Establishing venous access in children may be difficult and time consuming because their veins are frequently small and embedded in subcutaneous fat tissue or visible veins may have been exhausted in previous attempts at venepuncture. Venous prominence can be increased by simple measures such as grip and relax and application of a warm compress for a few minutes. Ultrasound guided catheterization and smart catheters, which contain a Doppler probe, have also been used to improve the success rate of venous access but may not be available everywhere. A venous access algorithm has been proposed for children: in emergency cases, two attempts at venous access were allowed on each side and if these were unsuccessful then intraosseous or central venous access should be attempted and expert help should be obtained . However, the pretibial intraosseous injection technique is only suitable for short-term use, and is not the first choice in routine anaesthesiology practice . In elective cases, two attempts on each side following topical local anaesthesia should be carried out and if these are unsuccessful then alternative sites and adjunctive measures such as warming, ultrasound guidance, use of venous distension device or transillumination are advised. The technique of transillumination for venous access can be achieved by using a high power, cold-light source. Although there have been a few reports on the use of transillumination for intravenous (i.v.) access, this technique is uncommon in anaesthesiology practice . We aimed to investigate the efficacy of the transillumination technique in establishing venous access when traditional attempts had failed.
Following local ethics committee approval, 334 consecutive children undergoing general anaesthesia were enrolled in the study. The children's ages were in the range 0-36 months, with a median age of 13.2 months (interquartile range 20.0). Their weights were between 2 and 23 kg (median 9.0; interquartile range 5.0). Two hundred and five of the children were male. The same two senior physicians carried out all venepuncture attempts following induction of inhalational anaesthesia. One hundred of these 334 patients, after two failed attempts with standard technique or with no visible veins, were evaluated with transillumination. Initially all extremities were searched for a visible or palpable vein suitable for cannulation. The transillumination technique was established with a 200-W cold-light source and its fibreoptic cable (Karl Storz, 485 B type, Tutlingen, Germany). The extremity was stabilized and examined for venous access with the fibreoptic light source, which was placed against the palmer or plantar surface of the hand or foot, respectively (Fig. 1). When visible veins were identified a catheter was introduced into a suitable vein. The catheter was flushed to check for successful cannulation. Patients in whom venous access could only be achieved after more than two attempts or in a longer time than 30 min were counted as unsuccessful.
Venous cannulation was successfully achieved with the routine method in 234/334 (70%) of children. A total of 100 (30%) out of 334 children underwent transillumination. Two-thirds of these patients were below 20 months of age, and in 46 of them, all visible veins had been exhausted in previous therapies. In the other 54 patients, visible or palpable veins could not be identified with routine method. Transillumination was helpful for venous access in 80 of these 100 patients and a vein could be cannulated in the first or second attempt in less than 5 min. Transillumination failed in the other 20 patients as venous access could not be achieved after more than two attempts or in a longer time than 30 min. The reason for failure was obesity in 10 patients and previous multiple attempts at venous puncture in the other 10.
Thus, successful venous cannulation could be achieved in 314 of 334 patients when transillumination was available.
Kuhns and colleagues  described the first use of transillumination for infant venepuncture in radiology. Dinner  introduced a specially manufactured transilluminator named the ‘Landry Light’ consisting of two closely positioned fibreoptic lights that effectively illuminate non-visible veins, however this transilluminator has not gained popularity . Furthermore, transillumination may be used to identify the radial and ulnar arteries in premature infants or newborns and guide arterial access since foetal haemoglobin contains more reduced oxyhaemoglobin than adults .
Lenhardt and colleagues  reported from their single-blinded prospective study that active warming increased the success rate of venous access in adult patients from 72% to 94%. Basic standard measures of the groups were the same in this study and designing a single-blinded controlled survey is not a problem. Transillumination may not have any advantage in a patient with visible veins. Goren and colleagues  proposed the transillumination technique on a difficult venous access population in emergency units. Although they stated that transillumination could be carried out using a common otoscope, we believe that a 200-W cold-light source improves the visualization of the veins and increases the success rate. Higher energy light sources may result in burning of the skin and should be avoided.
In our study, the success rate of transillumination was 80% in patients with difficult venous access. Transillumination improved the total success rate of venous cannulation from 70% to 94% in children undergoing general anaesthesia.
In conclusion, transillumination may be a useful technique to improve the success rate of difficult venous cannulation in infants and young children.
*Department of Anaesthesiology and Reanimation, Medicine Faculty, Pamukkale University, Denizli, Turkey
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