מאמר על יעילות השיטה בילדים

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Society for Pediatric Anesthesia Section Editor: Peter J. Davis Intravenous Sodium Bicarbonate Verifies Intravenous Position of Catheters in Ventilated Children Ilan Keidan, MD,*† Erez Ben-Menachem, MBCHB, FANZCA,* Sno Ellen White, MD,† and Haim Berkenstadt, MD* BACKGROUND: Vascular access in children carries a significant risk of accidental extravasation of IV fluids and medications with the potential for tissue injury. In this prospective controlled study we assessed the diagnostic utility of using IV diluted sodium bicarbonate to confirm placement of IV catheters in ventilated children. Diluted sodium bicarbonate was created using undiluted standard 8.4% (1 mEq/mL) sodium bicarbonate mixed in a 1:3 and 1:5 ratio with sterile water to achieve a final diluted concentration of 2.1% (0. 25 mEq/mL) and 1.05% (0.125 mEq/mL) sodium bicarbonate, respectively. METHODS: In 18 ASA I–II mechanically ventilated children ages 1 to 8 years, the effects of 1 mL/kg of dilute 2.1%, 1.05% sodium bicarbonate, or 0.9% normal saline, injected in a randomized order, were analyzed. All children had oxygen saturation, arterial blood pressure, electrocardiograph, and end-tidal carbon dioxide (ETCO 2 ) monitoring. In addition, venous blood samples were taken before injection and 10 minutes after the final injection for analysis of venous blood pH and electrolytes. RESULTS: In children, IV diluted 2.1% sodium bicarbonate resulted in significantly increased ETCO 2 (mean of 32.8 3.4 mm Hg to 39.0 3.5 mm Hg, P 0.001), a mean increase of 6.2 mm Hg (95% prediction interval: 4.3 to 8.1 mm Hg) within 3 breaths. Intravenous diluted 1.05% sodium bicarbonate caused a less pronounced but still significant increase in ETCO 2 (33.4 3.8 mm Hg to 36.3 3.4 mm Hg, P 0.001), a mean increase of 2.9 mm Hg (95% prediction interval: 1.8 to 4.1 mm Hg) within 3 breaths. Normal saline did not result in any significant changes, with a mean increase of 0.06 mm Hg (95% prediction interval: 1.3 to 1.4 mm Hg). Both concentrations of sodium bicarbonate were easily differentiated from normal saline injection by blinded anesthesiolo- gists observing the change in ETCO 2 values immediately after injection. Analysis of pre- and postinjection venous pH, bicarbonate, and sodium levels could not detect clinically significant changes. A small but statistically significant increase in venous bicarbonate was noted. CONCLUSION: The injection of 2.1% sodium bicarbonate in mechanically ventilated ASA I–II children identified intravascular placement and patency of an IV catheter by an increase in the exhaled CO 2 concentration. The injections did not have any clinically significant effects on blood pH, bicarbonate, or sodium concentration. (Anesth Analg 2012;115:909 –12) I t is a common clinical problem to be presented with a pediatric patient with IV access for which there is doubt about the usability of the catheter. Vascular access is often bandaged, obscuring clinical assessment, children may not be capable of verbally communicating pain at injection sites, and a “twiddler’s syndrome” has been described in which the child manipulates the catheter, causing it to migrate out of the vessel. 1 Additionally, fluid leakage into surrounding tissue may initially go unnoticed owing to the distensibility of subcutaneous tissues in the very young. Even with infusion devices programmed to alarm in response to increasing infusion pressures, 2 hopefully allowing early identification of infiltration, the high compliance of subcutaneous tissues in children leads to failure of the alarm and reduces the effec- tiveness of this safety feature. 3 Moreover, manual IV boluses may generate higher pressures, resulting in rupture of fragile vessels. Traditionally, correct IV placement has been con- firmed by a return flow of blood and gentle flushing of the cannula with saline and observation of the surrounding tissues. However, these methods are not consistently accurate because small-caliber vessels and potentially dehydrated pa- tients do not allow return flow of blood, and highly compliant or edematous tissues may obscure extravasation of saline and give a false sense of security. Infiltration, the unintentional leakage of IV fluids into the surrounding tissue, is the most common complication of vascular access. Extravasation, the leakage of IV medi- cations into tissues can also occur. Both can cause injury, and the terms will be used interchangeably in this manuscript. The incidence of peripheral IV infiltration was reported to be 23%–78% for neonates 4 and 11%–28% for children, 5,6 whereas percutaneous central venous catheters were reported to have an infiltration rate of 1% to 16%. 7 Extravasation of IV medi- cations may result in tissue damage with the potential for skin From the *Department of Anesthesia and Intensive Care, Sheba Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Israel; †Department of Anesthesiology, University of Florida, Gainesville, Florida. Accepted for publication March 27, 2012. Funding: Department funds were used to support this study, specifically for purchase of drugs and statistical analysis of data. The authors declare no conflict of interest. Reprints will not be available from the authors. Address correspondence to Erez Ben-Menachem, MBCHB, FANZCA, De- partment of Anesthesia and Intensive Care, Sheba Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Hashomer 52621, Israel. Address e-mail to [email protected]. Copyright © 2012 International Anesthesia Research Society DOI: 10.1213/ANE.0b013e318258023b October 2012 Volume 115 Number 4 www.anesthesia-analgesia.org 909

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Society for Pediatric Anesthesia

Section Editor: Peter J. Davis

Intravenous Sodium Bicarbonate Verifies IntravenousPosition of Catheters in Ventilated ChildrenIlan Keidan, MD,*† Erez Ben-Menachem, MBCHB, FANZCA,* Sno Ellen White, MD,†and Haim Berkenstadt, MD*

BACKGROUND: Vascular access in children carries a significant risk of accidental extravasationof IV fluids and medications with the potential for tissue injury. In this prospective controlledstudy we assessed the diagnostic utility of using IV diluted sodium bicarbonate to confirmplacement of IV catheters in ventilated children. Diluted sodium bicarbonate was created usingundiluted standard 8.4% (1 mEq/mL) sodium bicarbonate mixed in a 1:3 and 1:5 ratio withsterile water to achieve a final diluted concentration of 2.1% (0. 25 mEq/mL) and 1.05% (0.125mEq/mL) sodium bicarbonate, respectively.METHODS: In 18 ASA I–II mechanically ventilated children ages 1 to 8 years, the effects of 1 mL/kgof dilute 2.1%, 1.05% sodium bicarbonate, or 0.9% normal saline, injected in a randomized order,were analyzed. All children had oxygen saturation, arterial blood pressure, electrocardiograph, andend-tidal carbon dioxide (ETCO2) monitoring. In addition, venous blood samples were taken beforeinjection and 10 minutes after the final injection for analysis of venous blood pH and electrolytes.RESULTS: In children, IV diluted 2.1% sodium bicarbonate resulted in significantly increased ETCO2(mean of 32.8 � 3.4 mm Hg to 39.0 � 3.5 mm Hg, P � 0.001), a mean increase of 6.2 mm Hg(95% prediction interval: 4.3 to 8.1 mm Hg) within 3 breaths. Intravenous diluted 1.05% sodiumbicarbonate caused a less pronounced but still significant increase in ETCO2 (33.4 � 3.8 mm Hg to36.3 � 3.4 mm Hg, P � 0.001), a mean increase of 2.9 mm Hg (95% prediction interval: 1.8 to 4.1mm Hg) within 3 breaths. Normal saline did not result in any significant changes, with a meanincrease of 0.06 mm Hg (95% prediction interval: �1.3 to 1.4 mm Hg). Both concentrations ofsodium bicarbonate were easily differentiated from normal saline injection by blinded anesthesiolo-gists observing the change in ETCO2 values immediately after injection. Analysis of pre- andpostinjection venous pH, bicarbonate, and sodium levels could not detect clinically significantchanges. A small but statistically significant increase in venous bicarbonate was noted.CONCLUSION: The injection of 2.1% sodium bicarbonate in mechanically ventilated ASA I–IIchildren identified intravascular placement and patency of an IV catheter by an increase in theexhaled CO2 concentration. The injections did not have any clinically significant effects on bloodpH, bicarbonate, or sodium concentration. (Anesth Analg 2012;115:909–12)

It is a common clinical problem to be presented with apediatric patient with IV access for which there is doubtabout the usability of the catheter. Vascular access is often

bandaged, obscuring clinical assessment, children may not becapable of verbally communicating pain at injection sites, anda “twiddler’s syndrome” has been described in which thechild manipulates the catheter, causing it to migrate out of thevessel.1 Additionally, fluid leakage into surrounding tissuemay initially go unnoticed owing to the distensibility ofsubcutaneous tissues in the very young. Even with infusion

devices programmed to alarm in response to increasinginfusion pressures,2 hopefully allowing early identification ofinfiltration, the high compliance of subcutaneous tissues inchildren leads to failure of the alarm and reduces the effec-tiveness of this safety feature.3 Moreover, manual IV bolusesmay generate higher pressures, resulting in rupture of fragilevessels. Traditionally, correct IV placement has been con-firmed by a return flow of blood and gentle flushing of thecannula with saline and observation of the surroundingtissues. However, these methods are not consistently accuratebecause small-caliber vessels and potentially dehydrated pa-tients do not allow return flow of blood, and highly compliantor edematous tissues may obscure extravasation of saline andgive a false sense of security.

Infiltration, the unintentional leakage of IV fluids intothe surrounding tissue, is the most common complicationof vascular access. Extravasation, the leakage of IV medi-cations into tissues can also occur. Both can cause injury,and the terms will be used interchangeably in this manuscript.The incidence of peripheral IV infiltration was reported to be23%–78% for neonates4 and 11%–28% for children,5,6 whereaspercutaneous central venous catheters were reported to havean infiltration rate of 1% to 16%.7 Extravasation of IV medi-cations may result in tissue damage with the potential for skin

From the *Department of Anesthesia and Intensive Care, Sheba MedicalCenter, affiliated with the Sackler Faculty of Medicine, Tel Aviv University,Israel; †Department of Anesthesiology, University of Florida, Gainesville,Florida.

Accepted for publication March 27, 2012.

Funding: Department funds were used to support this study, specifically forpurchase of drugs and statistical analysis of data.

The authors declare no conflict of interest.

Reprints will not be available from the authors.

Address correspondence to Erez Ben-Menachem, MBCHB, FANZCA, De-partment of Anesthesia and Intensive Care, Sheba Medical Center, affiliatedwith the Sackler Faculty of Medicine, Tel Hashomer 52621, Israel. Addresse-mail to [email protected].

Copyright © 2012 International Anesthesia Research SocietyDOI: 10.1213/ANE.0b013e318258023b

October 2012 • Volume 115 • Number 4 www.anesthesia-analgesia.org 909

necrosis, with tissue sloughing being reported in as many as44% of infants with infiltrations.8

Another important consequence of inappropriate place-ment of IV access is repeated cannulation. This procedure isstressful for both children and parents and has been ratedas the most distressing part of hospital admissions and thecause of the most pain while in hospital.9 Against thisbackdrop, there are multiple clinical scenarios in whichthere is a strong desire to confirm correct functioning of adoubtful “in situ” catheter.

Given the regular occurrence of the clinical dilemmaalready outlined, shortcomings of traditional methods, andthe risk of tissue damage from extravasation, we decided totest a technique that may differentiate between an infil-trated IV catheter and a correctly sited catheter.

In this prospective controlled trial, the diagnostic utilityof using IV-injected dilute 2.1% (0. 25 mEq/mL) and 1.05%(0.125 mEq/mL) sodium bicarbonate in mechanically ven-tilated children was tested. The technique is based on theobserved phenomenon of increased end-tidal carbon diox-ide (ETCO2) concentration after the IV administration ofsodium bicarbonate,10 and mechanically ventilated chil-dren under general anesthesia were chosen because of thecontrolled setting and ability to accurately measure ETCO2

and other physiological variables. In an effort to reduce thesequelae of extravasated sodium bicarbonate, which ishyperosmolar and highly alkaline, it was diluted withsterile water, and its physicochemical properties weretested. We have already investigated the value of thetechnique in mechanically ventilated adult patients andperformed a safety study of subcutaneously injected so-dium bicarbonate in rats; the results have recently beenpublished.11 Our aim in this study was to identify whethera lower concentration of sodium bicarbonate would stillhave diagnostic utility, investigate the effects of a bolus ofdiluted sodium bicarbonate on the unique physiology ofchildren, and measure possible serum electrolyte changes.

METHODSInstitutional ethics committee approval was granted forthis study, and prior written consent was obtained from thelegal guardians of all children before enrollment. EighteenASA I–II patients ages 1 to 8 years undergoing electivesurgery under general anesthesia with tracheal intubationand controlled mechanical ventilation were studied. Gen-eral anesthesia was induced using a sevoflurane inhaledtechnique. Midazolam premedication was given at thediscretion of the treating anesthesiologist. After inductionof general anesthesia, a free-flowing 22-gauge IV cannula(BD Venflon, Helsingborg, Sweden) was placed in theupper limb of the patient. Correct IV placement wasconfirmed by free aspiration of blood. Rocuronium 0.5mg/kg was then given, and the trachea was intubated withan appropriately sized cuffed endotracheal tube. The cuffwas inflated until there was no detectable leak, with cuffpressure kept below 20 cmH2O. The ventilator was set attidal volumes of 10 mL/kg of body weight, positive end-expiratory pressure of 5 cm/H2O, and respiratory rate (RR)of 15 breaths per minute. After tracheal intubation, andbefore surgery, a period of 5 minutes was allowed, at theend of which baseline ETCO2 was established. The patient

then received a 1 mL/kg bolus of 0.9% normal saline, 2.1%sodium bicarbonate, or 1.05% sodium bicarbonate. Sodiumbicarbonate was diluted with sterile water and was ana-lyzed for pH (Glass Electrode Radiometer, Copenhagen,Denmark) and osmolarity (Osmostation, OM 6050 A. Men-arini Industries, Florence, Italy). Each patient received all 3solutions given as a bolus and injected in a randomizedorder in 5-minute intervals. The injections were giventhrough the cannula side-port close to the insertion site.Injection pressures were not measured, and no flush fluidswere given. All injections and data collection occurred afterinduction of anesthesia and hemodynamic and ventilatorystabilization and before commencement of surgery. Injec-tions were performed by an anesthesiologist not involvedin the patient’s anesthetic care so that the treating anesthesi-ologist remained blinded to the injectate. The data collectedincluded patient demographics, ETCO2 values during 11consecutive breaths after the injection (S/5 anesthesia moni-tor; Datex Ohmeda now a division of GE Healthcare,Waukesha, WI), heart rate for 5 minutes after injection, andnoninvasive arterial blood pressure measured 2.5 and 5minutes after the injection. An increase of 10% in theETCO2 from baseline was considered a positive result.Venous blood samples were taken at baseline and 10minutes after all 3 solutions had been injected. Thesevenous blood samples were analyzed for pH and electro-lyte levels. The blinded treating anesthesiologist was askedafter each injection to determine whether sodium bicarbonateor normal saline had been given. A power analysis wasconducted, with � � 0.05, 1 � � � 0.9, difference to bedetected � 2 mm Hg, with an SD of differences of 1 mm Hg.The minimum required sample size for a 2-sided paired ttest � 5 pairs, with 18 pairs allowing the power of the test tobe 100%. Paired comparisons between ETCO2 before and afterinjection as well as blood pH and electrolytes were madeusing the Student paired t test. A �-square test of goodness offit was performed to determine whether the blinded observerssuccessfully detected the sodium bicarbonate or normal salineinjections in the 18 patients. Data were analyzed using SPSSsoftware (version 19; IBM Corp., Somers, NY).

RESULTSThe physical characteristics of the injected diluted sodiumbicarbonate are outlined in Table 1. Diluting sodium bicar-bonate with sterile water decreased the osmolarity of theinjectate from 2000 mOsm/L for the undiluted sodiumbicarbonate to 447 mOsm/L for the diluted 2.1% sodiumbicarbonate and 250 mOsm/L once diluted to 1.05%. Thedilution did not have any effect on the pH of the injectate.

Eighteen patients ages 1 to 8 years old were enrolled inthis study (mean age: 5 � 2 years). Mean patient weightwas 22 � 8 kg (range 9 to 34 kg). Peak ETCO2 increased by

Table 1. The Physicochemical Characteristics ofDiluted Sodium Bicarbonate

Sodium bicarbonate(diluted with sterile water)

Undiluted(8.4%)

1:1(4.2%)

1:3(2.1%)

1:5(1.05%)

Osmolarity (mOsm/L) 2000 818 447 250pH 8.6 8.68 8.72 8.77

A Technique to Confirm IV Line Position in Children

910 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA

�10% in all patients after injection with dilute 2.1% sodiumbicarbonate (from a mean value of 32.7 � 3.4 mm Hg to39.0 � 3.5 mm Hg, P � 0.001). The peak ETCO2 occurred inthe second breath after the completion of the injection in 16out of 18 patients and in the third breath in the remaining2 of 18 patients. Injection with diluted 1.05% sodiumbicarbonate resulted in a significant increase in ETCO2

(from a mean value of 33.4 � 3.8 mm Hg to 36.3 � 3.4 mmHg, P � 0.01), but reached a 10% increase in only 5 of the18 patients (28%). Normal saline did not result in a signifi-cant increase in ETCO2 levels (Fig. 1). The blinded anesthe-siologist could consistently detect the injection with 2.1%sodium bicarbonate, but the detection rate with 1.05%bicarbonate was 80%. All other physiological variables (RR,heart rate, blood pressure) remained unchanged. Afterinjection, venous blood samples showed no increase inblood pH, serum sodium, or ionized calcium, and a smallstatistically significant, but clinically insignificant, increasein bicarbonate (Table 2).

DISCUSSIONThis study describes the novel use of a clinically observedphenomenon to confirm the correct placement and viabilityof an IV catheter placed in mechanically ventilated, endo-tracheally intubated pediatric patients. ETCO2 increaseafter injection of 2.1% sodium bicarbonate appears to

reliably confirm IV placement of an IV catheter. The use of1.05% sodium bicarbonate is less reliable. Care should betaken if testing an IV cannula previously or concurrentlybeing used for medications, because sodium bicarbonatemay be incompatible with certain drugs, including epi-nephrine, norepinephrine, dobutamine, midazolam, cal-cium salts, and magnesium salts.

The complications of extravasation from a nonfunction-ing IV catheter can be serious. The American Society ofAnesthesiologists Closed Claims Project database reflectsthis, with 2.1% of all claims (all ages) between 1975 and2000 being related to peripheral catheters; of these, 28%were due to skin slough or necrosis and 17% were due toswelling, inflammation, or infection.12 It was calculatedthat 55% of all complications were the result of extravasa-tion of drugs or fluid. Given the seriousness of the problemof inadvertent extravasation with the potential for injury,increased costs, and risk of litigation, it would seem sen-sible to develop techniques, such as outlined above, thatassist in preventing such negative outcomes. All IV medi-cations and fluids can cause tissue damage, but certainsubstances are associated with a greater risk of tissue necro-sis.13 Moreover, though this study investigated confirmationof placement and patency of peripheral IV cannulas, thetechnique may be equally useful for central venous accesscatheters, and further studies in this setting are warranted.The consequences of misplaced or migrated central vascularaccess can be catastrophic with the potential for infusion offluids into the pleural or abdominal cavity. Cardiovascularcollapse could potentially occur should inotropic infusions begiven through a catheter not positioned intravascularly. Over-all, given the frequency of the problem, the potential compli-cations and associated costs, and the distress caused topatients and families, a simple clinical test such as describedin this study could beneficially impact health care spendingattributable to hospital-acquired conditions and improve con-sumer satisfaction assessments.

Figure 1. Bland–Altman plot of increase inend-tidal CO2 against baseline, pre-, and postin-jection (2.1% sodium bicarbonate, 1.05% so-dium bicarbonate, 0.9% normal saline).

Table 2. Venous Blood Samples Before and Afterthe Injection of the Study Injectates

Beforeinjection

Afterinjection Significance

Blood pH 7.39 � 0.04 7.39 � 0.05 NSSodium bicarbonate

(mEq/L)20.75 � 1.4 22.19 � 1.8 �0.05

Sodium (mEq/L) 135.5 � 2.1 135.6 � 1.7 NSIonized calcium (mmol/L) 1.1 � 0.4 1.05 � 0.5 NS

NS � not significant.

October 2012 • Volume 115 • Number 4 www.anesthesia-analgesia.org 911

Any solution with osmolarity greater than plasma osmo-larity causes damage by exerting an osmotic pressure leadingto a compartment syndrome. Similarly highly alkaline solu-tions with pH above 9.0 can cause direct cellular injury, and itis recommended that infused solutions should have a pHbetween 5 and 9.14 Potent vasoconstictors can also causenecrosis secondary to tissue ischemia. Drugs commonly usedin the perioperative setting with the potential to cause tissuedamage are listed in Table 3, although other drugs notcommonly associated with tissue damage still have the po-tential to cause injury, including propofol.15

Vesicants are substances that have physical or chemicalproperties that make them capable of causing inflamma-tion, pain, and blistering of tissues, potentially causingtissue death and necrosis, with injury to surrounding tissueif wrongly administered subcutaneously. Sodium bicarbon-ate is considered a vesicant secondary to its high pH andhigh osmorality. Although we did not specifically investi-gate the effect of subcutaneous injection of dilute sodiumbicarbonate in pediatric patients, its minimally useful con-centration is likely to enhance the safety of this techniqueby decreasing the osmolarity of the injectate. The safety ofsubcutaneous injection of dilute 4.2% sodium bicarbonatehas been tested in a rat model and appears safe.11 Notably,a useful minimum concentration (2.1% sodium bicarbon-ate) has been found for this technique in pediatric patients.Conspicuously, the peak increase in ETCO2 was seen at thesecond to third breath, in contrast to the seventh breath inadults.11 It is likely that this earlier increase is the result of thehigher relative cardiac output and faster circulation time seenin children. It is likely that the technique is equally applicableto children whose lungs are ventilated via a laryngeal mask;however, spontaneously breathing patients may not exhibitthe same CO2 increase because they may partially compensatewith an increased RR. Further studies that observe RR andexhaled CO2 in pediatric patients with lung disease, sponta-neously breathing, or awake pediatric patients may be war-ranted. Additional investigation may be useful to confirm theoptimal volume, concentration, and total dose of sodiumbicarbonate for this technique. Reassuringly, the 2.1% sodiumbicarbonate bolus (0.25 mEq/kg), even if repeated severaltimes a day, is well below the recommended 8 mEq/kg/daysodium bicarbonate dose limit for children younger than 2years of age. Until further evidence suggests otherwise, wewould consider contraindications to include premature in-fants, especially those with intraventricular hemorrhage, andchildren with increased intracranial pressure.

In summary, we present a useful technique, using 1mL/kg of dilute 2.1% sodium bicarbonate and the resultant

ETCO2 increase, to confirm correct intravascular placementof peripheral IV cannulas in anesthetized, mechnicallyventilated patients. No adverse events or complicationswere detected. This simple test may aid in reducing thecomplications of infiltration, and the patient and familydistress caused by the common clinical scenario of the“doubtful” peripheral IV cannula.

DISCLOSURESName: Ilan Keidan, MD.Contribution: This author helped design the study, implementthe study, and compose the manuscript.Name: Erez Ben-Menachem, MBCHB, FANZCA.Contribution: This author helped implement the study andcompose the manuscript.Name: Sno Ellen White, MD.Contribution: This author helped compose the manuscript andthe revision.Name: Haim Berkenstadt, MD.Contribution: This author helped implement the study andcompose the manuscript.This manuscript was handled by: Peter J. Davis, MD.

REFERENCES1. Servetar EM. A case report of Twiddler’s syndrome in a

pediatric patient. J Pediatr Oncol Nurs 1992;9:25–82. Perdue MB. Intravenous complications. In: Hankins L, Lon-

sway RA, Hendrick C, Perdue MB, eds. Infusion Therapy inClinical Practice. 2nd ed. St. Louis, MO: Saunders, 2011:418–45

3. Hee HI, Lim SL, Tan SS. Infusion technology: a cause for alarm.Pediatr Anaesth 2002;12:780–5

4. Franck LS, Hummel D, Connell K, Quinn D, Montgomery J.The safety and efficacy of peripheral intravenous catheters inill neonates. Neonatal Netw 2001;20:33–8

5. Kassner E. Evaluation and treatment of chemotherapy extrava-sation injuries. J Pediatr Oncol Nurs 2000;17:135–48

6. Garland JS, Dunne WM Jr, Havens P, Hintermeyer M, BozzetteMA, Wincek J, Bromberger T, Seavers M. Peripheral intrave-nous catheter complications in critically ill children: a prospec-tive study. Pediatrics 1992;89:1145–50

7. Wynsma LA. Negative outcomes of intravascular therapy ininfants and children. AACN Clin Issues 1998;9:49–63

8. Pettit J, Hughes K. Intravenous extravasation: mechanisms,management, and prevention. J Perinat Neonatal Nurs 1993;6:69–78

9. Cummings EA, Reid GJ, Finley GA, McGrath PJ, Ritchie JA.Prevalence and source of pain in pediatric inpatients. Pain1996;68:25–31

10. Okamoto H, Hoka S, Kawasaki T, Okuyama T, Takahashi S.Change in end-tidal carbon dioxide tension following sodiumbicarbonate administration: correlation with cardiac outputand haemoglobin concentration. Acta Anaesthesiol Scand1995;39:79–84

11. Keidan I, Ben-Menachem E, Barzilai A, Nur I, Berkenstadt H.Intravenous sodium bicarbonate verifies intravenous position ofcatheters in ventilated patients. Anesth Analg 2011;113:279–81

12. Bhananker SM, Liau DW, Kooner PK, Posner KL, Caplan RA,Domino KB. Liability related to peripheral venous and arterialcatherization: a closed claims analysis. Anesth Analg 2009;109:124–9

13. Doellman D, Haaway L, Bowe-Geddes LA, Franklin M, Le-Donne J, Papke-O’Donnell L, Pettit J, Schulmeister L, Stranz M.Infiltration and extravasation: update on prevention and man-agement. J Infus Nurs 2009;32:203–11

14. Vesely TM, Stranz M, Masoorli S, Hadaway LC. The diverseand conflicting standards and practices in infusion therapy.J Vasc Devices 2002;7:9–25

15. Roth W, Eschertzhuber S, Gardetto A, Keller C. Extravasationof propofol is associated with tissue necrosis in small children.Pediatr Anesth 2006;16:887–9

Table 3. Drugs Used in Anesthesia with thePotential to Cause Tissue Damage

Hyperosmolaragents

Acids/alkalis

Vasocontrictiveagents

Hypertonic saline Thiopental EpinephrinePotassium chloride Diazepam NorepinephrineCalcium chloride Phenytoin DobutamineCalcium gluconate Vancomycin MetaraminolMannitol VasopressionSodium bicarbonate PhenylephrineGlucose �10%

A Technique to Confirm IV Line Position in Children

912 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA