed that successful IV placements required an average of 2 venipunctures over 28 minutes. Although nurse experience and self-rated competence were correlated with attaining a successful IV placement, time of day, predicted difficulty of the venipuncture, and cooperativeness of the child appeared to be better predictors of success.

Peripheral Difficult Venous Access in Children

Early identification of DVA is the first step in optimizing patient care. The consensus panel described DVA as a clinical condition in which multiple attempts and/or special interventions are anticipated or required to achieve and maintain peripheral venous access. Special interventions are defined as the use of any technique or hospital resource with the potential to improve peripheral IV insertion success rates. These include traditional methods of enhancing the visibility and palpability of peripheral veins (eg, warming the catheter site to induce vasodilation); advanced visualization technologies such as ultrasound, transillumination, and nearinfrared lighting; and enlisting designated IV specialists and/or hospital staff with extensive experience in starting pediatric IVs. Some children may need more invasive interventions such as intraosseous (IO) infusion, a peripherally inserted central catheter, or a central venous catheter (CVC) to achieve parenteral access. There is a dearth of clinical evidence on the incidence of DVA in pediatric patients. Studies of IV insertion success rates indicate that 5% to 33% of children require more than 2 needle sticks to achieve IV access. Even when interventions such as transillumination and ultrasound are used, up to 15% of children still require more than 2 attempts to establish venous access. A recent prospective analysis of 593 insertion attempts in centers with pediatric hospitalist services showed that successful placement Establishing peripheral intravenous (IV) access in pediatric patients can be challenging. Clinical studies show that only 53% to 76% of children are successfully cannulated on the first attempt. Multiple failed attempts are painful and upsetting for the child and distressing for family members and caregivers, yet there are no guidelines or consensus statements on the recognition and management of this problem. In January 2008, a panel of physicians and nurses specializing in emergency medicine, anesthesia, critical care, and hospital medicine convened to discuss peripheral difficult venous access (DVA) in children. Daniel Rauch, MD, FAAP, and Laura L. Kuensting, MSN(R), RN, CPNP, cochaired the roundtable discussion, which was made possible by a grant from Baxter Healthcare, Inc. The main objectives of the meeting were to estimate the frequency of DVA in pediatric patients; describe its clinical and emotional impact on the patient, the patient’s family, and clinicians; develop terminology that accurately describes the condition; review the factors that help identify children with DVA; and

Paraquat ingestion: a challenging diagnosis.

Paraquat is an herbicide that is highly toxic to humans. Pediatric ingestion has become uncommon in the United States because of preventative efforts. We report here an unintentional, fatal paraquat ingestion by an 8-year-old child. Storage in an inappropriate container, confusion between herbicide trade names, nonspecific symptoms, and a delay in follow-up produced challenges in the diagnosis. In the absence of a clear history of ingestion, paraquat poisoning should be suspected in children who develop skin and mucous membrane burns, gastrointestinal symptoms, acute kidney injury, and respiratory failure.

Peripheral Intravenous Access in Pediatric Inpatients

Background. Peripheral intravenous (PIV) line placement is a time-consuming procedure performed on the majority of general pediatric inpatients, with significant discomfort to patients. Objective. To determine parameters of pediatric PIV placement, including success rates, time to success, and factors associated with success. Design. Prospective study involving direct observation of PIV placement by trained research staff. Setting. General inpatient wards at 2 medium-sized pediatric hospitals. Patients. Hospitalized children younger than 19 years. Results. Successful placement was achieved in 95.8% (567/592) cases with a median time of 9 minutes. Children younger than 2 years were less likely to have success on the first attempt (38.9% vs 53.5%) and have longer time to success (11 minutes). Conclusions. Children younger than 2 years experienced lower first-attempt successful PIV placement and took longer. The overall success rate was similar to prior reports; these data are the first to show differential PIV success by patient age.

Alternatives to intravenous rehydration in dehydrated pediatric patients with difficult venous access.

Intravenous (IV) catheter placement in the pediatric patient population can be challenging. Many health care providers automatically choose IV fluid administration to treat dehydration, often not considering other routes. This article reviews the available literature on difficulties in obtaining IV access in the pediatric population and discusses alternative methods for fluid replacement, their respective advantages and disadvantages, and place in therapy.

New trends in diagnostic investigations in poisoned patients

Evaluating a suspected poisoning or drug overdose provides a special challenge to clinicians. Prompt diagnosis in these cases allows the choice of an appropriate antidote or, more commonly, the provision of appropriate supportive care. On the basis of fictional portrayals in the popular media, many have the misconception that just ‘sending a sample to the lab’ will provide the answers to these clinical quandaries.

Radiopacity of ingested transdermal medicinal patches: a simulated human model.

Division of Medical Toxicology, Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, PA 19141, USA Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine & University of Virginia Health System, Charlottesville, VA 22908, USA Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA