See also

Communicating procedures to children
Minimising distress in healthcare setting 

Procedural pain management guideline
Peripheral Intravenous device management guideline

Key points

1. Anxiety, pain, distress and subsequent needle phobia are associated with repeated attempts at intravenous (IV) access; appropriate preparation can minimise the distress caused
2. It is important to justify the need for the procedure and combine with blood sampling if needed
3. If available, consider ultrasound guidance if intravenous cannulation is predicted to be difficult or a longer-term access device if prolonged therapy is anticipated
4. Some children are at higher risk of decompensation with multiple IV attempts, eg child with congenital heart disease and single ventricle physiology

Background

• Multiple attempts at intravenous insertion can cause significant distress for patients so alternatives should always be considered within the clinical context:
  • oral fluids or medications if child can tolerate
  • fluids or medication via NG, or via PEG in a child with gastrostomy tube
  • IM or intraosseous 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
• Monitor IV site for signs of infection or extravasation
• If prolonged IV therapy is anticipated, plan for longer term access eg PICC or midline
• Remove unused cannulas to minimise infection

Selection of intravenous access

The following guidance should be considered when referring patient for IV access

If available, consider ultrasound guidance by an experienced clinician if intravenous cannulation is predicted to be difficult or prolonged therapy is anticipated (see table below)

Potential complications

• Unsuccessful procedure or multiple attempts
• Accidental arterial cannulation
  • Bright red backflow of blood into IV cannula
  • The cannula flashback appears pulsatile or there is pulsatile movement of blood in IV tubing
  • Backflow of blood into IV tubing despite fluid bag at level higher than IV insertion site
  • IV inserted in a 'high risk' area ie antecubital fossa
  • Management if uncertain
    • Do not use cannula
    • Urgent blood gas analysis from inserted cannula
• Thrombophlebitis or infection
• Extravasation injury

Equipment, analgesia, anaesthesia and sedation

Procedure

• Explain the procedure to the child and parents and obtain verbal consent
• Ensure to perform appropriate hand hygiene throughout

Sites

• Using a tourniquet assess for the most suitable vein; in children, the most suitable vein may not necessarily be palpable
• Dorsum of the non-dominant hand is preferred with the vein running between the 4th and 5th metacarpals is most frequently used
• In addition to the usual sites in adults, commonly used sites in children include the volar aspect of the forearm, dorsum of the foot and the great saphenous vein at the ankle
• Consider practicalities of splinting eg areas of flexion such as elbow, foot in a mobile child

Transillumination

• Application of a cold light directly to the skin in a darkened room can be helpful in finding veins in neonates and infants
• Only cold lights (usually fibre-optic sources) should be used. Normal torches can burn the skin and should not be used
• Transillumination is a useful skill which requires practice but is simple once mastered

Ultrasound guided approach

• Scan carefully for the most suitable vein
• The most commonly used vein with the highest success rate in children is the cephalic vein in the proximal forearm
• Other sites include the long saphenous vein at or just proximal to the ankle, or the medial aspect of the upper arm (midline catheter)

Assess difficulty of intravenous cannulation

1. History of 'difficult' IV access in the medical record
2. Patient or caregiver reports a history of difficulty in cannulating or venepuncture
3. Clinical assessment
4. The DIVA (difficult intravenous access) score may be helpful

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, eg congenital heart disease with single ventricle physiology. In this scenario if >2 attempts are required involve the senior clinician and consult the treating cardiology team

Technique

Holding

• Ask assistant to stabilise limb, by holding joints above and below if necessary
• When applying tourniquet, be careful not to pinch skin or compress artery
• In infants, when accessing the hand, grasp as shown; this achieves both immobilisation and tourniquet (see Figure 1 below)

Figure 1: holding an infant's hand	Figure 2: shallow angle of insertion

Inserting the cannula

• Decontaminate skin with alcohol 70% or chlorhexidine 2% swabs and leave to dry for at least 30 seconds. Use 'no-touch' technique for insertion after decontamination
• Insert just distal to and along the line of the vein
• Angle at 10-15° (see Figure 2 above), or between 30-45° if using ultrasound guidance
• Advance needle and cannula slowly
• A 'flash back' of blood may not occur for small veins and 24G cannula
• Once in the vein, advance the needle and cannula slowly a further 2-3 mm along the line of the vein before advancing cannula off needle
• Apply slight occlusive pressure to the vein above while preparing to take blood samples
• Dispose of sharps appropriately

Taking blood samples

• For 24G cannula it is often easier to let blood drip passively into collection bottles (see Figure 3 below)
• When taking blood for culture or gas from a small cannula, aspirate blood from the hub of the cannula using a blunt 'drawing up' needle and syringe (see Figure 4 below)
• For a larger cannula, a syringe can be used to aspirate blood
• For 22G or 20G cannula a vacuum connector can be used

Figure 3: passive blood collection for infants	Figure 4: aspirating blood for culture or gas

Securement

• Remove tourniquet before strapping
• Connect the saline-primed 3-way connector or extension set to the end of the cannula by screwing it firmly on. Flush the connector tubing with more saline to confirm intravenous placement
• Use sterile tapes to secure the hub and a clear dressing over the cannula site such as Tegaderm™. Ensure that the proximal tip and area of skin around are always easily visible (Figure 5 below). Extravasation injuries can occur especially if the site is not readily accessible for regular nursing checks
• Consider placing a small piece of sterile gauze underneath the hub of the cannula to prevent pressure areas
• Tapes and splint should secure the limb proximal and distal to the cannula (keeping thumb free) but not too tightly (Figure 6 below)
• Arm splints are not required for lines placed in the cephalic vein in the forearm (typically ultrasound guided). Cover the whole distal extremity in net bandage (eg surgifix tubular-fast). In very young children, consider bandaging the other hand as well to prevent them from removing the cannula

Figure 5: secure with TegadermTM so that IV site is visible	Figure 6: Strap so that joint is immobilised, but avoiding tapes being too tight

Post-procedure care

• Documentation of procedure and device in child's chart
  • Indication for insertion
  • Size, site, number of attempts, any difficulties
  • Maintenance
  • Plan for removal
• Running a 'drug line' (3-5 mL/hr of sodium chloride 0.9%) through the cannula may keep it patent for a longer period of time
• Regularly inspect insertion site for complications (tenderness, blockage, inflammation, discharge) as per local hospital policy. Check the other hand if it has also been bandaged
• Unless complications develop, the peripheral IV should remain in situ until IV treatment is complete
• Daily documented review by medical team regarding ongoing need for IV access or whether it can be removed to minimise infection risk

Difficulty with IV insertion

• Each clinician should have a maximum of 2 attempts before escalating
• Strongly consider ultrasound assistance, if available

Flowchart for difficulty with IV insertion

*Experienced clinician with at least 2 years of acute paediatric experience

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

See video

Watch the Intravenous Access Peripheral video:

Parent information

Intravenous cannula factsheet (NSW)
Care of your IV drip (SA)
Cannula (WA)
Peripheral intravenous cannula (WA)

Last updated September 2025