Considerations for Vascular Access in Paediatric Patients

In paediatric care, securing and maintaining vascular access remains one of the most challenging and emotive clinical tasks performed across acute, community, and specialist settings.

While difficult vascular access is widely recognised in paediatric practice, its prevalence is not routinely captured in formal quality metrics.

A single-centre paediatric emergency department study in Australia reported that 36% of children required two or more cannulation attempts, with two thirds of the cohort restrained via wrapping or holding, and 8% requiring four or more adults present to achieve restraint (1).

Importantly, difficult access was strongly associated with identifiable factors, such as younger patient age, vein visibility, and experience of the clinician.

The System-Wide Impact of Effectively Managing Vascular Access in Paediatrics

Difficult vascular access in children (DVAC) is often perceived as a localised clinical problem. However, evidence suggests that when DVAC is not managed proactively, the effects propagate across teams, departments, and services.

In many cases, DVAC can be predicted and better managed to avoid issues including:

• Damaging patient and carer experience
• Eroding trust in clinicians and organisations
• Consuming disproportionate staff time
• Disrupting system flow and capacity
• Increasing long‑term access complexity
• Driving high‑cost escalation
• Affecting workforce wellbeing
• Delaying the patient’s progression through care pathways

Key Considerations to Inform DVAC Practice

A recommended approach to DVAC requires consideration of a range of factors, which directly impact outcomes. These are:

1. Environment and preparedness
2. A child and family-friendly experience
3. Recognising difficult vascular access early
4. Limiting the number of IV attempts
5. Escalation as protective for patients
6. Technical best practice
7. Use of ultrasound
8. Alternative access options

1.     Environment and preparedness shape success

Best practice vascular access begins long before skin puncture. Successful teams pay close attention to the environment, equipment, and emotional state of the patient.

Preparation should comprise:

• Ensuring adequate lighting and positioning
• Selecting the smallest effective cannula for vein preservation
• Having all equipment ready before beginning cannulation
• Allowing time for topical analgesia where appropriate
• Checking the child is positioned comfortably
• Using distraction, play specialists, or parental support

While these elements may seem basic, their absence is a common contributor to failure. In hurried or understaffed environments, there may be a temptation to “just get it done”. This often leads to avoidable harm. Many failed attempts can be attributed to poor preparation rather than inadequate skill (2).

2.     A child and family-friendly experience

Vascular access is often the first, and most memorable interaction a child has with healthcare professionals during an admission. Painful repeated attempts or prolonged procedures can undermine trust not only in the moment, but for future care.

Effective management of pain and anxiety is therefore fundamental to quality care. This includes:

• Appropriate use of analgesia, such as sucrose
• Honest, age-appropriate explanations and patient-centric communication
• Involving parents and carers as partners in the process/procedure
• Recognising when distress outweighs procedural benefit

A calm, supported child is more likely to stay still, and this improves first attempt success.

Parents and carers consistently report that poorly managed and/or difficult venous access:

• Is one of the most traumatic aspects of hospital admission
• Leads to treatment avoidance and anxiety in the future

Conversely, children who feel listened to and respected are more likely to cooperate, and families who trust the team are more likely to support necessary escalation. This means that clinicians should balance immediate need with long-term wellbeing and look beyond the cannulation tray to consider the child’s physical, emotional, and future healthcare needs.

3.     Recognising difficult vascular access early

Difficulty is often apparent before a tourniquet is applied and a modified approach may be required based on the following factors:

• Younger age
• Dehydration
• Shock
• Obesity
• Chronic illness/frequent admissions
• Previous chemotherapy
• Non‑visible or non‑palpable veins
• A history of previous difficult cannulation

Failing to anticipate difficulty often leads to repeated blind attempts, increasing distress and reducing future options. Meanwhile, acknowledging difficulty early allows clinicians to choose the most appropriate technique or device from the outset, before distress and vein damage occur.

4.     Limiting the number of intravenous attempts

In paediatric vascular access, first-attempt success is disproportionately important. Evidence and experience show that the first-attempt is the least painful, the least traumatic, and the most likely to succeed. With each subsequent attempt, veins become more fragile, children more distressed, and procedural success less likely (3).

Clinicians should carefully consider vein selection to choose the best vein available to tolerate cannulation, rather than the most familiar, and look proximally if distal veins are poor.

It is also advisable to use adjuncts early, such as:

• Tourniquet optimisation
• Warming techniques
• Transillumination
• Ultrasound (where available and trained)

These should be used proactively to maximise first attempt success, rather than being introduced following a failed attempt.

Setting explicit limits on the number of attempts – both per clinician and per episode – helps protect the child and supports consistent team decision-making. Stopping should never be considered a failure; it is an active, patient‑centred clinical choice.

5.     Escalation as a protective step

When DVAC is not anticipated, escalation often occurs late, under pressure and in response to deterioration. This frequently leads to:

• Emergency Intraosseous (IO) access placement, rather than early planned access
• Central line insertion in suboptimal conditions
• Use of theatre or interventional radiology as a rescue measure

Although many organisations have escalation pathways for difficult vascular access, delays still occur and the obstacles are often cultural rather than procedural.

A 2023 study (4) found that families frequently describe repeated escalation through increasingly senior staff, often after several traumatic, failed access attempts. It concluded that a culture change is needed, for clinicians and healthcare services to recognise the subsequent psychological distress of children and young people due to repeated cannulation.

Common cultural obstacles include:

• Reluctance by the clinician to ‘give up’ for fear of failure/loss of image
• Fear of using perceived ‘advanced’ techniques
• Concerns about deskilling
• Limited access to trained staff or equipment

Addressing these barriers demands leadership, education, and shared language. Escalation should be framed as proactive and protective, rather than an admission of failure.

6.     Technical best practice

When it comes to paediatric cannulation, controlled, deliberate movements are more effective than speed because children’s veins are superficial, mobile, and easily compressed or blown. A common technical cause of failure is advancing the needle but not the cannula into the vein.

Clinicians could:

• Stabilise the limb and the vein effectively, by holding above and below joints if necessary
• Minimise hand repositioning once skin is breached
• Avoid advancing the cannula too quickly after flashback
• Use gentle traction rather than excessive pressure
• Maintain a shallow angle of insertion
• Manage vein movement and the risk of collapse

While technical competence is key, good decision-making is critical to first-pass success.

7.     Use of ultrasound

Ultrasound has transformed paediatric vascular access and should be considered early in children with predicted difficult access, rather than as a ‘fallback’ option.

Ultrasound-guided access allows appropriately trained clinicians to:

• Identify veins that are not visible or palpable
• Assess vein size, depth, and trajectory
• Avoid unsuitable or fragile vessels
• Improve first‑attempt success

However, ultrasound is not a guarantee of success; it is part of a broader access strategy, positioned:

• Above blind peripheral cannulation
• Below emergency Intraosseous (IO) access
• Alongside midlines for planned care

8.     Alternative access options

Preserving venous capital requires clinicians to think beyond the immediate need and consider the child’s likely healthcare journey. A child with cancer, renal disease, or complex needs may require reliable access for years to come.

Despite optimal preparation and technique, peripheral IV access is not always the most appropriate choice. Persisting with peripheral attempts when the likelihood of success is low exposes children to unnecessary harm and delay.

Alternative access options should be considered based on urgency, duration of therapy, and the child’s broader needs. These options include:

• Intraosseous (IO) access – provides rapid, reliable vascular access via the bone marrow and could be viewed as a legitimate first‑line option in emergencies, not a last resort. It enables prompt delivery of fluids and medications when IV access is delayed or impractical.
• Midlines – for children requiring IV therapy beyond a few days, offering stable access as a vein‑preserving alternative to repeated short cannulae and without the risks associated with central lines
• Existing central access devices – children with Port-a-Cath or other central devices already have reliable vascular access for a reason, so this should usually be considered first-line access. Avoiding these devices due to unfamiliarity can result in unnecessary peripheral attempts, IO placement, or distress.
• Planned central access – for children with predictable long‑term IV needs, planned central access may reduce cumulative harm compared to repeated peripheral trauma. Central access is rarely the best initial option and must be justified by clinical need.

DVAC – The Takeaways

Effective vascular access in paediatric patients relies upon a series of interconnected choices shaped by experience, technique, judgment and compassion.

Children should not experience variable harm based upon where they are being treated, the time of day, or which clinician happens to be present. Thoughtful system design, supported by education and training, helps deliver the best outcome for all.

It is also important to recognise that failed cannulation attempts are not only distressing for patients; they can be emotionally challenging for clinicians too. But, by treating DVAC as a strategic, patient‑centred process, clinicians can reduce harm, build trust, and improve outcomes across the healthcare journey.

References

1. Dunstan L, Sweeny AL, Lam C, Goucher B, Watkins S, George S, Snelling PJ. Factors associated with difficult intravenous access in the paediatric emergency department: a prospective cohort study. Emerg Med Australas. 2024.
   
2. Schults JA, Kleidon TM, Gibson V, Ware RS, Monteagle E, Paterson R, et al. Improving peripheral venous cannula insertion in children: a mixed methods study to develop the DIVA Key. BMC Health Serv Res. 2022;22:220.
   
3. Morrell  E.  Reducing risks and improving vascular access outcomes.  J Infus Nurs. 2020;43(4):222-228. doi:10.1097/NAN.0000000000000377
   
4. Sharp R, Muncaster M, Baring CL, Manos J, Kleidon T, Ullman AJ. The parent, child and young person experience of difficult venous access and recommendations for clinical practice: A qualitative descriptive study. J Clin Nurs. 2023;32(17–18):6690–6705

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