Clinical and demographic factors associated with pediatric difficult intravenous access in the operating room

Abstract

Background: Pediatric intravenous catheter insertion can be difficult in the operating room due to the technical challenges of small diameter vessels and the need to rapidly gain intravenous access in anesthetized children. Few studies have examined factors associated with difficult vascular access in the operating room, especially accounting for the increased possibility to use ultrasound guidance. Aims:The primary aim of the study was to identify factors associated with pediatric difficult vascular access in the operating room. Our primary hypothesis was that Black race, Hispanic ethnicity, and ultrasound use would be associated with pediatric difficult vascular access. Methods:We performed a retrospective analysis of prospectively collected data from a cohort of pediatric patients who had intravenous catheters inserted in the operating room at an academic tertiary care children's hospital from March 2020 to February 2021. We measured associations among patients who were labeled as having difficult vascular access (>2 attempts at access) with demographic, clinical, and hospital factors.Results: 12 728 intravenous catheter insertions were analyzed. Multivariable analysis showed significantly higher odds of difficult vascular access with Black non-Hispanic

“Mining large data on small veins to inform pediatric perioperative difficult intravenous access”

“…The translational value of the Ballard et al study is not only corroborative evidence of earlier studies but also informs future studies of difficult venous access in anesthetized children, such as recording techniques used for all IV attempts, having an impartial observer count the number of IV attempts (or perhaps evidence of attempts in the recovery area), and ensuring accurate event timestamps. 5,12 There are factors not mentioned here (or in similar studies) that might be worth pursuing in a prospective study, such as parent/caregiver report of prior difficulties with vascular access, reports of prior difficulties with vascular access based on failed attempts before coming to the operating room, congenital heart disease, and total number of previous IVs.…”

“…4 Early identification of risk factors for difficult venous access is the first step in optimizing this aspect of perioperative patient care, as the anesthesiologist may be able to adjust their management of IV placement accordingly. In this issue of the journal, Ballard et al 5 identified factors associated with pediatric difficult venous access by analyzing data on all pediatric patients who had an IV catheter inserted in the operating room at their tertiary care, urban pediatric hospital over a 1-year period.…”

“…[9][10][11] The significant association between insertion by the attending anesthesiologist and difficult venous access was an interesting finding in the study. 5 At first glance, this finding could be interpreted as "attending anesthesiologists blow more IVs than other clinicians." The authors explain how this might be attributable to institutional practice rather than attending ineptitude.…”

“…Earlier studies in anesthetized children have identified several factors associated with difficult venous access, including obesity, patient age and race, time of day of induction of anesthesia, and American Society of Anesthesiologists (ASA) Physical Status classification 4,7,8 . Ballard et al 5 report similar findings, such as non‐Hispanic Black race/ethnicity, younger age, higher body mass index, higher ASA status, and otolaryngology procedures being associated with higher odds of difficult venous access for children undergoing anesthesia. The commonality of these difficult venous access‐associated factors across multiple single‐center studies supports their use during preoperative planning to identify patients who are at greater risk for difficult venous access.…”

“…The Ballard et al study serves as a new data point on the progression of ultrasound use in pediatric anesthesia practice. Ballard et al reported robust ultrasound use during difficult venous access, as ultrasound was used for 21.3% of patients with difficult venous access 5 . The frequent use of ultrasound contrasts with much lower rates in two other studies of pediatric difficult venous access conducted on data from 2016 and 2019, which reported ultrasound use of less than 1% and 8.2%, respectively 7,13 .…”