title: Pediatric intravenous insertion in the emergency department: bevel up or bevel down?
abstract: OBJECTIVE
  Intravenous catheters are usually inserted with the bevel facing up. Bevel down may be superior in small and/or dehydrated children. We seek to determine whether there is a difference in the success rate of intravenous insertion using these 2 methods.
  
  
  METHODS
  We recruited children requiring an intravenous catheter in the emergency department where there was time to obtain consent. Patients were randomized to have the first attempt bevel up or bevel down. If the first attempt was unsuccessful, the alternate technique was used on second attempt. Attempts beyond 2 were not tracked.
  
  
  RESULTS
  We recruited 428 patients. Data are available from 396 (201 bevel-up and 195 bevel-down techniques). At least 63 different nurses participated. The nurses participated in the study a median number of 2 times (maximum, 36). Four nurses used the bevel-down technique more than 10 times. The success rate on first attempt was 75.6% (95% confidence interval [CI], 69.8-81.4) for bevel up and 60% (95% CI, 53.2-66.8) for bevel down. The success rate on second attempt was 56.8% (95% CI, 45.3-68.2) for bevel up and 42.9% (95% CI, 30.3-55.5) for bevel down. In the subgroup of infants weighing less than 5 kg, there was no difference between the 2 techniques on the first attempt, with bevel up having a success of 33% (95% CI, 8.4-57.6) and bevel down 30% (95% CI, 4.1-55.9).
  
  
  CONCLUSIONS
  The bevel-up technique performed superior to bevel-down technique in this study. The bevel-down technique might be useful in small infants.
authors.affiliation: Department of Emergency Medicine and Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada. blackkjl@dal.ca
authors.forename: Karen J L
authors.initials: KJ
authors.lastname: Black
authors.forename: Martin V
authors.initials: MV
authors.lastname: Pusic
authors.forename: Debbie
authors.initials: D
authors.lastname: Harmidy
authors.forename: David
authors.initials: D
authors.lastname: McGillivray
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002406:Catheterization, Peripheral / Q000295:instrumentation / Q000379:methods* / Q000451:nursing; D002648:Child; D002675:Child, Preschool; D004632:Emergency Medical Services / Q000379:methods*; D004636:Emergency Service, Hospital; D004867:Equipment Design; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007262:Infusions, Intravenous / Q000295:instrumentation / Q000379:methods* / Q000451:nursing; D008297:Male; D009339:Needles; D011446:Prospective Studies; D014680:Veins / Q000293:injuries; D014947:Wounds and Injuries / Q000517:prevention & control