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Updated: Nov 22, 2025
Assessment of Vascular Function in Patients With Chronic Kidney Disease
Published on: June 16, 2014
"Save the Vein" Initiative in Children With CKD: A Quality Improvement Study
Nisha S Singh1, JoLynn Grimes1, Gina K Gregg1
1Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO.
Insights
An initiative successfully increased peripheral intravenous (PIV) catheter placement in the dominant arm for pediatric patients with chronic kidney disease (CKD). This vein preservation strategy is crucial for future arteriovenous fistula creation in children requiring long-term hemodialysis.
Area of Science:
- Pediatric Nephrology
- Vascular Access Management
- Quality Improvement in Healthcare
Background:
- Arteriovenous fistulas are preferred for hemodialysis, but prior peripheral intravenous (PIV) catheter use can compromise future fistula creation.
- Pediatric patients with chronic kidney disease (CKD) may require lifelong dialysis, making vein preservation critical.
- Limited options for arteriovenous fistula creation pose a significant challenge for long-term pediatric hemodialysis.
Purpose of the Study:
- To implement and evaluate a quality improvement initiative focused on increasing PIV catheter placement in the dominant arm of hospitalized pediatric patients with advanced CKD.
- To preserve vascular integrity in pediatric CKD patients, thereby safeguarding options for future arteriovenous fistula creation.
- To reduce the incidence of PIV catheter placement in the non-dominant arm among pediatric CKD patients.
Main Methods:
- A quality improvement initiative was implemented at a single children's hospital.
- Key interventions included multidisciplinary team, patient, and parent education on vein preservation.
- Standardized protocols involved electronic medical record notes, "restricted extremity" arm bands, and vascular access team involvement.
Main Results:
- Baseline PIV catheter placement in the dominant arm was 47% (34/72), significantly increasing to 93% (345/371) post-initiative.
- In children under 5 years old, dominant arm PIV placement rose from 25% (2/8) to 94% (58/62).
- The study observed a reduction in PIV placement in the antecubital vein, with only 10% (38/371) occurring there post-initiative.
Conclusions:
- Education and standardized processes for vein preservation can effectively guide PIV catheter placement in pediatric CKD patients.
- This initiative demonstrates a successful strategy to preserve vasculature, enhancing future arteriovenous fistula options.
- Implementing targeted PIV placement protocols is vital for long-term vascular health in pediatric CKD management.
Rationale & Objective:
The preferred vascular access for hemodialysis recipients is an arteriovenous fistula in the nondominant arm. Prior placement of a peripheral intravenous (PIV) catheter can lead to vascular injury and limit options for arteriovenous fistula creation, a particular problem for children, who may need hemodialysis for their entire lifetime. We instituted an initiative to increase the frequency of PIV catheter placement in the dominant arm for hospitalized pediatric patients with advanced chronic kidney disease (CKD).
Study Design:
Quality improvement initiative.
Setting & Participants:
Children with CKD stage 3-5, receiving dialysis, and/or following kidney transplantation who were hospitalized at one children's hospital between September 2018 and August 2020.
Quality Improvement Activities:
Retrospective data on PIV catheter location for patients from January 1 to June 30, 2017, served as baseline data. Quality improvement activities consisted of: 1) education of the multidisciplinary treatment team, patients, and parents regarding importance of vein preservation; 2) placement of individualized notes in the electronic medical record identifying the preferred arm for PIV catheter placement; 3) use of "restricted extremity" arm bands; and 4) vascular access team participation to minimize attempts for PIV catheter placement.
Outcome:
Monthly compliance with placement of PIV catheters in dominant arms.
Analytical Approach:
Location of PIV catheter placements were determined monthly and used to create run charts describing compliance.
Results:
At baseline and before institution of this initiative, 34 of 72 (47%) PIV catheters were placed in patients' dominant arms, with only 2 of 8 (25%) PIV catheters placed in the dominant arm for children aged<5 years. After instituting the initiative, 345 of 371 (93%) PIV catheters were placed in the dominant arm of 93 children; in children aged<5 years, 58 of 62 (94%) PIV catheters were placed in the dominant arm. Only 38 of 371 (10%) PIV catheters were placed in the antecubital vein.
Limitations:
Single-center study.
Conclusions:
Education regarding the importance of vein preservation, along with implementation of a standardized process for identifying children for whom vein preservation is important, can help direct PIV catheter placement and potentially preserve vasculature in pediatric patients with CKD.
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