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lation and lowest in those aged 2 years or less. Consideration of alternative forms of vascular access in this population may be beneficial. Key words: ambulance; emergency medical services; intraosseous; intravenous; pediatric

Objective. Achieving successful peripheral intravenous (PIV) vascular access in children can be difficult. In the prehospital setting, opportunities are rare. Obtaining access becomes vital in emergent and life-threating conditions, such as seizures, hypoglycemia, and cardiac arrest. This study examines prehospital pediatric PIV attempts, success rates, and the impact of patient age. Methods. This was a retrospective chart review of patients aged 18 years or younger receiving prehospital PIV attempts from January 1, 2003, through May 31, 2011. Included cases were identified by querying electronic patient care reports for PIV attempts within the specified age range. The documentation of PIV attempts and successes was reported by emergency medical service providers. This study was approved by an institutional review board. Results. Throughout the 101-month study period, there were 261,008 ambulance responses. PIV attempts were made in 4188 patients aged 18 years or younger. PIV placement was successful in 3699 patients (88.3%) and failed in 489 (11.7%). Age was significantly associated with success. Each 1-year increase in age was associated with an 11% increase in odds of PIV success (odds ratio, 1.11; 95% CI, 1.09–1.12; p < 0.001). Success was lowest in patients younger than 2 years old, with an overall success rate of 64.1% (141/220). Accounting for multiple attempts, success was achieved in 53.0% of attempts (141/266). Conclusions. Prehospital PIV attempts are uncommon (2% of emergent responses). Success rates are significantly associated with patient age in the pediatric popu-


INTRODUCTION Obtaining vascular access in children is essential in treating emergent and life-threatening conditions, such as seizures, hypoglycemia, and cardiac arrest. Achieving successful peripheral intravenous (PIV) access in children can be difficult in the prehospital setting.1 The American Heart Association pediatric guidelines suggest intraosseous (IO) access as an alternative approach to vascular access in children or when PIV access fails.2 IO access provides a safe and effective alternative to the PIV option.3,4 Prehospital PIV success rates in children are largely unexamined. The objective of this study was to retrospectively review prehospital PIV attempts and subsequent success rates in the pediatric population. We aimed to determine if age has an impact on success. These findings may assist in better determining proper age ranges for use of semiautomatic IO devices.

METHODS This retrospective medical record review identified patients aged 18 years or younger who had prehospital PIV attempts. All data were reported by paramedics. This study was approved by an institutional review board. The ambulance service used in this study is a multisite agency throughout Minnesota and western Wisconsin. The population of the service areas varies from communities of fewer than 20,000 to those of more than 100,000. Patients receiving PIV access from January 1, 2003, through May 31, 2011, were included for analysis. Between 200 and 266 emergency medical

Received April 18, 2013, from Gold Cross (LAM), Division of Pediatric Critical Care Medicine (GMA), Department of Emergency Medicine (LJK, CSR), and Division of Biomedical Statistics and Informatics (CML), Mayo Clinic, Rochester, Minnesota. Revision received May 7, 2013; accepted for publication May 20, 2013. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Address correspondence to: Christopher S. Russi, DO, Department of Emergency Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905. e-mail: [email protected] doi: 10.3109/10903127.2013.818180



services providers (emergency medical technicianbasics and paramedics) were employed by the agency during the study period. In 2003, the ambulance service implemented an electronic medical record (EMSpro; Zoll Data Systems). Patients were identified by an intervention field labeled “IV” in the prehospital record. Ambulance staff complete this field. The study team reviewed specific prehospital patient care records to recover any missing data. Data were exported from the medical record database by vendor-provided reporting software. Analysis of data was performed using JMP (SAS version 8.0; SAS Institute, Inc.) statistical software. Comparisons of PIV success rates by sex and age group were evaluated using the χ 2 -test. The association of age with PIV success was further evaluated using logistic regression (univariate) models and summarized with odds ratios and 95% CIs. All tests were 2-sided and p-values less than 0.05 were considered statistically significant.



TABLE 1. Prehospital Peripheral Intravenous Vascular Access Success Rates by Age in Children Age, years

Infant 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Total

Success per patient (1 or more attempts)

Success by total PIV attempts

60/95 (63.2) 81/125 (64.8) 59/78 (75.6) 72/86 (83.7) 49/63 (77.8) 42/62 (67.7) 53/68 (77.9) 51/58 (87.9) 52/60 (86.7) 55/66 (83.3) 59/67 (88.1) 85/96 (88.5) 142/158 (89.9) 188/214 (87.9) 292/315 (92.7) 411/457 (89.9) 551/600 (91.8) 623/682 (91.3) 774/838 (92.4) 3699/4188 (88.3)

60/115 (52.2) 81/151 (53.6) 59/89 (66.2) 72/92 (78.3) 49/74 (66.2) 42/66 (63.6) 53/76 (69.7) 51/72 (70.8) 52/63 (82.5) 55/74 (74.3) 59/70 (84.3) 85/105 (81.0) 142/173 (82.0) 188/236 (79.7) 292/349 (83.6) 411/501 (82.0) 551/705 (78.2) 623/775 (80.3) 774/935 (82.8) 3699/4721 (78.4%)

Values are number of PIV placements/number of attempts (percentage). PIV, peripheral intravenous.

RESULTS In the 101 months queried, there were 261,008 ambulance responses. At least 1 PIV attempt was made on 4188 patients aged 18 years or younger, 2% of all emergency responses. Some patients required more than 1 PIV attempt; thus, the total number of attempts was 4721. Mean patient age was 14.1 years (SD, 5.1 years; median, 16.1 years; range, 0–18.9 years). Documentation of sex was missing for 26 patients (0.6%); of the remaining, 2236 (53.4%) were male and 1926 (46.0%) were female. Male patients were significantly more likely to have IV success than female patients (89 vs. 87%; p = 0.046), which is shown by age in.A total of 3699 patients (88.3%) had successful PIV placement and 489 (11.7%) had PIV failure. Most patients (n = 3735; 89.2%) had only 1 PIV attempt. There were 385 (9.9%), 58 (1.4%), 9 (0.2%), and 1 (0.02%) with 2, 3, 4, and 6 PIV attempts, respectively. First and multiple attempt success rates by age are shown in Table 1. Age was significantly associated with PIV success. Mean age for patients with PIV success was 14.5 years (SD, 4.8 years; median, 16 years; range, 0–18.9 years) compared with 11.3 years (SD, 6.5 years; median, 14.0 years; range, 0–18.9 years) for patients with PIV failure. Each 1-year increase in age was associated with an 11% increase in the odds of PIV success (odds ratio, 1.11; 95% CI, 1.09–1.12; p < 0.001). Figure 1 shows success by age with 1 or more attempts.

creased with age. For instance, success was achieved in 67.1% in patients younger than 3 years and 64.1% in those younger than 2 years. These success rates are lower than those of the total sample by 21.2 and 24.2%, respectively. When including all overall attempts (multiple attempts), success rates for patients younger than 3 years and younger than 2 years were 56.3 and 53.0%, respectively. Patient sex was a statistically significant factor in PIV success, although it may not be clinically significant because the difference was small and this sample size was large. Although the age range of pediatric patients differs from source to source, from this sample it is clear that the highest rate of attempts and highest rate of success occur on the older patients within the group. Only 1611 patients (38.4%) were younger than 15 years in the study, and only 220 (5.3%) were younger than 3 years.


PIV Success Rate, %

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90 80 70 60 50 0

DISCUSSION Overall, providers achieved PIV successfully in 88.3% of all cases; however, success rates significantly de-










Age, y FIGURE 1. Successful peripheral intravenous (PIV) access by patient age.

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Myers et al.



Given that this agency employed 241 providers on average, the scarcity of attempts on patients younger than 3 years is clear. Other research has reported a drastic cutoff in PIV success at age less than 2 years. Larsen et al.5 found that nurses employed at two children’s hospitals had very good overall success rates of more than 90%. However, in patients younger than 2 years, the success rate fell to 60%, the attempts took 5 minutes longer, and successful PIV access required more attempts. An alternative to PIV access is IO access. Sophisticated, semiautomatic IO devices have been shown to be highly effective in obtaining quick vascular access. Much of recently published research evaluates these IO tools in the adult population in the prehospital and emergency department settings.6–9 A recent study from Switzerland analyzed the use of PIV and IO techniques by emergency medical services over a 20year period and found an increase in the use of IO with better success in critically ill infants and toddlers.10 We recently published a study that examined the use of a semiautomatic IO device (EZIO; Vidacare) for pediatric patients, which was implemented by our service more than 3 years ago. This ambulance services medical guideline indicates the use of an IO in any condition in which a PIV cannot be obtained within two attempts, or PIV attempts appear futile in the opinion of the provider. The median patient age was 0.98 years, the first-attempt success rate was 83.9% (52/62), and the overall success rate (1 or more attempts) was 93.3% (56/60).11 In this study, the PIV success in patients younger than 1 year was 63.2%, a more than 30-percentage-point lower success rate than that found in our previous study. PIV access is more commonly attempted than IO access, even in the critically ill. De Maio et al. evaluated children (≤18 years) suffering from out-of-hospital traumatic cardiac arrest, finding that PIV attempts were made in 75% of patients while IO attempts were made in 13.6%.12 A drawback to using IO devices is the potential for adverse complications following placement. There have been reports of osteomyelitis13–15 ; however, a large-scale study reported the incidence of this at 0.6%.16 Tissue necrosis17 and compartment syndrome18–21 have been reported in case studies and in an animal study. These complications must be considered; however, to our knowledge the majority of research studies with larger sample sizes have found IO complications to be rare and, when encountered, not serious.6,8,9,22–25 Although PIV access is the preferred method of vascular access in even the youngest patients, given the low frequency with which it is attempted, the apparent difficulty in access, and presumed time lost in the process of multiple attempts, use of an IO device may be a more efficient first-line method when immediate treatment is needed (e.g., cardiac arrest, status epilepticus). Replacing PIV attempts with semiautomatic IO

attempts in the youngest patients may reduce attempt numbers, thereby reducing the time to insertion and subsequent time to medication delivery. Given that serious complications do exist, providers must take care not to use IO devices for convenience or prophylaxis but rather for life-threatening and emergent situations. Research involving the direct comparison between PIV and IO would provide better understanding of the application of the two techniques as well as multivariate analysis including patient condition (illness/injury severity).

LIMITATIONS Identification of patients as well as success rates and number of attempts was reported by ambulance staff in the prehospital record; thus, verification of data was not possible. This study focuses solely on success of PIV attempts and lacks data on difficulties encountered by ambulance crews when attempting PIV access. Individual providers’ experience and training considerations were not accounted for in this study. Patient condition and the need for an IV were not evaluated, nor was the time to placement. It’s unknown whether patients not necessarily requiring an IV had fewer attempts made on them, thus reducing the chances of success on multiple attempts.

CONCLUSIONS Prehospital peripheral IV success rates are significantly associated with patient age in the pediatric population. Each 1-year increase in age was consistent with an 11% increase in the odds of successful placement. Success rates were lowest in the age range of 0–2 years.

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Prehospital peripheral intravenous vascular access success rates in children.

Achieving successful peripheral intravenous (PIV) vascular access in children can be difficult. In the prehospital setting, opportunities are rare. Ob...
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