CONSTRUCCIÓN Y APLICACIÓN DE UN DIAGRAMA DE FLUJO DE TOMA DE DECISIONES PARA LA PUNCIÓN INTRAVENOSA PERIFÉRICA DIFÍCIL EN NIÑOS

Floriano, Claudia Maria de Freitas; Avelar, Ariane Ferreira Machado; Peterlini, Maria Angélica Sorgini

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Original Article • Texto contexto - enferm. 32 • 2023 • https://doi.org/10.1590/1980-265X-TCE-2023-0040en copiar

CONSTRUCCIÓN Y APLICACIÓN DE UN DIAGRAMA DE FLUJO DE TOMA DE DECISIONES PARA LA PUNCIÓN INTRAVENOSA PERIFÉRICA DIFÍCIL EN NIÑOS

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivos:

construir y verificar la aplicabilidad clínica de un diagrama de flujo para la evaluación de niños y adolescentes que serán sometidos a cateterismo intravenoso periférico según factores de riesgo de falla del procedimiento.

Método:

estudio metodológico y observacional, que siguió las pautas y pasos del instrumento AGREEII para la construcción del diagrama de flujo de toma de decisiones para la punción intravenosa periférica difícil. Posteriormente, se verificó la aplicabilidad clínica con niños y adolescentes, previa aprobación del mérito ético, siendo el resultado principal la tasa de éxito en el primer intento de punción. Se verificó, a través del análisis estadístico, la asociación del desenlace con los factores de riesgo planteados.

Resultado:

en la primera etapa del estudio se realizó una revisión bibliográfica para relevar los factores de riesgo de la punción difícil, encontrándose prematuridad, menos de tres años, piel más pigmentada, obesidad, enfermedades crónicas, deshidratación, vasos difíciles de visualizar y/o palpar, antecedentes de múltiples punciones y complicaciones de la terapia intravenosa. Después de aplicar el diagrama de flujo, se encontró que el 96,3% de los niños y adolescentes evaluados tenían riesgo de ser puncionados más de una vez, y que el 43,9% se sometió a más de un procedimiento con éxito. Los que no tuvieron éxito en el primer intento eran menores de tres años, tenían enfermedad crónica, dificultad para la visualización y palpación de los vasos y antecedentes de múltiples punciones.

Conclusión:

la construcción del diagrama de flujo se basó en los factores de riesgo para punción difícil identificados en la literatura. La aplicabilidad clínica demostró que puede ser una herramienta útil para identificar a niños y adolescentes con riesgo de fracaso de la punción.

DESCRIPTORES:
Enfermería pediátrica; Cateterismo periférico; Infusiones intravenosas; Factores de riesgo; Medición de riesgos

Author/Year/Study design/Sample	Intervention/Comparison	Results	Evidence
*Hartman et al., 2018*1. Hartman JH, Baker J, Bena JF, Morrison SL, Albert NM. Pediatric vascular access peripheral IV algorithm success rate. J Pediatr Nurs [Internet]. 2018 [cited 2022 Oct 24];39:1-6. Available from: https://doi.org/10.1016/j.pedn.2017.12.002 https://doi.org/10.1016/j.pedn.2017.12.0... .11. Hartman JH, Baker J, Bena JF, Morrison SL, Albert NM. Pediatric vascular access peripheral IV algorithm success rate. J Pediatr Nurs [Internet]. 2018 [cited 2022 Oct 24];39:1-6. Available from: https://doi.org/10.1016/j.pedn.2017.12.002 https://doi.org/10.1016/j.pedn.2017.12.0... Study: Before and after. Sample: 419 pre-intervention children, 302 post-intervention children.	Check puncture success rate before and after using a multicomponent algorithm.	Each year added to age, the higher the success rate on the first attempt.	2b.
*Gerceker et al., 2018*2. Gerceker GO, Ayar D, Ozdemir EZ, Bektas M. The impact of the difficult vascular access, fear, and anxiety level in children on the success of first-time phlebotomy. J Vasc Access [Internet]. 2018 [cited 2022 Oct 24];19(6):620-5. Available from: https://doi.org/10.1177/1129729818765598 https://doi.org/10.1177/1129729818765598... .22. Gerceker GO, Ayar D, Ozdemir EZ, Bektas M. The impact of the difficult vascular access, fear, and anxiety level in children on the success of first-time phlebotomy. J Vasc Access [Internet]. 2018 [cited 2022 Oct 24];19(6):620-5. Available from: https://doi.org/10.1177/1129729818765598 https://doi.org/10.1177/1129729818765598... Study: Observational. Sample: 155 children: 4 to 10 years.	Check the success rate on the first attempt and the relationship with children’s degree of anxiety and past history of difficult puncture.	There was a correlation between success in the first attempt and age and previous history of difficult puncture.	2c.
*Choden et al., 2018*3. Choden J, Carr PJ, Brock AR, Esterman A. Nurse performed peripheral intravenous catheter first time insertion success in pediatric patients in Bhutan: An observational study. J Vasc Access [Internet]. 2018 [cited 2022 Oct 24];20(2):184-9. Available from: http://doi.org/10.1177/1129729818792826 http://doi.org/10.1177/1129729818792826... .33. Choden J, Carr PJ, Brock AR, Esterman A. Nurse performed peripheral intravenous catheter first time insertion success in pediatric patients in Bhutan: An observational study. J Vasc Access [Internet]. 2018 [cited 2022 Oct 24];20(2):184-9. Available from: http://doi.org/10.1177/1129729818792826 http://doi.org/10.1177/1129729818792826... Study: Observational. Sample: 200 children: 0 to 12 years.	Check the first attempt success rate and potential factors that could influence success.	Success in the first puncture attempt was influenced by age, more pigmented skin and the veins not being visible.	2c.
Demir et al., 2017.1515. Demir D, Inal S. Does the use of a vein visualization device for peripheral venous catheter placement increase success rate in pediatric patients? Pediatr Emerg Care [Internet]. 2017 [cited 2022 Nov 10];35(7):474-9. Available from: http://doi.org/10.1097/PEC.0000000000001007 http://doi.org/10.1097/PEC.0000000000001... Study: Randomized controlled. Sample: 129 children: 72 in the experimental group and 57 in the control group	Assess the degree of difficulty in visualizing and palpating the veins, the presence of venous damage.	Children whose veins were difficult-to-see and palpable and the presence of a lesion at the puncture site benefited from infrared equipment use.	1b.
Parker et al., 2016.55. Parker SIA, Benzies KM, Hayden KA. A systematic review: effectiveness of pediatric peripheral intravenous catheterization strategies. J Adv Nurs [Internet]. 2017 [cited 2022 Oct 24];73(7):1570-82. Available from: https://doi.org/10.1111/jan.13211 https://doi.org/10.1111/jan.13211... Study: Systematic review. Sample: 15 studies were included in the final review.	Identify interventions associated with success in the first puncture attempt in hospitalized children.	Children with difficult-to-see or non-palpable veins benefited from ultrasound and transillumination use to visualize the veins.	1b.
*Guillon et al., 2015*16. Guillon P, Makhloufi M, Baillie S, Roucoulet C, Dolimier E, Masquelier AM. Prospective evaluation of venous access difficulty and a near-infrared vein visualizer at four French haemophilia treatment centers. Haemophilia [Internet]. 2015 [cited 2022 Nov 10];21(1):21-6. Available from: https://doi.org/10.1111/hae.12513 https://doi.org/10.1111/hae.12513 ... .1616. Guillon P, Makhloufi M, Baillie S, Roucoulet C, Dolimier E, Masquelier AM. Prospective evaluation of venous access difficulty and a near-infrared vein visualizer at four French haemophilia treatment centers. Haemophilia [Internet]. 2015 [cited 2022 Nov 10];21(1):21-6. Available from: https://doi.org/10.1111/hae.12513 https://doi.org/10.1111/hae.12513 ... Study: Random multicentric. Sample: 450 children with hematological problems, 229 of which made up the intervention group and 221, the control group	Check the clinical usefulness of infrared to help visualize the veins of children with and without risk for difficult puncture and risk factors associated with difficult puncture.	Risk for puncture failure was caused by unavailable veins, young age, overweight and difficult-to-see veins.	2b.
*Kiger et al., 2014*17. Kiger T, Knudsen EA, Curran W, Hunter J, Schaub A, Williams MJ, et al. Survey of heat use during peripheral IV insertion by health care workers. J Infus Nurs [Internet]. 2014 [cited 2022 Nov 10];37(6):433-40. Available from: https://doi.org/10.1097/nan.0000000000000074 https://doi.org/10.1097/nan.000000000000... .1717. Kiger T, Knudsen EA, Curran W, Hunter J, Schaub A, Williams MJ, et al. Survey of heat use during peripheral IV insertion by health care workers. J Infus Nurs [Internet]. 2014 [cited 2022 Nov 10];37(6):433-40. Available from: https://doi.org/10.1097/nan.0000000000000074 https://doi.org/10.1097/nan.000000000000... Study: Observational. Sample: 907 professionals who performed peripheral intravenous puncture.	Identify common practices performed during puncture.	Using heat to facilitate the puncture was more used in children that was difficult-to-see or palpable veins and with a previous history of difficult puncture.	2c.
Graaff et al., 2013.1818. de Graaff JC, Cuper NJ, Mungra RA, Vlaardingerbroek K, Numan SC, Kalkman CJ. Near-infrared light to aid peripheral intravenous cannulation in children: a cluster randomised clinical trial of three devices. Anaesthesia [Internet]. 2013 [cited 2022 Nov 10];68(8):835-45. Available from: https://doi.org/10.1111/anae.12294 https://doi.org/10.1111/anae.12294... Study: Randomized and controlled. Sample: 1,383 children were divided into four groups. 444 composed the control group; 357, intervention group 1; 292, intervention group 2; and 290, the intervention group 3.	Compared the use of three infrared devices to visualize the veins with the conventional technique in children.	In the subgroup of children whose veins were not visible, the equipment helped to visualize the veins.	1b.
Van der Woude et al., 2013.1919. van der Woude OC, Cuper NJ, Getrouw C, Kalkman CJ, de Graaff JC. The effectiveness of a near-infrared vascular imaging device to support intravenous cannulation in children with dark skin color: a cluster randomized clinical trial. Anesth Analg [Internet]. 2013 [cited 2022 Nov 10];116(6):1266-71. Available from: https://doi.org/10.1213/ane.0b013e31828e5bde https://doi.org/10.1213/ane.0b013e31828e... Study: Randomized and controlled. Sample: 88 children: 45 composed the control group and 43, the experimental group.	Check whether children with dark skin color who would use transillumination to assist in puncture had greater success in the procedure on the first attempt.	Children younger than three years old and whose veins were difficult to visualize and palpate had greater success in the first attempt in the group that used infrared.	1b.
*Heinrichs et al., 2013*20. Heinrichs J, Fritze Z, Vandermeer B, Klassen T, Curtis S. Ultrasonographically guided peripheral intravenous cannulation of children and adults: a systematic review and meta-analysis. Ann Emerg Med [Internet]. 2013 [cited 2022 Nov 10];61(4):444-54 e1. Available from: https://doi.org/10.1016/j.annemergmed.2012.11.014 https://doi.org/10.1016/j.annemergmed.20... .2020. Heinrichs J, Fritze Z, Vandermeer B, Klassen T, Curtis S. Ultrasonographically guided peripheral intravenous cannulation of children and adults: a systematic review and meta-analysis. Ann Emerg Med [Internet]. 2013 [cited 2022 Nov 10];61(4):444-54 e1. Available from: https://doi.org/10.1016/j.annemergmed.2012.11.014 https://doi.org/10.1016/j.annemergmed.20... Study: Systematic review. Sample: nine studies.	Assess whether ultrasound-guided puncture in children decreases procedure failure and the number of attempts.	Children under 10 years of age had fewer attempts and less procedure time when ultrasound was used.	1a.
*Chiao et al., 2013*21. Chiao FB, Resta-Flarer F, Lesser J, Ng J, Ganz A, Pino-Luey D, et al. Vein visualization: patient characteristic factors and efficacy of a new infrared vein finder technology. Br J Anaesth [Internet]. 2013 [cited 2022 Nov 10];110(6):966-71. Available from: https://doi.org/10.1093/bja/aet003 https://doi.org/10.1093/bja/aet003 ... .2121. Chiao FB, Resta-Flarer F, Lesser J, Ng J, Ganz A, Pino-Luey D, et al. Vein visualization: patient characteristic factors and efficacy of a new infrared vein finder technology. Br J Anaesth [Internet]. 2013 [cited 2022 Nov 10];110(6):966-71. Available from: https://doi.org/10.1093/bja/aet003 https://doi.org/10.1093/bja/aet003 ... Study: Randomized and crossed. Sample: 384 pediatric patients.	Assess factors related to patients that make it difficult-to-see veins and verify whether using transillumination technology helps in locating the veins.	Vein visualization was more difficult among children aged zero to two years with dark skin color and infrared equipment helped to locate at least six veins.	1b.
*Goff et al., 2013*22. Goff DA, Larsen P, Brinkley J, Eldridge D, Newton D, Hartzog T, et al. Resource utilization and cost of inserting peripheral intravenous catheters in hospitalized children. Hosp Pediatr [Internet]. 2013 [cited 2022 Nov 10];3(3):185-91. Available from: https://doi.org/10.1542/hpeds.2012-0089 https://doi.org/10.1542/hpeds.2012-0089... .2222. Goff DA, Larsen P, Brinkley J, Eldridge D, Newton D, Hartzog T, et al. Resource utilization and cost of inserting peripheral intravenous catheters in hospitalized children. Hosp Pediatr [Internet]. 2013 [cited 2022 Nov 10];3(3):185-91. Available from: https://doi.org/10.1542/hpeds.2012-0089 https://doi.org/10.1542/hpeds.2012-0089... Study: Observational. Sample: 592 children who were punctured 1,135 times.	Check the cost of puncture performed by non-specialist nurses, its increase when other professionals or resources are needed and its association with child characteristics.	Children younger than two years old and between two and five years old suffered more than one puncture attempt, with a higher cost to perform the procedure. Dehydration was also a factor in the increase in cost.	2c.
*Kaddoum et al., 2012*23. Kaddoum RN, Anghelescu DL, Parish ME, Wright BB, Trujillo L, Wu J, et al. A randomized controlled trial comparing the AccuVein AV300 device to standard insertion technique for intravenous cannulation of anesthetized children. Paediatr Anaesth [Internet]. 2012 [cited 2022 Nov 10];22(9):884-9. Available from: https://doi.org/10.1111/j.1460-9592.2012.03896.x https://doi.org/10.1111/j.1460-9592.2012... .2323. Kaddoum RN, Anghelescu DL, Parish ME, Wright BB, Trujillo L, Wu J, et al. A randomized controlled trial comparing the AccuVein AV300 device to standard insertion technique for intravenous cannulation of anesthetized children. Paediatr Anaesth [Internet]. 2012 [cited 2022 Nov 10];22(9):884-9. Available from: https://doi.org/10.1111/j.1460-9592.2012.03896.x https://doi.org/10.1111/j.1460-9592.2012... Study: Randomized and controlled. Sample: 146 children: 72 composed the experimental group and 74, the control.	Check the effectiveness in increasing the success of puncture when infrared equipment is used to assist the procedure.	Children with more pigmented skin and whose vein was difficult-to-see and/or palpable had a higher success rate with infrared puncture.	1b.
*Peterson et al., 2012*24. Peterson KA, Phillips AL, Truemper E, Agrawal S. Does the use of an assistive device by nurses impact peripheral intravenous catheter insertion success in children? J Pediatr Nurs [Internet]. 2012 [cited 2022 Nov 10];27(2):134-43. Available from: https://doi.org/10.1016/j.pedn.2010.10.009 https://doi.org/10.1016/j.pedn.2010.10.0... .2424. Peterson KA, Phillips AL, Truemper E, Agrawal S. Does the use of an assistive device by nurses impact peripheral intravenous catheter insertion success in children? J Pediatr Nurs [Internet]. 2012 [cited 2022 Nov 10];27(2):134-43. Available from: https://doi.org/10.1016/j.pedn.2010.10.009 https://doi.org/10.1016/j.pedn.2010.10.0... Study: Observational. Sample: 546 children who were punctured 1,354 times in up to four attempts.	Check if the success of puncture would be greater with transillumination equipment use compared to the traditional method.	Children’s age influenced the success of puncture, with every six months of increase in age, the better procedure success when the equipment with LED is used.	2c.
*Negri et al., 2011*12. Negri DC, Avelar AFM, Andreoni S, Pedreira MLG. Predisposing factors for peripheral intravenous puncture failure in children. Rev Lat Am Enfermagem [Internet]. 2011 [cited 2022 Nov 10];27(1):5-10. Available from: https://doi.org/10.1590/S0104-11692012000600009 https://doi.org/10.1590/S0104-1169201200... .1212. Negri DC, Avelar AFM, Andreoni S, Pedreira MLG. Predisposing factors for peripheral intravenous puncture failure in children. Rev Lat Am Enfermagem [Internet]. 2011 [cited 2022 Nov 10];27(1):5-10. Available from: https://doi.org/10.1590/S0104-11692012000600009 https://doi.org/10.1590/S0104-1169201200... Study: Cohort Sample: 335 children and adolescents.	Determine predictive variables or those that influenced the success of puncture.	Clinical history of failed previous punctures, malnutrition, previous hospitalizations and previous IVT use influenced procedure success.	2b.
Champman et al., 2011.2525. Chapman LL, Sullivan B, Pacheco AL, Draleau CP, Becker BM. VeinViewer-assisted intravenous catheter placement in a pediatric emergency department. Acad Emerg Med [Internet]. 2011 [cited 2022 Nov 10];18(9):966-71. Available from: https://doi.org/10.1111/j.1553-2712.2011.01155.x https://doi.org/10.1111/j.1553-2712.2011... Study: Randomized and controlled. Sample: 326 children and adolescents: 163 in the control group and 163 in the experimental group.	Check the procedure time, number of attempts, pain referred by patient and degree of satisfaction of professionals and parents in relation to transillumination equipment use.	Children younger than two years had a shorter puncture time when the infrared was used to aid the puncture.	2b.
*Perry et al., 2011*26. Perry AM, Caviness AC, Hsu DC. Efficacy of a near-infrared light device in pediatric intravenous cannulation: a randomized controlled trial. Pediatr Emerg Care [Internet]. 2011 [cited 2022 Nov 10];27(1):5-10. Available from: https://doi.org/10.1097/pec.0b013e3182037caf https://doi.org/10.1097/pec.0b013e318203... .2626. Perry AM, Caviness AC, Hsu DC. Efficacy of a near-infrared light device in pediatric intravenous cannulation: a randomized controlled trial. Pediatr Emerg Care [Internet]. 2011 [cited 2022 Nov 10];27(1):5-10. Available from: https://doi.org/10.1097/pec.0b013e3182037caf https://doi.org/10.1097/pec.0b013e318203... Study: Randomized and controlled. Sample: 123 children between zero and 20 years old: 61 composed the experimental group, and 62, the control.	Compare success in the first attempt at guided puncture with and without infrared equipment in children with compromised veins.	Children younger than one year old, weighing less than 10 kg, who had some chronic disease, who were dehydrated and who had a history of difficult puncture had a better success rate for puncture when infrared was used.	2b.
*Riker et al., 2011*14. Riker MW, Kennedy C, Winfrey BS, Yen K, Dowd MD. Validation and refinement of the difficult intravenous access score: a clinical prediction rule for identifying children with difficult intravenous access. Acad Emerg Med [Internet]. 2011 [cited 2022 Nov 10];18(11):1129-34. Available from: https://doi.org/10.1111/j.1553-2712.2011.01205.x https://doi.org/10.1111/j.1553-2712.2011... .1414. Riker MW, Kennedy C, Winfrey BS, Yen K, Dowd MD. Validation and refinement of the difficult intravenous access score: a clinical prediction rule for identifying children with difficult intravenous access. Acad Emerg Med [Internet]. 2011 [cited 2022 Nov 10];18(11):1129-34. Available from: https://doi.org/10.1111/j.1553-2712.2011.01205.x https://doi.org/10.1111/j.1553-2712.2011... Study: Observational. Sample: 366 children, 75 for each age group, between 0 and 11 months, 12 and 23 months, 24 and 25 months and 36 months or more.	Check the success rate in the first puncture attempt using tourniquet among patients who were assessed in terms of skin color and whether the veins were visible and palpable.	Non-palpable veins, non-visible veins, age and history of admission to the Neonatal Intensive Care Unit significantly influenced puncture success in the first attempt.	2c.
*Nafiu et al., 2010*27. Nafiu OO, Burke C, Cowan A, Tutuo N, Maclean S, Tremper KK. Comparing peripheral venous access between obese and normal weight children. Paediatr Anaesth [Internet]. 2010 [cited 2022 Nov 10];20(2):172-6. Available from: https://doi.org/10.1111/j.1460-9592.2009.03198.x https://doi.org/10.1111/j.1460-9592.2009... .2727. Nafiu OO, Burke C, Cowan A, Tutuo N, Maclean S, Tremper KK. Comparing peripheral venous access between obese and normal weight children. Paediatr Anaesth [Internet]. 2010 [cited 2022 Nov 10];20(2):172-6. Available from: https://doi.org/10.1111/j.1460-9592.2009.03198.x https://doi.org/10.1111/j.1460-9592.2009... Study: Observational. Sample: 103 children between 2 and 18 years.	Check the relationship between Body Mass Index and the ease of obtaining a successful puncture.	Obese children with non-visible and non-palpable veins had a lower rate of success in the first attempt, a greater number of attempts and time for the procedure to be successful.	2c.
Hess HA, 201028. Hess HA. A biomedical device to improve pediatric vascular access success. Pediatr Nurs [Internet]. 2010 [cited 2022 Nov 10];36(5):259-63. Available from: https://www.researchgate.net/publication/47741351_A_biomedical_device_to_improve_pediatric_vascular_access_success https://www.researchgate.net/publication... .2828. Hess HA. A biomedical device to improve pediatric vascular access success. Pediatr Nurs [Internet]. 2010 [cited 2022 Nov 10];36(5):259-63. Available from: https://www.researchgate.net/publication/47741351_A_biomedical_device_to_improve_pediatric_vascular_access_success https://www.researchgate.net/publication... Study: Observational. Sample: 241 children between zero and 17 years old: 91 composed the experimental group, and 150, the control group.	Check first puncture attempt success, procedure time and number of attempts using transillumination equipment.	Children under six years of age were successful in the first attempt at a larger puncture in the group that used infrared.	2c.
*Larsen et al., 2010*13. Larsen P, Eldridge D, Brinkley J, Newton D, Goff D, Hartzog T, et al. Pediatric peripheral intravenous access: does nursing experience and competence really make a difference? J Infus Nurs [Internet]. 2010 [cited 2022 Nov 10];33(4):226-35. Available from: https://doi.org/10.1097/NAN.0b013e3181e3a0a8 https://doi.org/10.1097/NAN.0b013e3181e3... .1313. Larsen P, Eldridge D, Brinkley J, Newton D, Goff D, Hartzog T, et al. Pediatric peripheral intravenous access: does nursing experience and competence really make a difference? J Infus Nurs [Internet]. 2010 [cited 2022 Nov 10];33(4):226-35. Available from: https://doi.org/10.1097/NAN.0b013e3181e3a0a8 https://doi.org/10.1097/NAN.0b013e3181e3... Study: Observational. Sample: 592 children between zero and 18 years old who were punctured 1,135 times.	Check the number of attempts and the time required by pediatric nurses for a successful puncture and which characteristics related to children and professionals could interfere with the time and number of puncture attempts.	Children under two years of age with a history of difficult puncture had a higher rate of failure in the first puncture attempt.	2c.
*Simhi et al., 2008*29. Simhi E, Kachko L, Bruckheimer E, Katz J. A vein entry indicator device for facilitating peripheral intravenous cannulation in children: a prospective, randomized, controlled trial. Anesth Analg [Internet]. 2008 [cited 2022 Nov 10];107(5):1531-5. Available from: https://doi.org/10.1213/ane.0b013e318185cdab https://doi.org/10.1213/ane.0b013e318185... .2929. Simhi E, Kachko L, Bruckheimer E, Katz J. A vein entry indicator device for facilitating peripheral intravenous cannulation in children: a prospective, randomized, controlled trial. Anesth Analg [Internet]. 2008 [cited 2022 Nov 10];107(5):1531-5. Available from: https://doi.org/10.1213/ane.0b013e318185cdab https://doi.org/10.1213/ane.0b013e318185... Study: Randomized and controlled. Sample: 202 children between 3 months and 17 years old: 101 composed the control group, and 101, the experimental group.	Check first attempt success, number of attempts and the total time for the procedure to be successful, after assessing the veins with and without devices to facilitate the intravenous catheter insertion.	Children with veins that are difficult-to-see and not palpable benefited from using the device to facilitate puncture.	2b.
*Yen et al., 2008*30. Yen K, Riegert A, Gorelick MH. Derivation of the DIVA score: a clinical prediction rule for the identification of children with difficult intravenous access. Pediatr Emerg Care [Internet]. 2008 [cited 2022 Nov 10];24(3):143-7. Available from: https://doi.org/10.1097/pec.0b013e3181666f32 https://doi.org/10.1097/pec.0b013e318166... .3030. Yen K, Riegert A, Gorelick MH. Derivation of the DIVA score: a clinical prediction rule for the identification of children with difficult intravenous access. Pediatr Emerg Care [Internet]. 2008 [cited 2022 Nov 10];24(3):143-7. Available from: https://doi.org/10.1097/pec.0b013e3181666f32 https://doi.org/10.1097/pec.0b013e318166... Study: Cohort. Sample: 650 children between zero and 21 years old.	Develop an instrument with clinical, sensitive and easy-to-apply factors to identify children who may be difficult to puncture.	Age, history of prematurity, veins visibility and palpation were the effective variables to assess children difficult to be punctured.	2b.
*Atalay et al., 2005*31. Atalay H, Erbay H, Tomatir E, Serin S, Oner O. The use of transillumination for peripheral venous access in paediatric anaesthesia. Eur J Anaesthesiol [Internet]. 2005 [cited 2022 Nov 10];22(4):317-8. Available from: https://doi.org/10.1017/s026502150524053x https://doi.org/10.1017/s026502150524053... .3131. Atalay H, Erbay H, Tomatir E, Serin S, Oner O. The use of transillumination for peripheral venous access in paediatric anaesthesia. Eur J Anaesthesiol [Internet]. 2005 [cited 2022 Nov 10];22(4):317-8. Available from: https://doi.org/10.1017/s026502150524053x https://doi.org/10.1017/s026502150524053... Study: Observational. Sample: 334 children aged 0-36 months who were punctured 434 times.	Investigate the effectiveness of the transillumination technique to perform puncture.	Children with a mean age of 20 months, non-visible or non-palpable veins and previous IVT use benefited from LED equipment use. Obesity and previous history of multiple punctures were the variables that prevented success.	2c.
*Goren et al., 2001*32. Goren A, Laufer J, Yativ N, Kuint J, Ben Ackon M, Rubinshtein M, et al. Transillumination of the palm for venipuncture in infants. Pediatr Emerg Care [Internet]. 2001 [cited 2022 Nov 10];17(2):130-1. Available from: https://doi.org/10.1097/00006565-200104000-00013 https://doi.org/10.1097/00006565-2001040... .3232. Goren A, Laufer J, Yativ N, Kuint J, Ben Ackon M, Rubinshtein M, et al. Transillumination of the palm for venipuncture in infants. Pediatr Emerg Care [Internet]. 2001 [cited 2022 Nov 10];17(2):130-1. Available from: https://doi.org/10.1097/00006565-200104000-00013 https://doi.org/10.1097/00006565-2001040... Study: Observational. Sample: 100 children aged between 2 and 36 months: 40 of them required transillumination use.	Investigate the effectiveness of using transillumination in the palmar region to perform puncture.	Children with a mean age of 16.7 months, dehydrated, septic and with veins difficult-to-see had a better success rate with LED equipment use.	2c.
*Franck et al., 2001*33. Franck LS, Hummel D, Connell K, Quinn D, Montgomery J. The safety and efficacy of peripheral intravenous catheters in ill neonates. Neonatal Netw [Internet]. 2001 [cited 2022 Nov 10];20(5):33-8. Available from: https://doi.org/10.1891/0730-0832.20.5.33 https://doi.org/10.1891/0730-0832.20.5.3... .3333. Franck LS, Hummel D, Connell K, Quinn D, Montgomery J. The safety and efficacy of peripheral intravenous catheters in ill neonates. Neonatal Netw [Internet]. 2001 [cited 2022 Nov 10];20(5):33-8. Available from: https://doi.org/10.1891/0730-0832.20.5.33 https://doi.org/10.1891/0730-0832.20.5.3... Study: Observational. Sample: 57 children who were punctured 264 times.	Establish the prevalence of complications related to puncture and identify risk factors.	Gestational age influenced the number of puncture attempts.	2c.
*Fein et al., 1999*34. Fein JA, Callahan JM, Boardman CR, Gorelick MH. Predicting the need for topical anesthetic in the pediatric emergency department. Pediatrics [Internet]. 1999 [cited 2022 Nov 10];104(2):e19. Available from: https://doi.org/10.1542/peds.104.2.e19 https://doi.org/10.1542/peds.104.2.e19... .3434. Fein JA, Callahan JM, Boardman CR, Gorelick MH. Predicting the need for topical anesthetic in the pediatric emergency department. Pediatrics [Internet]. 1999 [cited 2022 Nov 10];104(2):e19. Available from: https://doi.org/10.1542/peds.104.2.e19 https://doi.org/10.1542/peds.104.2.e19... Study: Observational. Sample: 4,926 children were assessed and 2,052 were included.	Assess nurses’ ability to verify whether screened patients would be punctured and determine risk factors for puncture failure.	Children younger than one year old, with chronic diseases, had a higher risk of being punctured and not being successful.	2c.

Variables	Number of attempts		p
	1 (n=60)	2 or more (n=47)
	f(%)	f(%)
Age (years)			0.233^*
Mean ± SD^§	6.6±4.5	5.5±5.3
Sex			0.936^†
Female	26 (43.3)	20 (42.6)
Male	34 (56.7)	27 (57.4)
Body Mass Index			0.883^†
Thinness	7 (11.7)	7 (14.9)
Eutrophy	42 (70.0)	32 (68.1)
Obesity	11 (18.3)	8 (17.0)
Skin pigmentation			0.686^†
More	27 (45.0)	23 (48.9)
Less	33 (55.0)	24 (51.1)
Type of treatment			0.493^†
Clinical	48 (80.0)	40 (85.1)
Surgical	12 (20.0)	7 (14.9)
Clinical condition			0.095^†
Acute	26 (43.3)	13 (27.7)
Chronic	34 (56.7)	34 (72.3)
Previous IVT use^\|\|			0.795^†
Yes	19 (31.7)	16 (34.0)
No	41 (68.3)	31 (66.0)
Time of previous IVT use^\|\| (days)			0.888^‡
Mean ± SD	4.5±4.5	6.3±8.8
Previous complication related to IVT^\|\|			0.205^†
No	25 (41.7)	14 (29.8)
Yes	35 (58.3)	33 (70.2)
Intravenous catheter gauge (Gauge)			0.491^†
22	23 (38.3)	15 (31.9)
24	37 (61.7)	32 (68.1)

Predisposing factors for peripheral intravenous puncture failure	Number of attempts		p
	1 (n=60)	2 or more (n=47)
	f(%)	f(%)
Premature birth history			0.961^*
Yes	10 (55.5)	8 (44.5)
No	50 (56.2)	39 (43.8)
Less than 3 years			0.003*
Yes	14 (36.8)	24 (63.2)
No	46 (66.7)	23 (33.3)
More pigmented skin			0.686*
Yes	33 (57.9)	24 (42.1)
No	27 (54.0)	23 (46.0)
Obese			0.860*
Yes	11 (57.9)	8 (42.1)
No	49 (55.7)	39 (44.3)
Chronic disease			0.095*
Yes	34 (50.0)	34 (50.0)
No	26 (66.7)	13 (33.3)
Dehydration			0.129^†
Yes	4 (100.0)	Z^‡
No	56 (54.4)	47 (45.6)
Difficult-to-see veins			0.046*
Yes	18 (43.9)	23 (56.1)
No	42 (63.6)	24 (36.4)
Veins not palpable			0.064*
Yes	10 (40.0)	15 (60.0)
No	50 (61.0)	32 (39.0)
History of multiple punctures			0.025*
Yes	38 (49.4)	39 (50.6)
No	22 (73.3)	8 (26.7)
Complication of previous IVT^§			0.389*
Yes	36 (52.9)	32 (47.1)
No	24 (61.5)	15 (38.5)

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[1] CORRESPONDING AUTHOR
Claudia Maria de Freitas Floriano cmffloriano@gmail.com