Pediatric Anesthesia - Technical Challenges When Performing Ultrasound-Guided Peripheral Intravenous Placement in Children

Sep 30, 2026

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Ultrasound (US) guidance is an essential skill for peripheral intravenous (PIV) placement in children, used either as a first-line approach or as a rescue technique after failed attempts, especially in children with difficult intravenous access (DiVA). Evidence supports improved first-attempt and overall success with US guidance, yet trainees may face technical barriers. This review summarizes common US-guided PIV technical challenges and practical strategies to enhance cannulation success, including considerations for special populations such as premature neonates, pediatric burns, epidermolysis bullosa, and children receiving bleomycin sclerotherapy.

LanguageEnglish

CategoryHealthcare

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Pages10

Reading Time25 min

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Pediatric Anesthesia Technical Challenges When Performing Ultrasound-Guided Peripheral Intravenous Placement in Children Maria Moustaqim-Barrette1,2 | Lauren Riehm1 | Dimitri Parra3 | Farrukh Munshey1,2 1Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Canada | 2Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada | 3Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada Correspondence: Farrukh Munshey ([farrukh.munshey@sickkids.ca](farrukh.munshey@sickkids.ca)) Received: 27 August 2025 | Revised: 8 October 2025 | Accepted: 27 October 2025 Funding: The authors received no specific funding for this work. ABSTRACT Ultrasound (US) guidance has become an essential skill for peripheral intravenous (PIV) placement in children. It may be used as a primary approach or as a rescue technique after failed attempts, particularly in children with difficult intravenous access (DiVA). An increasing amount of literature shows the benefit of using US guidance for PIV placement in children with DiVA. With more consistent availability of US machines across many institutions, their use for PIV placement is becoming commonplace, with several types of clinicians performing the procedure. Novice proceduralists and those in training may encounter technical challenges that may impede successful PIV cannulation. Having strategies to avoid, troubleshoot, and overcome technical challenges is essential for improving the technique of US guidance for PIV access. The purpose of this review was to summarize the literature around the most common technical challenges that arise when performing US-guided PIV placement in children and practical strategies that may improve cannulation success. We also highlight US-guided PIV placement considerations specific to special populations, including premature neonates, pediatric burns, epidermolysis bullosa, and those receiving bleomycin sclerotherapy. 1 | Introduction Timely, successful peripheral intravenous (PIV) access with minimal attempts is a foundational skill in pediatric care. Formost patients, PIV access is achieved with standard palpation and landmark techniques. These methods may fail in children with difficult intravenous access (DiVA), leading to repeated attempts, delays, compromised safety, parental and patient distress [1, 2] . While no universal definition exists, we define DiVA as two or more failed PIV attempts using traditional techniques with an experienced clinician, absence of visible or palpable veins on exam, and/or a documented history of difficult access [3] . The reported incidence of DiVA in children can range from 8% to 50%[3] . Ultrasound (US) guidance improves both first attempt and overall success rates [2, 4–7], and recent evidence suggests it may benefit all pediatric patients, even those without a DiVA history, when compared to landmark techniques [1, 2, 8] . The inherent challenge of cannulating small, fragile, and mobile veins can be further complicated in children with certain comorbidities [9]. Those with chronic kidney disease (CKD) require vessel preservation for future dialysis limiting potential options for vascular access [10] . Others have scarred, edematous, or grafted skin due to burns and/or surgery. Children with epidermolysis bullosa (EB) are at risk of blistering from minimal trauma, necessitating meticulous technique with placement and securement. Children on chemotherapy often have fragile veins, which may be sclerosed or thrombosed [11] . Repeated cannulations and prior central lines in such patients may further deplete viable access sites. Even with intact veins, anatomic challenges This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-comm

FAQs

What is difficult intravenous access (DiVA) in children, according to the review?

DiVA is defined as two or more failed PIV attempts using traditional techniques with an experienced clinician, absence of visible or palpable veins on exam and/or a documented history of difficult access.

How does ultrasound guidance help with pediatric PIV placement?

US guidance improves first-attempt and overall success rates. It can be used as a primary approach and may benefit even children without a DiVA history compared with landmark techniques.

What technical steps are emphasized for ultrasound-guided PIV placement?

The review divides the steps into ergonomics, prescanning, needle entry through the skin, and needle entry into the vein, aiming to improve safety, consistency, and confidence.

Sep 30, 2026

Uploaded by acoobca