Intravenous cannula placement in children for induction of general anesthesia: Prospective audit and identification of success factors

Abstract

Background Approaches to pediatric induction of anesthesia vary widely. While oral sedative premedication and inhalational induction are common, total intravenous anesthesia is becoming increasingly popular. Total intravenous anesthesia without anxiolytic premedication, which is the most commonly used technique in our hospital, requires intravenous (IV) cannula placement in an awake child. Aims To quantify the success rate of IV cannula placement in 1 or 2 attempts and to identify success factors and barriers. Methods With ethical approval and written informed consent from participating anesthesiologists, a prospective audit of IV cannulation was undertaken over a 1‐month period. The attending anesthesiologist captured basic demographics, IV insertion characteristics, setting, distraction techniques, the behavior of the child, number of attempts, and success/failure. A logistic regression model for successful IV cannulation was created. Anesthesiologists and procedural suite nurses participated in semi‐structured interviews to identify success factors, barriers, and teaching approaches. Results Data from 984 cases were analyzed. IV induction was planned in 562 cases, and IV cannulation was successful in 90% of these patients. Anxiolytic premedication was given in 6% of cases. Observations indicated that 64% of children were pain‐ and reaction‐free, and 90% experienced minimal or no reaction. Predictors for success included older child's age and child behavior at first encounter. Qualitative interview data from 13 participants suggested success factors included effective distraction, preparing the family for IV induction, parental presence, support of the operating room team, effective use of local analgesic cream, adapting the approach to the individual child, and the anesthesiologist's efficiency. Barriers included needle phobia, uncooperative child, anxious parents, ineffective use of analgesic cream, and unfavorable anatomy. Distraction techniques varied by age and developmental stage of the child. Conclusions Cannulation for planned IV induction is feasible for most children, enabling increased use of total intravenous anesthesia as an institutional anesthetic strategy.

Association of dexmedetomidine with recovery room and hospital discharge times: A retrospective cohort analysis

“…We also do not have the specific reason for the use of dexmedetomidine in each case, or whether propofol or remifentanil infusions rates were adjusted following its administration. Although our aim was to limit our cohort to children undergoing TIVA, we also have no information on any low doses of volatile anesthetics that may have been used initially in the cases of difficult intravenous cannulation; a recent audit in our institution found that cannulation for induction of anesthesia was successful in 90% of our patients 22 …”

“…Although our aim was to limit our cohort to children undergoing TIVA, we also have no information on any low doses of volatile anesthetics that may have been used initially in the cases of difficult intravenous cannulation; a recent audit in our institution found that cannulation for induction of anesthesia was successful in 90% of our patients. 22 We must recognize the potential impact of practice variability on our data (Figure 4), though the relationship between dexmedetomidine dose and PACU duration was not diminished by including individual anesthesiologist in our regression model. We must also acknowledge a potential expectation bias among nursing staff depending on whether a patient has or has not received dexmedetomidine during their procedure: Anticipating a longer recovery, they may delay efforts to rouse the patient.…”

Carbon footprint of inhalational and total intravenous anaesthesia for paediatric anaesthesia: a modelling study

“…When TIVA is the planned technique, but inhalational induction is performed due to unsuccessful intravenous access, using the already-prepared intravenous drugs for maintenance would be the lower-carbon option, as these drugs would otherwise be wasted. Though it can be difficult to predict which patients may require inhalational induction, with appropriate strategies success rates of 90% can be achieved for venous access in the paediatric setting, 31 making TIVA a realistic option for induction in most cases.…”