Pediatric IV Access Nursing Guide 2026: PIV, IO, and Vascular Access by Age

PIV Site Selection by Age

Catheter Gauge Selection

Technique Tips for Pediatric PIV

Before You Start

• Apply topical anesthetic (EMLA or LMX cream) 45–60 minutes before if non-emergent — makes the procedure less traumatic
• Use a warm compress for 5–10 minutes to dilate veins (especially in cold, vasoconstricted kids)
• Position child in parent's lap when possible — less anxiety than lying on table alone
• Child life specialist involvement for toddlers and preschoolers significantly reduces distress
• Use distraction techniques: tablet videos, blowing, counting; developmentally appropriate
• Use tourniquet sparingly in neonates and small infants (veins are very superficial; gentle pressure only)

During the Procedure

• Stabilize the extremity — wiggling causes catheter failure; have a second person hold
• Enter at 10–15° angle (shallower than adults — veins are more superficial)
• Advance slowly; flashback may be minimal in small veins
• Never force: resistance = not in the vein or against a valve
• Secure well — children pull at lines; use soft restraints (Posey) on infants if needed for safety
• Splint joints (especially antecubital and foot sites) to prevent kinking

After Placement

• Check for infiltration frequently — pediatric skin is delicate; infiltration causes significant tissue damage
• Assess site q1–2 hours in neonates and infants; q2–4 hours in older children
• Label site with date, time, gauge, and your initials
• Limit vesicant and irritant medications to central access when possible

Intraosseous (IO) Access

IO Overview

• Provides access to the non-collapsible venous sinusoids of the bone marrow
• ALL medications, fluids, and blood products given IV can be given IO
• Onset of drug action is comparable to IV administration
• Temporary (usually ≤24 hours); convert to PIV or central line ASAP

IO Sites (Most to Least Preferred)

• Proximal tibia (2 cm below tibial tuberosity, medial flat surface) — most common site in all ages
• Distal tibia (2 cm above medial malleolus)
• Distal femur (3 cm above the lateral femoral condyle)
• Humeral head (adults and larger children; used with EZ-IO device)
• Sternum (specialized adult device; avoid in children <12)

Insertion Devices

• EZ-IO (powered drill): Most common in emergency settings; 15mm (pink) pediatric, 25mm (blue) standard, 45mm (yellow) obese/humeral
• Cook IO needle (manual): Standard screw-type; no power required
• Bone Injection Gun (BIG): Spring-loaded; single use

Confirming IO Placement

• Needle stands upright without support
• Can aspirate bone marrow (red-tinged fluid)
• Flush flushes without resistance and without subcutaneous swelling
• Pain with IO flush in conscious patients — IO lidocaine 0.5 mg/kg (max 40 mg) slow push before each flush

Pediatric Fluid Rates

Holliday-Segar Formula (Maintenance Fluid Rate)

Fluid Resuscitation (PALS)

• Isotonic crystalloid (NS or LR): 20 mL/kg IV/IO bolus over 5–20 minutes
• Reassess after each bolus: HR, CRT, BP, mental status, urine output
• Repeat bolus as needed up to 60 mL/kg in first hour for septic shock
• After 3 boluses with no improvement: consider vasopressors, blood products, or alternative diagnosis
• Signs of adequate resuscitation: HR normalizing, CRT <2 sec, improved LOC, urine output ≥1 mL/kg/hr

Special Vascular Access

Scalp Veins (Neonates/Infants)

• Temporal, supraorbital, and frontal veins — clearly visible in neonates
• Must clip hair and confirm direction of blood flow (veins in scalp run toward heart — insert catheter toward face, not toward crown)
• Use only for medications/fluids — NOT for blood draws
• Emotionally difficult for parents; explain procedure clearly; reassure hair grows back

Umbilical Venous Catheter (UVC)

• Used in neonates within first few days of life; umbilical stump must be fresh
• Access to umbilical vein (larger, single vessel — veins have two walls, arteries have thick walls)
• Used for emergency medications, TPN, blood products in critically ill neonates
• Risk: portal vein thrombosis, liver necrosis if not properly positioned; requires X-ray confirmation

PICC Lines (Pediatric)

• Inserted in antecubital, basilic, or cephalic vein; tip in SVC
• Used for antibiotics, TPN, chemotherapy, long-term access (>5 days)
• Neonatal PICC lines can be as small as 1.9 Fr

NCLEX High-Yield Points

• IO is the FIRST alternative to IV in pediatric emergency — not repeated PIV attempts
• All medications given IV can be given IO; onset comparable to IV
• Holliday-Segar formula: 4 mL/kg/hr for first 10 kg; 2 mL/kg/hr for next 10; 1 mL/kg/hr thereafter
• Fluid resuscitation bolus: 20 mL/kg isotonic crystalloid over 5–20 minutes
• Catheter gauge is INVERSELY related to size (smaller gauge number = larger catheter)
• EMLA cream requires 45–60 minutes for adequate anesthesia; plan ahead for non-emergent access
• IO lidocaine before each flush in conscious patients — IO insertion and flushing is painful
• Scalp vein insertion: catheter goes toward the FACE, not the crown (blood flows toward heart)