Technical Challenges of Ultrasound-Guided IV Placement in Children

Ultrasound-guided peripheral intravenous (IV) catheter placement has emerged as a valuable technique in pediatric care, particularly for children with difficult intravenous access. Compared with traditional landmark-based methods, ultrasound guidance can improve first-attempt success rates, reduce the number of venipuncture attempts, and enhance patient and caregiver satisfaction. Despite these benefits, the literature consistently highlights that ultrasound-guided IV placement in children presents distinct technical challenges that limit its universal success and adoption. These challenges arise from pediatric anatomy, operator skill requirements, patient cooperation, equipment constraints, and procedural ergonomics.

A primary technical challenge relates to pediatric anatomy and physiology. Children have smaller, more fragile veins with thinner vessel walls, increasing the risk of vein collapse or infiltration during cannulation. Veins may also be located deeper beneath the skin, particularly in infants, toddlers, and children with obesity, which complicates ultrasound visualization and needle advancement. Compared with adults, pediatric patients have greater anatomical variability and fewer consistent landmarks, making vein identification and cannulation more technically demanding even when ultrasound is used. These factors require precise probe positioning, optimal image optimization, and careful needle control to avoid posterior wall puncture or extravasation.

Operator skill and training represent another major barrier. Ultrasound-guided IV placement requires proficiency in both ultrasound image acquisition and real-time needle visualization, skills that are not routinely taught in standard pediatric training. Clinicians must master hand–eye coordination, probe orientation, and depth perception while simultaneously advancing the catheter. Needle tip visualization is particularly challenging, especially with the commonly used short-axis, out-of-plane approach, where the needle appears only as a bright dot on the screen. Losing sight of the needle tip can lead to failed cannulation or vessel injury. Although the long-axis, in-plane approach allows continuous visualization of the needle, it requires precise alignment that can be difficult to maintain in small pediatric veins. The lack of standardized training curricula and inconsistent opportunities for supervised practice further contribute to variability in success rates among providers.

Patient cooperation and movement significantly affect procedural success. Anxiety, fear, or discomfort during IV placement presents significant challenges in many children, as it leads to movement that disrupts ultrasound imaging and needle targeting. Even small movements can cause loss of vessel visualization or needle alignment. While immobilization techniques and distraction strategies may help, they are not always sufficient. In some cases, sedation may be considered, but this introduces additional risks, resource requirements, and clinical decision-making complexities.

Equipment-related limitations also pose challenges. High-frequency linear transducers are essential for visualizing superficial pediatric veins, yet access to appropriately sized probes may be limited, particularly in smaller institutions or resource-constrained settings. Ultrasound machines may not be readily available in all clinical areas, and suboptimal image quality can impair vein identification and needle tracking. Additionally, selecting the correct catheter length

is critical, as deeper veins accessed under ultrasound guidance are associated with higher failure rates if standard-length catheters are used.

Finally, procedural ergonomics can either ease or exacerbate the challenges of using ultrasound-guided IV placement in children. Proper positioning of the patient, ultrasound machine, probe, and operator is necessary to maintain stable visualization and comfortable hand movements. Poor ergonomics can lead to technical errors, increased procedure time, and operator fatigue. The integration of ultrasound imaging with dynamic needle advancement requires refined psychomotor coordination, which develops only with repeated practice.

References

1. Mitchell EO, Jones P, Snelling PJ. Ultrasound for pediatric peripheral intravenous catheter insertion: a systematic review. Pediatrics. 2022;149(5):e2021055523. DOI: 10.1542/peds.2021-055523

2. Moustaqim-Barrette M, Riehm L, Parra DA, Munshey F. Technical challenges when performing ultrasound-guided peripheral intravenous placement in children. Paediatr Anaesth. 2025. DOI: 10.1111/pan.70076

3. Munshey F, Parra DA, McDonnell C, Matava C. Ultrasound-guided techniques for peripheral intravenous placement in children with difficult venous access. Paediatr Anaesth. 2020;30(2):108-115. DOI: 10.1111/pan.13780

4. Bruant A. Recent advances in ultrasound-guided peripheral intravenous catheter insertion. Curr Pediatr Rev. 2025;15(10):359. DOI: 10.3390/nursrep15100359