Using a Vein Locator for Pediatric PICC Insertion Can Increase Puncture Efficiency and Improve Pain Management
Abstract
Background: The peripherally inserted central catheter (PICC) plays an important role in clinical work. However, inserting PICCs, especially in infants and young children, is often challenging. This study aimed to evaluate the application of a venous locator for PICC insertion in children.
Methods: This study reviewed pediatric patients who underwent PICC insertion from January 2019 to December 2020 in the Department of Pediatric Surgery, Xinhua Hospital affiliated with Shanghai Jiaotong University, School of Medicine. Among the patients, 176 underwent the traditional procedure and 179 underwent the venous locator–assisted procedure. The venous locator used in our center is the AV400 (AccuVein, USA). We compared the basic characteristics of the two groups, vein selection, procedure duration, number of insertion attempts, pain score evaluations, PICC-related complications, family member satisfaction, and other parameters.
Results: The proportion of multiple puncture attempts during insertions was significantly lower in the locator group than in the traditional method group (control group, p < 0.001). The success rate of first-attempt punctures in non–first-time catheterized children was higher when using the vein locator (p < 0.001). The venous locator also increased the success rate of insertions in low-weight children. Additionally, the locator group experienced fewer cases of PICC-related phlebitis (p = 0.029). There was no significant difference in other complications, such as catheter-related infections, thrombosis, catheter blockage, catheter displacement, catheter breakage, puncture site exudate, or accidental catheter removal. The use of a venous locator also decreased the pain experienced by children under 12 months of age (p = 0.043) and significantly improved the satisfaction of family members (p = 0.006).
Conclusions: For pediatric patients who undergo PICC insertion, the use of a vein locator can reduce the number of multiple puncture attempts and improve puncture efficiency in non–first-time catheterized patients. This approach, to some extent, lowers PICC-related complications and thus merits clinical application.
1. Introduction
Intravenous infusion is one of the most common and essential procedures in clinical practice. Rapid and accurate venous puncture is particularly important for timely treatment and critical care. In pediatric wards, especially those with newborns and infants, venous puncture can be challenging. Typically, an indwelling peripheral catheter can only be used for approximately 3 days, making central venous insertion the preferred choice for children requiring long-term intravenous infusion. A peripherally inserted central catheter (PICC) offers the advantages of a long service life, a low infection rate, and relatively convenient care [1]. However, the PICC insertion presents certain operational difficulties, especially for newborns and infants [2]. Repeated punctures not only increase the pain experienced by children but also have the potential to cause conflicts between medical staff and patients and their family members. A vein locator uses infrared light to detect veins under the skin and clearly displays the location of blood vessels on the skin. Its use reduces the failure rate of the PICC insertion, greatly improves the accuracy of puncture, and reduces the degree of pain experienced by children [3]. Currently, there are few studies on the use of venous locators for PICC placement in children. Therefore, the aim of this study was to examine the effectiveness of using venous locators to assist with PICC insertion in children.
2. Materials and Methods
2.1. Patients
This study reviewed children who underwent PICC insertion in the Department of Pediatric Surgery at Xinhua Hospital, which is affiliated with Shanghai Jiao Tong University, School of Medicine, from January 2019 to December 2020. Our center introduced the AV400 at the end of 2019 and began to use it routinely for PICC insertion. Therefore, the children included in this study from January to December 2020 were those who received PICC insertions with the assistance of the AV400 device. Moreover, we selected patients who underwent traditional PICC placement methods from January to December 2019 as the control group.
The study was authorized by the Ethics Committee of Xinhua Hospital (XHEC-D-2024-178). The indications for the PICC insertion in our department are as follows: (1) long-term use of intravenous infusion (more than 14 days), (2) need for intravenous nutritional preparations through the central vein, and (3) clinical evaluation of difficult veins [4]. The children were divided into two groups, the traditional method puncture group (control group) and the venous locator–assisted group (locator group), on the basis of whether the venous locator was used during puncture. The venous locator used in this study was the AV400 (AccuVein, USA). Hemoglobin in the blood absorbs infrared rays, reducing the amount of infrared rays reflected back from the patient’s body. The detection system of the instrument uses the change in reflection to determine the location of the vein and then projects the direction of the vein onto the patient’s skin in real time, presenting the venous image to medical staff.
2.2. PICC Insertion Process
During insertion, the operator in the control group performed the procedure based on anatomical positioning, whereas the operator in the locator group employed the AV400 for venous positioning. All PICC insertions in this study were performed by two skilled nurses. The AV400 was held perpendicularly by an assistant approximately 18 cm over the patient’s limb where the vein was expected to be located (Figure 1), and direct contact between the AV400 and the eyes could be avoided. In addition to the visualization technique used, all other aspects of placement were performed using institutional standards.
In this study, multiple punctures were defined as the operator failing to achieve a successful puncture on the first attempt and repeatedly trying to insert the needle. Non–first-time puncture was defined as a child who had previously undergone the PICC insertion.
To reduce discomfort caused by the puncture, we performed adequate local infiltration anesthesia before the procedure. For children who were expected to have poor cooperation, especially neonates and infants, we provided sufficient sedation before the procedure. Additionally, we implemented necessary soothing measures, such as playing music or cartoons, to help alleviate the children’s anxiety.
2.3. Observation Indicators
We collected patients’ medical information for comparative analysis. Additionally, by reviewing the operation records, we documented the number of puncture attempts, puncture site, catheter length, and PICC-related complications for each patient. Catheter-related complications included phlebitis, catheter infection, catheter displacement, catheter breakage, catheter blockage, thrombosis, puncture site exudate, and accidental catheter removal. Catheter infection was defined by the presence of infection-related symptoms and pathogen evidence from catheter culture.
Postpuncture, we evaluated the pain experienced by the children. Owing to the varying ages of the patients, we used different scales for different age groups. The CHIPPS scale was used for children aged 0–12 months, and the modified OPS scale was used for children aged 12 months and older. The evaluation was conducted 5 minutes after puncture. The CHIPPS scale [5] evaluates pain through crying, facial expression, body posture, leg posture, and fidgeting, with a total score of 10. A score of 0–3 indicates no pain, whereas a score of ≥ 4 indicates the need for analgesia [6]. The modified OPS scale assesses crying, limb movement, excitability, posture, and pain complaints, with a score of ≥ 3 indicating pain behavior [7, 8]. We also evaluated family members’ satisfaction using a self-developed nursing satisfaction questionnaire. The satisfaction questionnaire consisted of 10 questions, including those concerning patient satisfaction with preoperative education, the puncture technique, and catheter management, among others. Each question was rated on a scale from 1 to 10, with 10 being the highest score. The total score was 100 points: ≥ 90 points indicated very satisfied, 75–90 points indicated satisfied, 60–75 points indicated average, and < 60 points indicated dissatisfied. Total satisfaction was calculated as (very satisfied + satisfied)/total number of surveys ∗ 100%.
2.4. Statistical Methods
All the research data were entered into Excel and processed using SPSS 22.0 statistical software. The measurement data are expressed as the means ± standard deviations, and the Mann–Whitney U test was used for comparisons. Enumeration data were analyzed by the rate via the chi-square test. A p value of < 0.05 was considered to indicate statistical significance.
3. Results
3.1. Comparison of Basic Information
This study reviewed 355 children who underwent the PICC insertion, with 176 in the control group and 179 in the locator group. There was no significant difference in the sex composition between the two groups. The median age and weight of the children in the control puncture group were lower at the time of puncture (Table 1). The main veins selected for insertion in both groups were the basilic vein, the great saphenous vein, and the median cubital vein. The control group had a greater proportion of dorsal hand vein punctures, whereas the locator group had a greater proportion of median cubital vein selections (Table 1). The PICC indwelling catheter length in the locator group exceeded that of the control group.
| Events | Control group (n = 176) | Locator group (n = 179) | p value |
|---|---|---|---|
| Gender (male/female) | 97/79 | 107/72 | 0.374 |
| Median age (months) | 1 (0–146) | 3 (0–179) | 0.009 |
| 0-1 (months) | 102 (57.95%) | 79 (44.13%) | 0.009 |
| 1–12 (months) | 41 (23.30%) | 34 (18.99%) | 0.321 |
| 12–36 (months) | 13 (7.39%) | 21 (11.73%) | 0.164 |
| > 36 (months) | 20 (11.36%) | 45 (25.14%) | 0.001 |
| Median weight (kg) | 3.46 (1.17–26.40) | 4.6 (1.70–37.50) | 0.004 |
| Puncture site | |||
| Basilic vein | 52 (29.55%) | 66 (36.87%) | 0.143 |
| Median cubital vein | 24 (13.64%) | 44 (24.58%) | 0.009 |
| Popliteal vein | 14 (7.95%) | 11 (6.15%) | 0.505 |
| Great saphenous vein | 27 (15.34%) | 33 (18.44%) | 0.437 |
| Dorsal hand vein | 18 (10.23%) | 8 (4.47%) | 0.037 |
| Cephalic vein | 13 (7.38%) | 6 (3.35%) | 0.091 |
| Others | 28 (15.90%) | 11 (6.15%) | |
| Catheter length in body (cm) | 19.16 ± 5.80 | 21.72 ± 7.34 | 0.009 |
3.2. Comparison of Puncture Efficiency
The average number of puncture attempts in the control group was significantly greater than that in the locator group, and the proportion of multiple punctures was also significantly greater in the control group (Table 2). The PICC insertion is often difficult in low-weight children. A comparison of children weighing less than 3 kg revealed that the use of a vein locator significantly increased the success rate of catheter insertion in patients weighing less than 3 kg (Table 3). Many children at our center underwent multiple PICC insertions. Since these children often have veins with better conditions chosen for early puncture, selecting other veins for subsequent PICC insertion is more challenging. For children who were not inserted for the first time, the vein locator effectively reduced the number of punctures and improved the puncture success rate (Table 4). There was no significant difference in the average age or weight of the children who were not inserted for the first time between the two groups.
| Events | Control group (n = 176) | Locator group (n = 179) | p value |
|---|---|---|---|
| Average puncture attempts | 1.39 ± 0.91 (1–5) | 1.01 ± 0.08 (1–2) | < 0.001 |
| Multiple punctures | 34 (19.32%) | 1 (0.56%) | < 0.001 |
| Non-first puncture | 15 (8.52%) | 23 (12.85%) | 0.187 |
| Events | Control group | Locator group | p value |
|---|---|---|---|
| Weight ≤ 3 kg | n = 64 | n = 48 | |
| Average weight (kg) | 2.56 ± 0.39 | 2.49 ± 0.36 | 0.161 |
| Average puncture attempts | 1.33 ± 0.93 (1–5) | 1.00 ± 0.00 (1) | 0.011 |
| Multiple punctures | 8 (12.50%) | 0 (0.00%) | 0.010 |
| Events | Control group (n = 15) | Locator group (n = 23) | p value |
|---|---|---|---|
| Average weight (kg) | 9.25 ± 7.79 | 10.53 ± 8.11 | 0.442 |
| Average puncture attempts | 2.67 ± 1.63 (1–5) | 1.04 ± 0.21 (1–2) | 0.002 |
| Multiple punctures | 9 (60.00%) | 1 (4.35%) | < 0.001 |
3.3. Comparison of PICC-Related Complications
We summarized PICC-related complications after insertion. The control group experienced a greater incidence of catheter-related phlebitis compared with the locator group (Table 5). There was no significant difference in the incidence of catheter-related infections, catheter thrombosis, catheter blockage, catheter displacement, catheter breakage, puncture site exudate, or accidental catheter removal between the two groups (Table 5).
| Events | Control group (n = 176) | Locator group (n = 179) | p value |
|---|---|---|---|
| Infection | 12 | 5 | 0.086 |
| Phlebitis | 5 | 0 | 0.029 |
| Thrombosis | 1 | 1 | 1.000 |
| Blockage | 0 | 0 | 1.000 |
| Puncture site exudate | 0 | 0 | 1.000 |
| Breakage | 0 | 0 | 1.000 |
| Accidental removal | 1 | 0 | 0.496 |
3.4. Comparison of Pain Assessments
For different age groups, we used two pain assessment scales for comparison. For children younger than 12 months, the pain score of the locator group was significantly lower than that of the control group 5 minutes after surgery. For children older than 12 months, there was no significant difference in pain scores between the two groups (Table 6).
| Events | Control group (n = 176) | Locator group (n = 179) | p value |
|---|---|---|---|
| ≤ 12 months | 144 | 116 | |
| Pain score | 2.83 ± 0.89 | 2.62 ± 0.94 | 0.043 |
| > 12 months | 32 | 63 | |
| Pain score | 2.88 ± 0.89 | 2.81 ± 0.94 | 0.717 |
3.5. Comparison of Family Members’ Satisfaction
After puncture, we conducted a questionnaire survey on the satisfaction of the children’s family members. The overall satisfaction of the family members in the locator group was significantly greater than that of the family members in the control group (Table 7).
| Item | Control group (n = 176) | Locator group (n = 179) | p value |
|---|---|---|---|
| Very satisfied | 82 | 95 | |
| Satisfied | 69 | 74 | |
| Neutral | 15 | 8 | |
| Dissatisfied | 10 | 2 | |
| Total satisfaction rate (%) | 85.80 (151/176) | 94.41 (169/179) | 0.006 |
4. Discussion
The PICC is a central venous catheterization method that offers advantages over ordinary deep venous catheterization, including a longer catheter dwell time and a lower incidence of catheter-related complications [9]. However, the PICC insertion is usually quite difficult, especially for pediatric patients [2]. Factors such as age, nutritional status, skin conditions at the puncture site, skin color, vascular selection, and potential vascular variations can affect the success rate of the puncture [10, 11]. Venous visualization technology has been studied in clinical practice for decades, with researchers trying various devices for venous visualization [12, 13]. Early devices had heatable light sources but carried a risk of burns [14]. In recent years, vein locators such as the AV400 have been introduced in clinical practice, and the principle of infrared reflection has been used to expose subcutaneous superficial veins [15, 16]. In the present study, we utilized the AV400 to explore its value for the PICC insertion in children.
During venous puncture, the emphasis is often on the first-time success rate and optimal vascular access [17]. However, owing to significant individual differences among children, the first-time puncture success rate varies widely across studies. The PICC insertion is often performed under local anesthesia, which lacks the convenient operating environment provided by general anesthesia, making the procedure more challenging, especially for infants and malnourished children with poor venous conditions. Multiple puncture attempts increase the child’s pain and pressure on operators, creating a vicious cycle that can lead to conflicts between medical staff and family members. In this study, we found a significant difference in the overall puncture success rate between the two groups of children. The first puncture success rate was significantly greater in the locator group than in the control group. The proportion of children requiring multiple punctures was significantly larger in the control group. Improved puncture efficiency can reduce the separation anxiety caused by children being away from their families, increase family member satisfaction, and reduce potential conflicts between medical staff and families. In this study, although the proportion of multiple punctures in the locator group was lower than that in the control group, the median weight and age of the children in the locator group were greater than those in the control group. This difference in age and weight could affect the statistical power to some extent. Weight has been reported to be a risk factor for PICC insertion failure. To address this discrepancy, we compared the PICC insertion efficiency in low-weight children. Our statistics revealed that when children’s weights were comparable, the venous locator effectively reduced the proportion of multiple punctures in low-weight children and increased the puncture efficiency. Therefore, the conclusions of this study are reasonable. However, the conclusions regarding whether vascular imaging devices can improve puncture efficiency remain inconsistent between studies generally. Although this study suggests that the AV400 may increase the PICC puncture efficiency, its retrospective nature means that the scientific validity of this conclusion still requires further verification [3, 16, 18].
Many patients in our center are children, who suffer from severe malnutrition and require long-term parenteral nutritional support via a central venous channel, with intestinal failure. For these patients, PICC management is challenging, with a relatively high incidence of complications such as catheter infections. Consequently, many children face multiple insertions. These children often have poor venous conditions due to their previous history of puncture, making subsequent punctures more difficult. In this study, the use of the AV400 significantly increased the puncture success rate for children who did not undergo their first insertion. This finding suggests that when operators must choose a vein with poor conditions, the AV400 can improve the puncture efficiency.
In this study, we found that using the AV400 vein locator could effectively reduce the occurrence of certain catheter-related complications. The control group had a greater incidence of phlebitis than did the locator group. There were no significant differences between the two groups regarding other PICC-related complications, such as infections, thrombosis, catheter breakage, displacement, and accidental removal. PICC is a lifeline for many children, and catheter infection is one of the most common complications and a major reason for PICC removal. Using the AV400 increased the success rate of catheter puncture and potentially reduced the puncture time. The reduction in operation time may be one potential factor for the lower incidence of catheter infection in the locator group, but we did not observe this phenomenon. Some studies have also showed that PICC infection is related to the child’s age and the location of the catheter operation [19]. In this study, all the operations were completed in a ward operating room. Patients in the control group had a lower median age and weight, but they did not have a higher rate of catheter-related infections. It has also been reported that the location of the catheter puncture and the type of catheter are associated with the occurrence of PICC phlebitis [20]. In this study, the incidence of phlebitis in the AV400-locator group was lower, but there was no significant correlation between the puncture location, age, and other factors (data not listed), which may be related to the sample size and the retrospective nature of the study. Future studies with a larger sample size and prospective methodologies are needed to further clarify potential factors.
In the past, it was commonly believed that the nervous systems of children, especially newborns and infants, were not fully developed, making them less sensitive to harmful stimuli such as pain. Additionally, children often cannot express pain accurately. As a result, analgesia and pain management for children, particularly newborns and infants, have not received adequate attention. However, numerous studies have showed that children can experience a severe stress response to pain and lack corresponding central inhibitory factors, potentially experiencing pain more intensely compared with adults, which can have long-term effects on children [21, 22]. In this study, we provided sufficient analgesia for the children, maintaining overall pain scores at a low level. For newborns and infants, the use of venous locators further reduces postoperative pain, likely due to factors such as reduced operation time.
This study has several limitations. First, as a retrospective study, it is challenging to control for selection bias and other influencing factors. Second, few indicators related to PICC perioperative outcomes have been reviewed. Future studies should expand the sample size and research parameters through prospective studies to explore the advantages of venous locators for PICC insertions in children.
5. Conclusions
In summary, the use of venous locator to assist in the PICC insertion in pediatric patients can effectively increase the success rate of one-time punctures, reduce the number of multiple punctures, and alleviate pain in children. These benefits are especially beneficial for children with low body weight and a history of PICC insertion. The use of vein locators can also reduce the incidence of PICC-related phlebitis in children. Therefore, the application of vein locators in PICC insertions in children is highly recommended and worthy of promotion.
Conflicts of Interest
The authors declare no conflicts of interest.
Author Contributions
Tian Zhang: conceptualization and writing – review and editing. Chunyan Tang: methodology, writing – original draft, and writing – review and editing. Yang Liu: formal analysis, writing – original draft, and writing – review and editing. Xiaojing Wang: methodology and writing – review. Qun Yu: methodology and writing – review. Chunyan Tang and Yang Liu contributed equally to this work and share the first authorship.
Funding
This research was supported by the Shanghai Sailing Program (22YF1436700) and National Natural Science Foundation of China (82301004).
Acknowledgments
ChatGPT (Version 4.0, OpenAI, USA) was used for language polishing in the manuscript.
Open Research
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
