Intravenous therapy in Pediatrics

Intravenous therapy (IV) in pediatrics is a vital intervention used to deliver fluids, medications, blood products, or nutrition directly into a child’s bloodstream. It’s especially important when oral or enteral routes are not feasible due to illness, surgery, or critical care needs.

Candidates for Intravenous Therapy

• Children who have poor gastrointestinal absorption caused by diarrhea, vomiting, and dehydration.
• Those in need of high serum concentration of drug.
• Those who have persistent infections that require IV medications.
• Those with emergency problem.
• Those in need of continuous pain relief.

Indications for Intravenous Fluid Maintenance

• Maintenance replacement: Children who cannot take food orally, for example, children who underwent surgery, comatose patients, and children with respiratory disorders and inhibited from oral feed.
• Maintenance+ deficit replacement: Children who have severe dehydration, salt wasting renal disease, pyloric stenosis, and diabetes ketoacidosis.
• Adjusted maintenance and correction of electrolyte imbalance: Acute renal failure, nephritic syndrome, and burns.

Preferred Intravenous Sites

Site selection in the pediatric patients varies with the age. The best choice of site is the one that least restricts the movement of the child.

Common Sites

• Hand, wrist, forearm, foot, and ankle.
• Antecubital fossa should be used if other sites cannot be accessed.
• Scalp vein can be used if no other veins are
  available

Preparation of Child and Parents

• Using an age-appropriate developmental approach, explain the procedure to child and parents.
• Furnish information on misconceptions and clarify their doubts.
• Play can be employed during the preparation period to reduce stress and anxiety.
• Allowing child to handle equipment and to start an IV infusion on a toy animal or doll help familiarize them with the frightening aspects of the procedure.
• Introduce a child to another child who is coping well in the same situation.
• Arrange a quiet, private setting for the child during insertion, for example, procedure room, to avoid anxiety and stress concerning loss of control in front of others.
• The child should be provided with some distracting activity.
• Parents are told about the procedure, including the reason for it, how long the catheter must remain in place, and what they can expect during and after the insertion.
• Encourage the parents to participate in procedure.
• One way to control pain during the procedure is by the use of controlled breathing. The child can be taught to inhale slowly and exhale through the mouth through pursed lips.

Position

• Toddlers and young children can be held in parents lap with the child’s legs tucked between the parent’s legs and the child’s arm behind the parents. Ask the parents to hug the child to both restrain the child and provide comfort.
• Do not use any device to restrain the child unless it is necessary.
• Assistant should be prepared to grasp the child gently but firmly during the insertion.

Procedure

• Assemble the equipment.
• Perform hand hygiene. Don the gloves.
• A needle and syringe filled with NS solution is made ready.
• Precut the adhesive tape and keep it ready.
• Connect the IV tubing in the solution bag after checking the clarity and date of expiry and hang it on IV pole.
• Remove the air from the tubing by allowing some amount of fluid to run in.
• Allow the amount of fluid to be infused to run into the microdrip chamber and clamp it again.
• Apply the tourniquet over the extremity proximal to the venipuncture site.
• Locate the vein for needle insertion.

Other methods to visualize the vein include:

• Applying warm compress to the site.
• Running warm water over the extremity.
• Holding the limb in a dependent position below body level will help fill the veins for better visualization.
• Gentle tapping sometimes causes the vein to stand out.
• A commercial vein transilluminator is helpful in locating veins and assessing the depth and patency of vessels.
•  A BP cuff can also be used as a tourniquet and can give more control over the pressure needed to make the veins visible.
  If the scalp vein is to be used, the nurse needs to hold the infant or young child or mummy restraint may be applied. The nurse must hold the head in midline or turned to one side.
• Press the fingers against the bony skull and the prominence of the infant’s face.
• The head may then be pressed against the pad on the table or bed. Care must be taken to avoid interference with infant’s breathing during restraint.
• A tourniquet in the form of rubber band may be placed over the occiput.
• Clean the site with sterile antiseptic-soaked swabs.
• The IV cannula with the beveled side up is inserted in the skin. When it enters the blood vessels, blood may flow back into the cannula.
• Advance the cannula and remove the stylet (needle) and press the cannula site with the fingers of nondominant hand to prevent bleeding.
• Remove the tourniquet.
• Connect the cannula with the IV set.
• Secure the hub of the cannula with the adhesive tape.
• Transparent dressing is ideal because the insertion site is easily observed.
• Minimum tape should be used at the puncture site and on about 2.5-5 cm of the skin beyond the site to avoid obscuring the insertion site for early detection of infiltration.
• Opaque covering should be avoided. If it is used, the insertion site and extremity distal to the site should be visible to detect an infiltration.
• A protective cover is applied directly over the catheter insertion site to protect the infusion site. A commercial site protector IV house with ventilation holes can be used.
• If not available, padded boards or splints can be used to support the IV site. But its use can be minimized since it poses many disadvantages.
• A colorful and interesting sticker can be applied to the protective device to add a positive note to the procedure.
• Finger or toe areas are left Un occluded by dressings or tape to allow for the assessment of circulation.
• The thumb should not be immobilized because of the danger of contractures with limited movements later on.
• Minimize the use of restraints. If at all it is used frequent removal of the restraints provides the child with the opportunity to move the extremities.
• The flow rate is regulated carefully.
• The child should be positioned comfortably.

Nurse’s Responsibility in Administration of Intravenous Medication

• Most medications given by the IV route must be given at a specified rate and diluted properly to prevent overdose or toxicity.
• Careful maintenance of the IV site is required to prevent complications.
• Direct IV push medication is typically reserved for emergency situations and when therapeutic blood levels must be reached quickly to achieve the desired effect.
• Direct IV push administration requires that the drug be diluted appropriately and given at a specified rate, such as 2-3 minutes.

Care of Scalp Vein Site

• Family members should be reassured that child’s hair will grow back quickly.
• When scalp vein is used, the child’s hair is shaved over a small area.
• An inverted medicine cup or a paper cup with the bottom up is often taped over the site to protect it.
• The needle is stabilized with U-shaped taping and a loop of tubing is tapped so that if the child pulls on the tubing, the loop will absorb the pull and the site will remain intact.

 Administration of medications via a syringe pump

Procedure

• Verify the medication order.
• Gather the medication and necessary equipment and supplies.
• Wash hands and put on gloves.
• Attach the syringe pump tubing to the medication syringe and purge air from the tubing by gently filling the tubing with the medication from the syringe.
• Insert the syringe into the pump according to the manufacturer’s directions.
• Clean the port on the child’s IV access device or tubing, flush the device or tubing if appropriate (e.g., an intermittent infusion device (saline lock or heparin Lock), and attach the syringe tubing to the IV tubing or device.
• Set the infusion rate on the pumps as ordered.
• When the medication infusion is completed, flush the syringe pump tubing or deliver any medication remaining on the tubing, according to institution protocol.
• Document the procedure and the child response to it.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840.
5. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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