In this section
Procedural pain management guideline
Peripheral Intravenous device management guideline
RCH comfort kids resources
Multiple attempts at IV insertion can cause significant distress for patients so alternatives to IV access should always be considered within the clinical context e.g. Oral or NG fluids/medication, IM or IO medications in emergencies.
Cannulas inserted over joints, in areas of flexion or in the lower limb are more likely to fail than those inserted in the
hand or forearm
The following guidelines should be considered when referring patient for IV access
Peripheral IV access
Predicted dwell time: forearm > hand > foot > cubital fossa
Ultrasound guided peripheral IV access (may last up to 7 days)
If available, ultrasound guidance should be considered if intravenous cannulation is
predicted to be difficult or prolonged therapy is anticipated
Infants <3 months
Older infants & children
Have equipment ready before
the child enters the room
Additional equipment if performing
ultrasound guided intravenous cannulation
Explain the procedure to the child and parents and obtain verbal consent.
Score of 4 or more means >50% chance of failed initial attempt
If difficult intravenous cannulation is predicted based on the above criteria, ultrasound guided insertion should be considered if the equipment and expertise is available.
Some children are at higher risk of decompensation with multiple IV attempts, e.g. congenital heart disease with single ventricle physiology. If >2 attempts are required involve the senior clinician and consult the treating cardiology team.
Figure 4: aspirating blood for culture or
Each clinician should have a maximum of 2 attempts before escalating.
Strongly consider ultrasound assistance, if available, after 3-4 attempts
*Experienced Clinician – at least 2 years of acute paediatric experience
For emergency advice and paediatric or neonatal ICU transfers, see
RCH specific information: for assistance with difficult intravenous access
Last updated September, 2019