Neonatal and Pediatric Vessels

Better Care, Better Outcomes

Cephalic vein

Cephalic vein

Basilic vein
Median cubital
basilic vein

Basilic vein
Dorsal
venous arch

Dorsal digital
metacarpals

Cephalic vein

Cephalic vein

Neonatal
and Pediatric Vessels
AND PEDIATRIC VESSELS

NEONATAL

The use of peripheral intravenous catheters should be considered for infants

whouse
require
intravenous
access for catheters
no more than
seven
and in for
whom
access
The
of peripheral
intravenous
should
be days
considered
infants
who
is attained
within three
attempts.
require
intravenous
access
for no more than 7 days and in whom access is attained
three
attempts.
within
Utilize the
smallest
gauge and shortest length catheter that will accommodate
Utilize
the
smallest
gauge and shortest length catheter that will accommodate the
the prescribed therapy.
prescribed therapy.

Vessel Specifics

VESSEL SPECIFICS
Forearm

Basilic Vein
FOREARM

Cephalic
Basilic
Vein Vein

Hand

Dorsal Digital Metacarpals

HAND

Cephalic Vein
Advantages

DorsalDigital
VenousMetacarpals
Arch
Dorsal
Dorsal
Venous Arch
Disadvantages
Advantages

Advantages
- Readily visible
Easily
- Distalaccessible
location
Readily
visiblefree
- Keeps hands
Distal location
Disadvantages
Keeps
hands free

Advantages
Disadvantages
- Difficult
to anchor on infant
- Readily visible
- Distal
Increased
Easilylocation
accessible
nerveactivity
endings
- Interferes
with childs
- Bones

Readily
visible
Difficult
to
anchor
on infant
act as natural splints
Distal location
Interferes with child's activity
Bones act as natural splints

- Easily accessible

-D
 ifficult to observe in
chubby infants and toddlers

- Easily accessible

- Increased nerve endings

Disadvantages
Difficult to observe in
chubby infants and toddlers

Antecubital

Basilic Vein
Cephalic Vein
Median Cubital Veins

ANTECUBITAL
Advantages
Basilic
Vein
- Large
and readily visible
Cephalic
- EasilyVein
palpable
- Preferred
sitesVeins
in infants
Median
Cubital
- P referred sites for PICC
insertion
Advantages

Large and readily visible

Disadvantages
Easily
palpable
- Elbow
joint must remain
Preferred
extendedsites in infants
Preferred
sites for
- Limits activity
PICC
insertion
- Limits
phlebotomy

Disadvantages
Elbow joint must
remain extended
Limits activity
Limits phlebotomy

Cephalic v.

Cephalic v.

Basilic v.
Median cubital
basilic v.

Basilic v.
Dorsal
venous arch

Dorsal digital metacarpals

C ephalic v.

Cephalic v.

LEG
LEG
Leg

FemoralVein
Vein
Femoral
Femoral
Vein
Greater
Saphenous
Vein
Greater Saphenous Vein

Greater
Saphenous
Vein
PoplitealVein
Vein
Popliteal

Popliteal v.
Popliteal v.
Anterior tibial v.
Anterior tibial v.
Great saphenous v.
Great saphenous v.
Communicating v.
Communicating v.

Popliteal Vein

These
veins
should
onlybebeused
usedfor
forcentral
central
These
veins
shouldonly
only
These
veins
should
used
line
insertion
central line insertion.
linefor
insertion
Advantages
Advantages
APICC
dvantages
and CVCinsertion
insertion
PICC
- PICCand
and CVC
CVC insertion

Keeps
hands
free
Keeps
- Keepshands
handsfree
free
accommodatelarger
larger
catheter
-Can
Canaccommodate
accommodate
catheter
Can
larger
catheter

Dorsalis pedis v.
Dorsalis pedis v.
Lateral marginal v.
Lateral marginal v.
Femoral v.
Femoral v.

Disadvantages
Disadvantages
Disadvantages
-Possible
Possible arterial
puncture
arterial
puncture
Possible
arterial
puncture
More
difficult
to
access
Moredifficult
difficulttotoaccess
access
More

FOOT
ANKLE
FOOT
ANKLE
Foot&&
and
Ankle

Popliteal v.
Popliteal v.

Communicating v.
Communicating v.

Lesser saphenous v.
Lesser saphenous v.

Saphenous v.
Saphenous v.

Posterior tibial v.
Posterior tibial v.

Greater
Saphenous
Vein
Greater
Saphenous
Vein
Greater
Saphenous
Vein
Lesser
Saphenous
Vein
Lesser
Saphenous
Vein
Lesser
Saphenous
Vein
Dorsal
Venous
Arch
Dorsal
Venous
Arch
Dorsal
Venous
Arch

Median marginal v.
Median marginal v.

Commonly used in children

Commonly
usedininchildren
childrengenerally
generally
Commonly
used
not yet walking.
before
walking.
before walking.
Disadvantages
Advantages
Advantages
Disadvantages
Advantages
Disadvantages
Decreases
mobility
Highly
visible
Decreases
Highlyvisible
visible
Decreases
mobility
Highly
phlebitis
mobility
R

isk
of
in
older
patients
Readily
accessible

Readily
accessible
Risk
of
phlebitis
olderpatients
patients
Readily

accessible
Risk
of
phlebitis
ininolder
M

ore
difficult
to
advance
cannula
- Keeps hands free
Frees hands
Moredifficult
difficulttotoadvance
advancecannula
cannula
Frees
More
- Easy hands
to splint
Easytotosplint
splint
Easy

Superficial temporal v.
Superficial temporal v.

Scalp

Supratrochlear v.
Supratrochlear v.

SCALP
Superficial Temporal Vein
SCALP

Superficial
Temporal
Vein
Posterior Temporal
Auricular
Vein
Superficial
Vein
Posterior
Auricular
Vein
Supratrochlear
VeinVein
Posterior
Auricular
Supratrochlear
Vein
Supratrochlear Vein

Scalp veins can be used in children up to

18 months;
after
that,
the in
hairchildren
follicles up to 18
Scalp
veinscan
canbebe
used
Scalp
veins
used
intoughens
children up
to 18
mature
and
the
epidermis
months; after that, the hair follicles mature

months; after that, the hair follicles mature

and
theepidermis
epidermistoughens.
toughens.
and
the
Advantages
- Easily observed
Advantages
Advantages
- Readily
dilates
Easilyobserved
observed
Easily
No
valves
present
Readilydilates
dilates
-Readily
Allows
use
ofpresent
extremities

No
valves
No valves present
Allowsuse
useofofextremities
extremities
Disadvantages
Allows
- Hair must be removed

Posterior auricular v.
Posterior auricular v.

Disadvantages
- Infiltrates easily
Disadvantages

Hairmust
must
removed
Difficult
to secure
catheter
-Hair
beberemoved
Greater
family
anxiety
Infiltrateseasily
easily
Infiltrates

Difficult
to
securecatheter
catheter
Difficult to secure
Greaterfamily
familyanxiety
anxiety
Greater

Key Points and Considerations

Neonates are at higher risk of infiltration injuries
due to the use of infusion pumps, the need for
resuscitation and their inability to communicate pain
Mean dwell times have been reported between
36 and 50 hours
IV site checks should be documented at a minimum
of hourly

Vessel Location and Condition

Straight, soft, elastic veins are preferred
Prominent veins may not always be the best choice
as they may be positioned in an unsuitable location
Accidental removal may be less likely if placed in
the upper arm, however recognition of phlebitis
may be difficult
The lower the gestational age, the less mature the
skin will be; additionally, subcutaneous tissue around
vessels is less obvious as gestational age decreases;
therefore, vessels will be closer to the surface

Infusion Purpose
and Characteristics
Medications and solutions with high osmolarities
and high or low pH irritate the vein wall
Trauma to the vein is related to the composition
of the infusate
Solution Osmolality

Phlebitis Potential

<450 mOsm/kg

Low

450-600 mOsm/kg

Medium

>600 mOsm/kg

High

Commonly administered hyperosmolar solutions:

- Parenteral dextrose concentrations > 10%
- Parenteral nutrition
- Ampicillin
- Cefotaxime
- Sodium bicarbonate
- Phenobarbital
pH level <5 or >9 can lead to vein irritation
Increased irritation occurs with rapid administration and
inadequate time for the blood to buffer the infusate

Therapy Duration
Preservation of the veins is essential if prolonged
therapy is anticipated, therefore a PICC should
be considered

Site Selection
Select the appropriate and most distal vein first.
If the medication/solution has high potential for
vein irritation, select the most appropriate and
largest vessel to accommodate the infusion
Perform the venipuncture proximal to a previously
cannulated site, injured vein, bruised area or site
of a recent complication
Rotate access sites to the opposite extremity
when possible

Catheter Material and Size

Softer materials are less irritating to the intimal
lining of the vein
Select the smallest gauge appropriate to
accommodate the prescribed therapy

Patient Activity
Arm boards/immobilization devices should be used
to secure and protect vascular access sites in areas
of flexion; regular site and circulatory checks should
be performed, and removal of these devices may be
indicated on occasion
Avoid the lower extremities in the walking pediatric
patient if possible

Complications
Catheter-Related Bloodstream
Infection (CRBSI)
Inherent with the use of any vascular access device
Can be due to migration of skin flora from the
insertion site along the catheter tract, with
colonization of the catheter
Catheter colonization can also occur from
contamination of the catheter hub, insertion site
during placement, infusates or hematogenous
seeding from a distant site
Premature infants are at higher risk due to
deficiencies in their immune system and the
number of invasive procedures they undergo

Phlebitis
Definition: inflammation of the vein. Causes can
be mechanical, chemical or bacterial.
Signs and symptoms
- Pain
- Erythema or edema
- Red streak over venous pathway
- Palpable venous cord
- Purulent drainage
INS Standards provide a phlebitis scale to
quantify observations in documentation

Mechanical Phlebitis
Associated with movement of the catheter
against the vein wall causing irritation to the
intimal lining of the vein
Risk factors:
- Rapid or traumatic insertion
- Large catheter in relation to the size of the vein
- Inadequately secured catheter
- Extensive movement of the cannulated extremity
- Inexperienced inserter

Chemical Phlebitis
Most commonly associated with peripheral devices
Erythema often within two (2) hours of infusing
irritating medications or solutions

Catheter Occlusions
Can be partial, one-way or total
Caused by inadequate flushing, incompatible
medications or lipid residue
Large catheters with insufficient venous flow
increase the risk of thrombus formation

Indications for PICC Placement in Infants

Premature infants weighing <1,500 g
Unable to take enteral nutrition to achieve growth
and need IV fluids for > 7 days
Require hyperosmolar or irritating solutions or
medications
Infections requiring intravenous antimicrobial therapy
Gastrointestinal disorders

Congenital cardiac disorders

Limb anomalies
Lack of adequate peripheral venous access
Require vasoactive medications
Medical providers or parents preference

References
Alexander M, Corrigan A, Gorski L, et al. Infusion nursing: an evidence based approach.
3rd ed. St. Louis, MO: Saunders Elsevier; 2010:467-469.
Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs. 2011;34(1S)S46.
Pettit J, Wyckoff MM. Peripherally inserted central catheters: a guideline for practice.
2nd ed. Glenview, IL: National Association of Neonatal Nurses; 2007.
Phillips LD. Manual of I.V. therapeutics: evidence-based infusion therapy. 5th ed.
Philadelphia, PA: F.A. Davis Company; 2010:546-623.
Weinstein SM. Plumers principles & practice of intravenous therapy. 8th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2007.

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