PURPOSE OF THE CATHETER

Before sedation is administered to any pediatric patient, the need for sedation should be assessed. As with adults, pediatric vascular access is accomplished in various ways, and the choice of catheter varies. Many factors for choice of catheter also should be assessed when determining if sedation or distraction is appropriate for the child. The following areas must be considered: (a) purpose of the catheter, (b) length of therapy, (c) age and size of patient, (d) child's level of activity, (e) home situation, and (f) insurance coverage. Knowing the purpose of the catheter helps determine the type required for the therapy. Is the catheter for antibiotic therapy? Will the patient require more than one antibiotic and how often? If more than 2 antibiotics are ordered for the therapy, a double lumen may be required.

Will the catheter be used for chemotherapy? Again, consideration should be given for the number of agents used and how often they will be given. For instance, if the child is a candidate for bone marrow transplant, he or she will need at least 2 lumens to receive all the different medications required before and after transplant. Is the catheter providing total parenteral nutrition (TPN)? Will lipids be administered as well? A double lumen may be required. What types of fluids are going to be administered and/or will there be multiple transfusions? Having a second lumen is always beneficial if the child will need multiple lab draws along with treatment.

LENGTH OF THERAPY

There are no set rules about how long any catheter can stay in as long as the catheter is free of infection and there are no adverse reactions, such as mechanical phlebitis or tape allergy. Generally, in the younger pediatric population, a peripherally inserted central catheter (PICC) is a good option,1 so this type of vascular access device (VAD) can be considered if the therapy is longer than 7 days.2-4 The Infusion Nurses Society (INS) recommends a PICC when "therapy is anticipated to be a few weeks' to several months' duration. The administration of long-term antibiotic therapy, total parenteral nutrition, pain control, and vesicant or irritant medications are some of the clinical situations warranting PICC insertion."^5(p383) In these cases, PICCs can be used for short- or long-term therapies, whereas an internal implantable device or tunneled catheter would be preferred for long-term therapies.

AGE AND SIZE OF THE PATIENT

The age and size of the patient are also determinants in catheter selection. The use of ports is a good example. Because an implantable port requires a pocket of subcutaneous tissue for placement, some very small children with little to no subcutaneous tissue are not likely candidates for an implanted port. At the other end of the spectrum, a very large teenager with too much subcutaneous tissue probably needs an external catheter because the port may be difficult to palpate and access with a noncoring needle that is long enough.

There are also age and size considerations when the catheter of choice is a PICC. Because PICCs come in sizes from 2-French single lumens to 7-French triple lumens, practitioners have more options than ever before. Depending on the size of the patient and the vein, however, catheter size selection may be limited. It was determined previously that children who require TPN would require a double lumen. Many infants who weigh less than 5 pounds have limited vascular access that would support a 4-French or even a 3-French double-lumen catheter. These children are limited to a 2-French single-lumen catheter, and practitioners are challenged with delivering multiple medications through a single lumen. Again, this situation requires assessment with the primary physician to determine if the single vascular access catheter is appropriate or if a different one is required. Instead, does the patient require a triple or double lumen inserted by an advanced practitioner into the internal jugular, subclavian, or femoral vein?2,4,5

ACTIVITIES

One should assess the activity level of the child. Children need to be active even during treatment for illnesses. Try to keep children in as many of their current activities as is safe for them.6-8 For example, a 10-year-old girl was to receive short-term chemotherapy for approximately 6 weeks. During the initial assessment for the PICC that had been ordered, she became very sad and withdrawn. When questioned further, it was discovered that her family had just put in a new heated pool. She was an avid swimmer and was upset by knowing that she would be restricted from using it for a while because of the PICC. Although she did receive a PICC, there was consideration of an internal port to keep this child active. Remind parents and children to protect VADs if the child participates in contact sports in which an external catheter could be pulled out or a port could incur trauma. Take care if a child is a crawler or beginning walker who could get an external catheter tangled or caught on something if not secured well. Extra padding, securement devices, and taping are very important.

Peripheral IVs are placed in the adult population as another vascular access option. Infiltration and phlebitis are possible complications of peripheral IV therapy. In the pediatric population, this is another option. The saphenous vein in the foot leads to the inferior vena cava, which makes the vein a popular choice for many pediatric infusion therapists. Only when the child is walking does this choice become a risk for thrombus formation, as in adults. Depending on a facility's policies and practice, clinicians make that determination with the ordering physician.3,8

HOMECARE

As with adults, consider how the VAD will be cared for. An external device, such as a tunneled catheter or PICC, needs more care than an implanted one. External VADs require weekly dressing changes. External devices also offer choices of valved or nonvalved catheters, which offer the options of daily or weekly flushing to maintain catheter patency. Assessing whether a parent will be compliant with the care necessary for an external catheter is important. Is the family able to follow directions? Does the family speak English? Is there a support system or is this a single-parent family? Is the child cared for by grandparents or in foster care? Does the child attend daycare?

The final consideration is insurance. Does the parent or significant other have insurance that will cover the cost of catheter maintenance? If there is no insurance coverage for homecare or if there is no homecare for catheter maintenance, options such as ports that require minimal maintenance or flushing monthly should be considered. These are just a few of the questions to ask when placing a VAD in a pediatric patient.

DISTRACTION OR SEDATION ASSESSMENT

After the catheter has been selected, ask where the catheter will be placed and if the child can lie still to allow the inserter to maintain a sterile field. Because of the invasive nature of tunneled catheters and ports, these devices are placed in surgery or medical imaging with sedation or general anesthesia under the direction of a physician. Because PICCs can be inserted at the bedside, it should be determined if insertion is appropriate at the bedside or in a procedure room. Pediatric painful procedures guidelines recommend that painful procedures for children not be performed in their room.6-8,10,11 Their room should be a safe haven; this is important for all pediatric patients. If local anesthesia is given, such as EMLA cream (Astra Zeneca, Wilmington, DE) or lidocaine, the PICC insertion procedure itself is not painful, but pain is perceived differently by individuals. Each child is unique and requires individual consideration.11

AGE DIFFERENCES

Vascular access for most infants under the age of 3 months can be accomplished with the "hold and swaddle" technique.6 There is no contraindication for anesthesia with this age group, but many infants can be held and sterile fields maintained with 1 to 2 attempts at catheter placement. At the authors' facility, if a VAD cannot be placed with 2 attempts by 2 practitioners for a maximum of 4 attempts, then these children are referred for sedation. When attempting to insert a child's VAD without sedation, a calm voice, quietly singing or talking, and a pacifier are helpful. The authors recommend that 3 staff members perform the procedure: PICC clinician, limb holder, and pacifier handler. If the parent stays for the procedure, the parent handles the pacifier and comforts the child. A new technology, electronic distraction, can be used with infants.6 Headphones are placed over an infant's ears, and comforting songs or sounds are played during the procedure.

Studies have shown that newborns and infants are stressed by painful procedures, so pain control must be addressed.10,11 Topical anesthetics that are appropriate for a child's age should be used. EMLA is appropriate for all age groups and for neonates younger than 1 month.6 It should be applied to potential sites at least 1 hour before the procedure. LMX-4 cream (Ferndale Laboratories, Inc., Ferndale, MI) can be applied to infants older than 1 month at least 20 minutes before the procedure.6 The pacifier becomes an even better comfort item when it is dipped in Sweet Ease (24% sucrose solution) (Children's Medical Ventures, Norwell, MA). This medication gives infants the feeling that adults get after eating chocolate-calming endorphins are released. This medication should be delivered 3 to 4 minutes before starting the procedure. Before applying the tourniquet, dip the pacifier into the Sweet Ease and let the infant suck on it; continue with the Sweet Ease throughout the procedure. For infants who do not use a pacifier, place a few drops under the tongue and repeat every 2 to 3 minutes during the procedure.6

THREE MONTHS TO 10 YEARS

Placing PICCs in infants aged 3 to 6 months may be accomplished without sedation, but as infants grow larger and stronger, restraining them can become a challenge. Sedation should be considered for this group. Some children require a level of deeper sedation because minimal to moderate sedation may result in an unsuccessful catheter placement. PICC insertion in children closer to age 10 can be accomplished with minimal sedation or anxiolysis and distraction. As with any patient, assessment for procedure toleration is key to success. Some 8-year-old children might lie still for a procedure, but some 14-year-old children may have had previous traumatic IV insertions and subsequently experience severe vasospasm. The procedure should be scheduled with sedation or anesthesia. Most children between the ages of 3 months and 7 years are referred for scheduled anesthesia. In the authors' facility, the procedure is scheduled in a fluoroscopy room to alleviate repeated x-rays and increased anesthesia time. The catheters are placed by PICC clinicians rather than by interventional radiology personnel. A radiology technologist is in charge of the fluoroscopy machine, the PICC nurse places the PICC, and the anesthesiologist maintains the patient's airway and comfort.

DEVELOPMENTAL STAGE AND ASSESSMENT

Children's developmental stages vary, so the team relies on reassessment for PICC placement. The assessment is performed with the assistance of the primary care nurse, a child life specialist, the PICC clinician, and the parent, family member, or significant other. A child's developmental state and history of previous hospitalizations and/or difficult outpatient procedures should be the primary focus of the initial assessment.6-8,11 Positive experiences can be useful for helping a child be still. For another child of the same age, negative experiences can be just as influential. Children also have different temperaments that come into play.

LITERATURE REVIEW

In reviewing evidence-based practice with sedation practices and pain relief for children, it was found that most of the current literature discusses cancer and cancer pain for children. In the early literature, a common finding was that younger children express pain more intensely than older children. In 1995, Woodgate and Kristjanson12 researched children's behavioral responses to acute pain. Behavioral responses of young children in acute pain were described in a qualitative study. The study found phrases that children used to describe their pain, in addition to specific behaviors. Children responded very differently to pain in the study. Some were verbal and conveyed their pain to the clinician, whereas other children undergoing similar procedures were very quiet or "hiding" their pain. Assessing behavior for pain levels may not always represent the pain level for the pediatric patient.

In 2005, sedation was evaluated for children undergoing diagnostic studies. The facility reviewed patients' need for sedation with computerized tomography (CT) when it acquired a faster CT machine. All of the studies were "painless." Motion artifacts and the long duration of many procedures were indications for sedation. No decrease in the amount of sedation required for CT was found. In the quest to decrease sedation for a pediatric patient, the assessment of a child for procedure toleration and the ability to follow directions are essential.12 Emergency departments have been evaluating pain management in children. In 2005, a team evaluated factors that affect pain management in children in emergency departments. Pain assessment and strategies were evaluated for children with extremity fractures. The results demonstrated that the older the child, the more pain medication the patient received. Assessment for pain and pain management were not performed for all age levels.13

ASSESS THE CHILD

Does the child have an understanding of what his or her "job" is during the procedure? Explain that everyone in the room has a job to do; for example, the PICC nurse inserts the PICC, and the child life specialist, parent, or another nurse helps the child focus on something else. Tell the child that his or her job is to be still and listen to instructions. How well does the child follow directions? Can the child carry on a discussion and repeat what you have said about catheter insertion? Can the child be distracted? Some children ask to watch the procedure-a sign that sedation is not needed.

If the child is tearful or appears anxious about the procedure, sedation might be necessary. Further assessment is needed. Although the child remains still, his or her anxiety level could cause vasospasm, making insertion difficult. If a child has had previous difficult or traumatic IV starts, blood draws, or PICC placements, even a school-aged child is too apprehensive to have a catheter placed without sedation.

One assessment technique involves the use of ultrasound. Place the tourniquet on the patient's arm and assess for vein size and patient tolerance for the procedure. Does the vein appear to be getting smaller while visualized? Does the vein appear to be stabilized in size? Visualizing the vein before the procedure and applying EMLA or LMX-4 cream before the procedure assist the clinician in determining the patient's tolerance for the procedure. If the child can lie still and cooperate, attempt the procedure 1 or 2 times after applying lidocaine for local anesthesia. If there are 2 unsuccessful attempts, sedation should be considered.

PARENT/SIGNIFICANT OTHER PARTICIPATION

Parents and significant others can have an impact on the child's comfort level, a detail that is frequently overlooked.6,11 They can be helpful in distracting the child. If the parent is apprehensive or worried, however, the child may sense it and worry, too. Parental apprehension can elevate a child's anxiety level, even if the child's developmental age would allow a clinician to complete the procedure without sedation. Parents may be concerned because of their own previous experiences or their inability to comprehend the PICC placement. Education of the parent or significant other and the patient is essential and may affect whether the patient is sedated.7 For this reason, parents or significant others may need to leave the room during the procedure if they are adding to the child's anxiety.

DISTRACTION

Some facilities have child life specialists and other therapists who are a tremendous help with distraction. Child life specialists are helpful in educating the patient and family ahead of time. Once a relationship is established, the specialist might assist the child during the procedure. If child life specialists are not available, the primary nurse and/or parent/significant other can assume the role of distracter. Distraction should start as the veins are being assessed. Explaining every action to the child is important; there should be no surprises. Search toys and other "find it" games, such as "I Spy," work very well. The child's favorite video or music playing in the background is a good addition, if possible. Games also can be made a part of the procedure with the distraction. One technique is to challenge an older child to a race. Challenge a child to find objects on a set number of pages of an "I Spy" book while the PICC is being placed. The child can become intent on finding the objects before the PICC team has inserted the catheter. Wagers can be toys, games, or activities.

IMAGERY

Imagery is another distraction technique. Imagery works extremely well for school-aged and teenage patients and can even work for preschool-aged children.6 During the assessment phase, start asking questions about the child's interests: Where do you like to go? What do you like to do? Whom do you like to go with and be with? As the procedure progresses, extend the imagery to the sounds, smells, and feel of the air to keep the child thinking and distracted. It is important to talk the child through any uncomfortable feelings about the procedure without using negative phrases, such as "this might hurt" or "here comes the poke." Use terms such as "pressure" or "touching." For a child, imagery might take him or her through the sights, smells, and sounds of the candy store. Encourage the child to envision all the different kinds of candy. For example, ask how many colors can you see? Can you spot your favorite kind of candy? Is it soft or chewy? Have the child imagine the sound of the candy as it is scooped up.

THE REWARD

Bribes and promises of prizes work well with children to get them through the procedure. Many facilities have "coping boxes" or "reward closets" full of toys and books for children. To get started, fill a tool box with stress balls, search-and-find books, viewmasters, magic wands, and light toys. Be creative.

SUMMARY

Working with children can be fun but challenging. Placing the right VAD in a child for therapy is only the first step. Children and their families must be assessed for and instructed on the procedure and assessed for sedation or distraction. Not all children require sedation, but not all children can be distracted, either. Assess your pediatric patient for appropriateness for sedation or distraction. Use all your resources, including the parents and significant others. Assess the vein for vasospasm with the application of a tourniquet. Assess the child's ability to follow directions, hold still, and assist with maintaining a sterile field during the procedure. This assessment for sedation is just as important as the right catheter assessment for a successful procedure.

REFERENCES