2001
Intravenous Therapy
   CME Package

      August 2001
ACKNOWLEDGMENTS
             Prepared by: Doug Kunihiro

             Edited by:   Jim Harris, Program Manager
           ...
TABLE OF CONTENTS


Foreword.................................................................................................
2001 INTRAVENOUS THERAPY
     CONTINUING MEDICAL EDUCATION PACKAGE

FOREWORD
Since its inception, the York Region Base Hos...
Continuing Medical Education                    2001 Intravenous Therapy CME Package


In the prehospital setting, IVs are...
2001 Intravenous Therapy CME Package                        Continuing Medical Education


       •   Check the drug bag c...
Continuing Medical Education                       2001 Intravenous Therapy CME Package


         from the intracellular ...
2001 Intravenous Therapy CME Package                      Continuing Medical Education



Example 2:
You are running an IV...
Continuing Medical Education                       2001 Intravenous Therapy CME Package




ANATOMY AND PHYSIOLOGY
Before ...
2001 Intravenous Therapy CME Package                          Continuing Medical Education


In the event of such an inadv...
Continuing Medical Education                     2001 Intravenous Therapy CME Package


•   Avoid insertion sites where th...
2001 Intravenous Therapy CME Package                                             Continuing Medical Education


Comparing ...
Continuing Medical Education   2001 Intravenous Therapy CME Package


IV Placement Chart




Page 10                      ...
2001 Intravenous Therapy CME Package                              Continuing Medical Education


Choosing the Gauge of the...
Continuing Medical Education   2001 Intravenous Therapy CME Package


The IV Catheter




Page 12                         ...
2001 Intravenous Therapy CME Package   Continuing Medical Education


IV Bag and Solution Set




York Region Base Hospita...
Continuing Medical Education                  2001 Intravenous Therapy CME Package


IV Cannulation Technique
1.    REVIEW...
2001 Intravenous Therapy CME Package                      Continuing Medical Education

8.     APPLY GLOVES

9.     PREPAR...
Continuing Medical Education                  2001 Intravenous Therapy CME Package


      You should press firmly on the ...
2001 Intravenous Therapy CME Package                            Continuing Medical Education


How to Troubleshoot an IV I...
Continuing Medical Education                                           2001 Intravenous Therapy CME Package


Documentatio...
2001 Intravenous Therapy CME Package                      Continuing Medical Education


References
Advanced Life Support,...
2001 Iv Therapy Pkg
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Transcript of "2001 Iv Therapy Pkg"

  1. 1. 2001 Intravenous Therapy CME Package August 2001
  2. 2. ACKNOWLEDGMENTS Prepared by: Doug Kunihiro Edited by: Jim Harris, Program Manager David Austin, MD, FRCP(C), Medical Director Prepared by the York Region Base Hospital Program. For permission to reprint this material contact: York Region Base Hospital Program Markham Stouffville Hospital 280 Church Street, Markham, ON L6B 1B3 905-294-1177
  3. 3. TABLE OF CONTENTS Foreword.................................................................................................................................. 1 The Purpose of IV Therapy................................................................................................... 1 Complications of IV Therapy ................................................................................................ 2 Common Complications .................................................................................................... 2 Less Common Complications ........................................................................................... 2 Fluid Administration ........................................................................................................... 3 Drip Rates ............................................................................................................................ 4 Drip Rate Formula.......................................................................................................... 4 Anatomy and Physiology....................................................................................................... 6 Arterial Puncture................................................................................................................. 6 Nerve, Tendon or Ligament Damage.............................................................................. 6 IV Initiation (Cannulation)...................................................................................................... 7 Vein Selection..................................................................................................................... 7 Comparing Peripheral Cannulation Sites ....................................................................... 9 IV Placement Chart .......................................................................................................... 10 Choosing the Gauge of the Catheter ............................................................................ 11 Guide to Catheter Gauges .............................................................................................. 11 The IV Catheter ................................................................................................................ 12 IV Bag and Solution Set .................................................................................................. 13 IV Cannulation Technique............................................................................................... 14 How to Troubleshoot an IV Infusion ..............................................................................17 Documentation.................................................................................................................. 18 References ........................................................................................................................ 19
  4. 4. 2001 INTRAVENOUS THERAPY CONTINUING MEDICAL EDUCATION PACKAGE FOREWORD Since its inception, the York Region Base Hospital Program has been working toward the goal of helping its Paramedics deliver ever-improving levels of patient care. In recent years, this goal included research and development of a proposal to have the skill of IV initiation added to the Primary Care Paramedic (PCP) Program. This proposal was turned down as Primary Care Paramedics did not work partnered with Advanced Care Paramedics. Since that time, there has been a change in the Ambulance Act that now allows for IV initiation to be a Primary Care Paramedic skill. Additionally, the new National Occupational Competency Profile for PCPs includes IV starts and the college programs are now teaching this skill as part of their current curriculum. The Continuing Medical Education (CME) Committee selected IV therapy as the third of three educational topics for 2001. Why, you may ask, are we doing a CME on something that we, as PCPs, do not provide yet? Here are the reasons: 1) A committee of your fellow PCPs chose it. 2) This package will be helpful for those who see Advanced Care Paramedicine in their future. 3) It will help PCPs have a deeper understanding of the pertinent concepts, skills, and equipment so that they can better contribute to patient care when working with Advanced Care Paramedics (ACPs). 4) If we were to move towards a system in which PCPs have IV starts as part of their skill -set, it would help us with that transition. 5) It will help keep our seasoned paramedics up to date with recent college graduates, many of who have covered an expanded didactic program (including IV starts) as compared to the college programs of several (or many!) years ago. 6) It’s just good to keep learning. THE PURPOSE OF IV THERAPY Peripheral intravenous therapy is used world wide because it has numerous purposes, some of which are: • Fluid and/or electrolyte replacement • It provides a route for medications • It provides a route for nutritional support (not a prehospital concern) • Transfusion of blood products • Provides venous access for drawing blood for lab work
  5. 5. Continuing Medical Education 2001 Intravenous Therapy CME Package In the prehospital setting, IVs are started for fluid replacement and/or as a potential or actual route for emergency medications. COMPLICATIONS OF IV T HERAPY For all its uses and advantages, IV therapy is still an invasive procedure that has the potential for a number of complications. Some of these complications are as follows: Common Complications Interstitial IV – When a catheter is wrongly placed outside of a vein, it causes pain and swelling at the site. If certain drugs (like D50W) are pushed interstitially, they cause corrosive damage to the tissues. Phlebitis - A localized infection of the vein, usually caused by non-aseptic technique. Fluid overload - Too much fluid administered (or too quickly) can cause peripheral or pulmonary edema. Less Common Complications Thrombophlebitis - Injury, irritation, or sluggish flow rate can cause a clot to form, which if dislodged, becomes an embolism. This puts a patient at risk for CVA, MI, pulmonary embolism. Catheter embolism - The tip of the catheter may break off and become an embolism (risk of CVA, MI, PE); usually caused by forcing a catheter into a vein, forcing past a valve, or by advancing and withdrawing the catheter over the needle repeatedly (known by some as ‘fishing’). Bleeding - A missed IV site unattended may become a steady bleeder, especially if the patient is on anticoagulant medications. Nerve, tendon, or ligament damage - Poor knowledge of anatomy or poor technique could c ause accidental injury to any of these structures. Needlestick injuries - This is every paramedic’s and every nurse’s fear - the dirty needlestick. A needlestick is the healthcare worker’s greatest danger for transmission of HIV, Hepatitis B, Hepatitis C and other undesirable pathogens. Furthermore, “IV catheter needles (hollow bore blood filled needles) are associated with the greatest incidence of high risk needlestick injuries” (Ippolito G et al. 1997). It is not to be taken lightly. Sharp safety is really, really important. Some rules of thumb for safe handling of sharps are: • Always have the sharps container close by and open when starting the IV. • Never put a used IV needle anywhere but in the sharps box (not on the ground, not into the mattress, not on a nearby table, etc.). Page 2 York Region Base Hospital Program
  6. 6. 2001 Intravenous Therapy CME Package Continuing Medical Education • Check the drug bag carefully before venturing your hand near the sharps box. You never know who worked before you or if the drug bag fell and went upside down causing a sharp to fall out (it’s happened many times). Inadverte nt Arterial Puncture - Poor knowledge of anatomy could lead one to initiate arterial access, which is not suitable for drug administration. Blood supply to distal areas could also be impaired. Sepsis - Systemic infection caused by an infected IV site, leading to serious illness or death (yikes!). Fluid Administration Although in York Region we only carry one IV solution (normal saline), it is worthwhile reviewing the different types of IV fluids used in hospital and other prehospital settings. IV solutions are divided into two general categories: colloids and crystalloids. Colloids contain proteins or other molecules of high molecular weight that tend to remain intravascular for long periods of time. These molecules exert osmotic pressure (the pressure generated by the tendency of water to follow high concentrations of molecules), thus they draw interstitial and intracellular water towards the intravascular fluid compartment. Examples of colloid solutions are whole blood, plasma, packed red blood cells and plasma substitutes [eg., Dextran, Hespan, plasma protein fraction (Plasmanate)]. Colloids are superior in the replacement of blood loss because they largely remain intravascular and, in the case of whole blood and packed red blood cells, they have oxygen carrying capacity. Blood products are expensive, scarce, do not store well, and require cross matching. They are not a practical prehospital choice of fluids. Crystalloids are solutions made by dissolving crystals into water. Some examples of crystalloids are normal saline, Ringer’s (and Lactated Ringer’s), and Dextrose 5% (D5W). Crystalloids do not have the osmotic pressure that colloid solutions do but they are cheap, they store well, they are good fluid replacers (not blood replacers). There are a wide variety of solutions with varying amounts of dissolved particles in them to suit different patient needs. Crystalloids are frequently categorised by tonicity – which is the amount of particles present in a solution. Hypotonic solutions (e.g., D5W) have less dissolved particles than does plasma, and thus they have less osmotic pressure. Hypotonic solutions are fine as route for medication, they are not a good choice for fluid replacement, since most of the solution given intravenously will leave the vascular space. Hypertonic solutions (e.g., 5% Dextrose in Ringer’s, 10% Dextrose, 5% Dextrose and 0.45% Sodium Chloride) have more dissolved particles than plasma and, with their higher osmotic pressure, would have the initial effect of drawing water York Region Base Hospital Program Page 3
  7. 7. Continuing Medical Education 2001 Intravenous Therapy CME Package from the intracellular spaces to the intravascular space. However, most crystalloid hypertonic solutions are only hypertonic because they have high sugar content and, once that sugar is metabolized, the solution is no longer hypertonic and c an even be hypotonic, so it does not necessarily continue to boost circulating volume. This is the case with D5W, it is initially a hypertonic solution and becomes hypotonic once the sugar is metabolized. Isotonic solutions (e.g., Normal Saline [0.9%Sodium Chloride], Ringer’s Lactate have roughly the same amount of dissolved particles as plasma and they are a good, all purpose choice for medication routes and fluid replacement. Only about a third of both normal saline and Ringer’s Lactate remains intravascular an hour after administration, so it takes about three litres of such fluid to replace one litre of blood (and there still exists the problem of the loss of blood cells). Drip Rates Controlling the infusion rate of IV fluids is a simple, yet important calculation that is a review for many of you. Calculating the drip rate depends on the type of tubing you are using. There are two types of IV tubing – macrodrip and microdrip. Macrodrip tubing (our standard adult tubing) has a drip factor of either 10 gtts/ml or 15 gtts/ml (gtts is the standard abbreviation for ‘drops’). Microdrip tubing has a drip factor of 60 gtts/ml. It is used for pediatric patients because you want to maintain a closer watch on fluid volumes so as not to overload them. It is also used for precise infusion rates of drip medications (e.g., Dopamine, Lidocaine, Heparin). Drip Rate Formula gtts/minute = volume to be infused in one hour x gtts/ml for drip factor infusion time (60 minutes) Example 1: You have initiated an IV on a patient, and you want to set a TKVO (to keep vein open) rate, about 30 ml per hour. You are using macrodrip tubing with a drip factor of 15 gtts/ml. What is your drip rate? gtts/minute = 30 ml/hr x 15 gtts/ml 60 min = 7.5 gtts/min (let’s call i t 8 gtts/min), which is about one drop every 7 seconds Page 4 York Region Base Hospital Program
  8. 8. 2001 Intravenous Therapy CME Package Continuing Medical Education Example 2: You are running an IV on a child, and a physician gives you an order to run the IV at 50 ml/hr. Using a microdrip tubing with a drip factor of 60 gtts/ml, what’s your drip rate? gtts/minute = 50 ml/hr x 60 gtts/ml 60 min = 50 gtts/min The keen observer will note that with microdrip tubing, the math is really simple because the 60 gtts/min over the 60 min cancel each other out, meaning the drip rate ends up being the same number as the desired volume, i.e. the 50 ml/hr translates to being 50 gtts/min. Easy! York Region Base Hospital Program Page 5
  9. 9. Continuing Medical Education 2001 Intravenous Therapy CME Package ANATOMY AND PHYSIOLOGY Before choosing a vein as an IV site, you need to ensure that it is actually a vein – not an artery, tendon, or other anatomical structure. DIFFERENTIATION OF VEINS & ARTERIES (adapted from Villote, 1989) VEINS ARTERIES • • LOCATION Superficial & palpable, can Located deep, can also be also be deep close to the surface • • No palpable pulsation Pulsation palpable (except on pulseless patients) • • CHARACTERISTICS OF Dark blood with slow Bright red blood which return when cannulated flows back readily when BLOOD cannulated • Blood flow pulsates (except on pulseless patients) • • VALVES Present to prevent blood Absent flow in the reverse direction • • BLOOD FLOW Blood is carried toward the Blood flows away from the heart heart • • SUPPLY Usually supplies one area Numerous of the body, therefore damage can cause necrosis of dependent tissues Arterial Puncture If an artery is accidentally punctured, you may be unable to thread the IV cannula because arterial pressures are higher than venous pressures (in patients with a pulse). The cannula may pulsate. Blood will pulse from the site. There may also be blanching of the skin distal to the insertion site. If suspected arterial cannulation occurs: 1. Remove the cannula. 2. Apply direct pressure with sterile gauze for 5 minutes by the clock. Apply pressure for 10 minutes if the patient is on anticoagulant therapy. 3. Document the error and report it to receiving staff at the hospital. Nerve, Tendon or Ligament Damage This type of injury can be caused by improper technique or a lack of knowledge of anatomy. If may cause temporary or permanent injury to nerves, tendons, or ligaments. Page 6 York Region Base Hospital Program
  10. 10. 2001 Intravenous Therapy CME Package Continuing Medical Education In the event of such an inadvertent poke, a patient would experience intense pain (even electric shock-like if nerve damage) and possibly numbness. There would be no blood in the flashback chamber, obviously. If this occurs: 1. Remove the cannula. 2. Document the error and report it to receiving staff at the hospital. 3. Document any subsequent effects of the errant puncture. IV INITIATION (CANNULATION) Vein Selection Most people learning to start IVs have struggles simply because they do not take the time to choose a good vein. Vein s election might be the single most important factor in ‘getting’ or ‘missing’ IVs. Additionally, choosing the appropriate vein can have an impact on patient care and outcome (see below). Here are some considerations when choosing veins. • As a general principle, choose a vein that is most distal. Here’s why: if you have an unsuccessful IV start (in non-technical terminology: if you blow a vein), then you cannot use a vein distal to the blown site because fluid or drug given at the distal site may still extravasate at the blown site. Also, reserving antecubital veins is helpful to hospital staff, who are required to take blood samples from these sites. • Think of why the IV is being started. If a patient is in cardiac arrest, we do not care about choosing the most distal vein. We want to choose one that is as close to the patient’s heart as possible and ideally is a large vein through which we could infuse fluids quickly. The antecubital veins become prime choices in the arrest situation. Similarly, Adenosine (treatment for SVTs) must be given from a site as close to the heart as possible. • Choose a nice, ‘juicy’ vein. Veins that are easy to cannulate are prominent, feel spongy when palpated, and are big enough to accommodate the catheter. • Avoid starting IVs anywhere on the hand or arm of a patient who: i. Has a fistula on that arm ii. Has lymphedema (a condition causing an accumulation of lymphatic fluid in interstitial spaces, most commonly in arms and legs) on that side. Any invasive procedure on the affected side may cause serious long-term damage to the arm. iii. Has had a radical mastectomy or blood clot on that side iv. Has a fracture or dislocation proximal to the site. You do not want to infuse fluids or drugs into the area via any damaged veins. York Region Base Hospital Program Page 7
  11. 11. Continuing Medical Education 2001 Intravenous Therapy CME Package • Avoid insertion sites where there is bruising, scar tissue, disease, burns, etc. These will only cause you to “blow veins” more often. • When possible, choose the right side first (truly a prehospital concern only). This is simply good practice because if you need to make additional attempts en route to hospital, the right arm is very difficult to access once your patient is in the vehicle. Starting an IV in the right antecubital fossa while in a moving ambulance requires awkward, mechanically unsound, potentially dangerous body positioning which is best avoided when possible. • On obese patients, forearm veins will be nearly impossible to see or palpate, so look for hand veins first, then antecubital veins next. • Avoid the anterior or palm side of the wrist. The radial nerve is very superficial, and insertion can be very painful for patients. • Feet and leg veins are not good choices because of increased risk of thrombophlebitis and embolism. • Choose a section of a vein that is straight. Your catheter is straight so it is a lot easier to advance it through a nice, straight vein. • Starting IVs on pediatric patients is especially difficult because: 1. Their veins are much smaller and less prominent. 2. They tend not to listen to your instructions to ‘hold still’ because they are petrified of any procedure that involves a needle. The Doctor’s Advice: Our Medical Director, Dr. Austin, suggests that one of his favourite veins to cannulate is the cephalic vein, which starts around the base of the thumb and runs up the radial aspect of the forearm. It’s usually an adequately large vein and its location is fairly consistent from patient to patient. Page 8 York Region Base Hospital Program
  12. 12. 2001 Intravenous Therapy CME Package Continuing Medical Education Comparing Peripheral Cannulation Sites (Loeb, 1992) SITE ADVANTAGES DISADVANTAGES • • METACARPAL VEINS Easily accessible Wrist mobility decreased unless • Located on dorsum of hand; a short cannula is used Adapter lies flat on back of hand • • formed by union of digital veins Insertion painful because of large In adult or large child, bones of number of nerve endings hand act as a splint • • Site becomes phlebitic more Usually first choice for easily cannulation • May be contraindicated with an aged patient as thin skin & loss of connective tissue may predispose to extravasation of blood (Villote, 1989) • • BASILIC VEIN Straight strong vein suitable for Uncomfortable position for Runs along ulnar aspect of forearm large gauge cannula patient during insertion • & upper arm. Painful area to penetrate skin • Vein tends to roll on insertion • • CEPHALIC VEIN Large vein readily accepts large Decreases elbow joint mobility • Runs along radial aspect of forearm gauge cannula Vein tends to roll during insertion • & upper arm Does not impair mobility • • ACCESSORY CEPHALIC VEIN Large vein readily accepts large Sometimes difficult to position Runs along radius as a continuation gauge cannula adapter flush with skin • • of metacarpal veins of the thumb Does not impair mobility Adapter placed at bend of wrist, • movement can cause discomfort Does not require an armboard in or kinking of tubing older child or adult • Often palpable or visible in • ANTECUBITAL VEINS Difficult to immobilize joint children when other veins will not • Located in antecubital fossa (median Median cephalic vein crosses in dilate cephalic, located on radial side; front of brachial artery, • May be used for peripheral IV median basilic, on ulnar side; increasing the risk of arterial therapy in an emergency or as a median cubital, in front of elbow puncture and intra-arterial last resort joint) infusion of medication resulting in permanent damage • Veins may be small & scarred if blood has been drawn frequently • A last resort when no other sites • MEDIAN ANTEBRACHIAL VEIN Many nerve endings in area may available Arises from palm and runs along cause painful venipuncture • ulnar aspect of forearm Infiltration occurs easily increasing risk of nerve damage • • DIGITAL VEINS Last resort for fluid administration Finger is splinted with a tongue Run along dorsal & lateral portions or for non-irritating medications depressor, limiting mobility • of fingers (digits) Uncomfortable for patient • Infiltration occurs very easily • Cannot be used if metacarpal veins have already been used York Region Base Hospital Program Page 9
  13. 13. Continuing Medical Education 2001 Intravenous Therapy CME Package IV Placement Chart Page 10 York Region Base Hospital Program
  14. 14. 2001 Intravenous Therapy CME Package Continuing Medical Education Choosing the Gauge of the Catheter Crude analogies aside, ‘size does matter’ when it comes to choosing your IV catheter. It comes down to common sense. You choose a size appropriate for the situation and for the size of the vein. Larger bore IVs (18, 16, 14) are appropriate for rapid infusion of fluids and/or blood and blood products but you need a big vein to get them in (and they hurt more). Additionally, putting a cannula into a vein that is too small can cause damage to that vein and put the patient at risk for phlebitis (because blood can not easily flow around the catheter). Smaller bore IVs (20, 22, 24) are adequate as a simple route for medication, and they are less painful. Blood can be given through a 20 or even a 22 gauge catheter, but it will be slower than if given through large bore catheters. Guide to Catheter Gauges (Adapted from Loeb, 1992) GAUGE USES CONSIDERATIONS • • 14 Large adolescents or adults Very painful insertion • • Trauma Requires very large vein • Rapid infusion of fluids and/or blood & blood products • • 16 Adolescents & adults Painful insertion • • Trauma Requires large vein • Infusion of large volume of fluids • Infusion of blood & blood products • • 18 Older children, adolescents & Mildly painful insertion adults • • Fluid resuscitation Requires decent sized vein • Infusion of blood, blood components & viscous solutions • Obstetric patients • • 20 Children, adolescents & adults Commonly used • • Suitable for most infusions, Slower to infuse large amounts TKVO lines of fluid • Infusion of blood or blood components (Vollote, 1989) • • 22 Infants, toddlers, children, Easier to insert in small, thin, adolescents & adults fragile veins • (especially the aged & Use with slower flow rates • emaciated) Difficult to insert into tough skin • Suitable for most infusions • • 24 Neonates, infants, toddlers Flow rate would be very slow York Region Base Hospital Program Page 11
  15. 15. Continuing Medical Education 2001 Intravenous Therapy CME Package The IV Catheter Page 12 York Region Base Hospital Program
  16. 16. 2001 Intravenous Therapy CME Package Continuing Medical Education IV Bag and Solution Set York Region Base Hospital Program Page 13
  17. 17. Continuing Medical Education 2001 Intravenous Therapy CME Package IV Cannulation Technique 1. REVIEW THE INDICATION FOR IV ACCESS Is there an actual or potential need for IV access? 2. PREPARE THE PATIENT Many patients are anxious about IV therapy. Recognition of the patient’s feelings and education of the patient regarding the procedure, need and benefits is required. (Anxiety can cause vasoconstriction). Remember that a competent patient has the right to refuse the treatment. 3. SELECT THE EQUIPMENT Select the appropriate bag size of solution, administration set, and drip chamber. You will also need an IV catheter (see ‘Choosing the Gauge of the Catheter’), alcohol swabs, clear sterile bandage (e.g., Tegaderm), a 2”x2” bandage for any spills or misses, skin tape, and tourniquet. Your sharps box should be positioned close by with an open lid. 4. PREPARE THE SOLUTION SET Ensure that the solution bag is the right type and size. Check the bag for clarity (no particulates or discolouration), integrity (no leaks when you squeeze the bag), and expiry date. Attach the adm inistration set to the solution bag and prime (that is, run the IV solution through) the tubing. Usually, for macrodrip lines, these are prepared before the call. 5. SELECT THE INSERTION SITE Raise the stretcher to a comfortable height (if the patient is on the bed) and adjust lighting as possible. Place the patient in a comfortable position with the extremity toward you. See ‘Vein Selection’ for more details. 6. SELECT THE CANNULATION DEVICE Use the device with the smallest diameter that allows correct administration of therapy (see ‘Guide to Catheter Gauges’). The catheter must always be smaller than the selected vein 7. DILATE & PALPATE THE VEIN Apply the tourniquet above the insertion site tight enough to restrict venous flow, while maintaining arterial flow. Try not to leave the tourniquet on for more than two minutes. NOTE: if vasodilation is not adequate, enhance it by: Ø Lowering arm below heart level Ø Gently tapping vein with finger Ø “Milking” vein away from tourniquet Ø Asking patient to close and open fist a few times Page 14 York Region Base Hospital Program
  18. 18. 2001 Intravenous Therapy CME Package Continuing Medical Education 8. APPLY GLOVES 9. PREPARE THE SITE Cleanse area with an appropriate disinfectant (usually an alcohol swab) in a circular motion from centre to periphery. Cleanse the area to a size equal to or larger than the bandage. Avoid palpation of the site after cleansing. Let the alcohol dry before you make your start or it really stings for the patient. 10. INSERT THE CANNULATION DEVICE Ensure that the package was sealed. Remove the needle/cannula cap, holding the needle and cannula by the flash chamber. Inspect the cannulation device for imperfections (e.g., burrs, cracks, etc.). The plug on the flashback chamber should be tight, and the cannula should be able to spin on the needle (to ensure that it’s not stuck to the needle – a manufacturing defect that happens occasionally). Anchor the vein by holding the skin taut below the site (really important). Point the needle in the direction of the blood flow and hold it at 10 - 30 degree angle with the bevel up. Keeping your han d steady, pierce the skin and vein. Look for a slow flow of dark blood moving into the flashback chamber. 11. ADVANCING THE CANNULATION DEVICE Decrease the angle of the needle almost parallel with the skin. Advance the catheter (and needle) about a half a centimetre (until you’re sure the cannula itself, not just the needle, is in the vein). Now you have two choices to advance the cannula. You can hold the needle firmly and then advance the cannula off the needle. Or, you can withdraw the needle partially from the cannula, then advance the cannula. NOTE: If you feel resistance, do NOT force the cannula. You may damage a valve. Withdraw the needle and cannula together. Withdrawing the cannula first may cut the cannula on the sharp needle and cause a piece of free flowing cannula to form a cannula embolus. Attempt venipuncture at another site with a new cannula ________________________________________________________________ 12. RELEASE THE TOURNIQUET When the cannula is placed correctly, release the tourniquet. 13. WITHDRAW THE NEEDLE York Region Base Hospital Program Page 15
  19. 19. Continuing Medical Education 2001 Intravenous Therapy CME Package You should press firmly on the skin over the cannula tip to prevent bleeding on withdrawal. So long as you apply pressure to the right place, you need not stain anyone’s plush white carpet. With the other hand, withdraw the needle and dispose of it in the sharps container. Attach the tubing. 14. CONNECT THE FLUID FILLED TUBING TO HUB Maintaining the cannula position let the fluid flow freely for 2 – 5 seconds to assure proper placement of the cannula. Observe for swelling indicating infiltration or leakage. (See ‘How to Troubleshoot an IV’ for more details). Set the flow rate. 15. APPLY STERILE CLEAR DRESSING (e.g., Tegaderm) Apply over insertion site and the cannula hub. 16. TAPE THE IV TUBING TO THE SKIN Avoid placing tape on the clear dressing. Keep in mind that curving it too tightly can kink the tubing. 17. DOCUMENT THE PROCEDURE Document the date, time, location and size of cannulation device, condition of site, number of attempts (if more than one attempt was required), type and amount of solution, and rate of infusion, and sign. Page 16 York Region Base Hospital Program
  20. 20. 2001 Intravenous Therapy CME Package Continuing Medical Education How to Troubleshoot an IV Infusion (Adapted from Loeb, 1992 & Villote, 1989) If an infusion is running too slowly or not at all, the problem may be easily corrected. It’s helpful to start at the patient and work your way back to the IV bag. Check to see if: 1. The site is edematous or leaking. Remove the cannula – it’s likely interstitial. 2. The cannula tip may be resting against the wall of the vein. Move the cannula slightly. 3. The vein may be in spasm. Irritating or cold infusions may cause venous spasms. Apply a warm, moist towel to the arm to relieve spasm and increase the flow of the solution. 4. The tape is too tight. Re-tape if needed. 5. The tourniquet is still on. Remove it. 6. The joint above the site is flexed. Reposition the extremity or splint with an arm board. 7. The tubing is dangling below the site. Gravity may be preventing flow. Reposition the tubing. 8. The tubing is kinked, curved too tightly, or caught under the patient. Untangle the tubing. Use a firm “loop” to prevent tight curves at the cannula, and/or reposition the patient. 9. The clamp is closed or has crimped the tubing. Move it to a different position on the tubing and recalculate the rate. 10. The solution container is less that 90 cm (3 feet) above the site. Raise the IV pole. 11. The bag is empty. Replace it. If you are still unable to correct the rate of flow, restart the intravenous in the opposite hand or upper arm if possible. York Region Base Hospital Program Page 17
  21. 21. Continuing Medical Education 2001 Intravenous Therapy CME Package Documentation As with any prehospital procedure, proper documentation is required on the Ambulance Call Report (ACR). Documentation for IV starts (and misses) should include: • Date and time of insertion • Gauge and length of catheter • Type and amount of solution hung • Site of venipuncture (It’s fairly standard practice to record the site in terms of hand, forearm, antecubital fossa vs. metacarpal, cephalic, basilic, etc.) • Rate of infusion • Any untoward reaction • Amount infused upon arrival at hospital Here is sample documentation for a ‘TKVO’ IV started on a patient: Procedures Time Medicine or Procedure Code Result Initial s 0905 IV R hand, 20g x 30mm, with 3 7 0 Running Well VC 250 ml NS @TKVO, total vol. infused 30 ml Here is sample documentation for an IV started and a fluid bolus: Procedures Time Medicine or Procedure Code Result Initial s 2150 IV L antecubital fossa, 16g x 3 7 0 Running well, wide VC 30mm with 1000ml NS open, 500 ml bolus given, now ‘TKVO’, total vol. infused 520 ml. Here is sample documentation for an IV that went interstitial: Procedures Time Medicine or Procedure Code Result Initial s 0035 IV R hand, 22g x 25mm with 4 0 2 Swelling at site, IV VC * 250ml NS discontinued, dressing applied * For those who are curious, VC stands for Vince Carter (I had to choose someone’s initials.) Page 18 York Region Base Hospital Program
  22. 22. 2001 Intravenous Therapy CME Package Continuing Medical Education References Advanced Life Support, Toronto Institute of Medical Technology for the Ministry of Health, 1986 Caroline, Nancy L. Emergency Care in the Streets (4th ed.). Boston: Little, Brown and Company, 1991 Chameides, Leon (ed.), Textbook of Pediatric Advanced Life Support, American Heart Association, 1990 Credit Valley Hospital. Parenteral Therapy. Mississauga, ON: Credit Valley Hospital, 1992 Hadaway, Lynn C., Deliver Safer Peripheral IV Therapy, Springhouse Corporation, Springhouse, PA, 2001. Ippolito, G. et al., Prevention, Management and Chemoprophylaxis of Occupational Exposure to HIV, University of Virginia, 1997. Loeb, S. (ed.). Photoguide to Drug Administration. Springhouse, PA, 1992 Millam, Doris A., On the Road to Successful IV Starts, Nursing 2000, Springhouse Corporation, Springhouse, PA, 2000. Pons, Peter T (ed.) & Cason, Debra (ed.). Paramedic Field Care: A Complaint-Based Approach. St. Louis: Mosby-Year Book, Inc. 1997 Rosen, Peter (ed.) & Barkin, Roger M.(ed.). Emergency Medicine Concepts and Clinical Practice (3rd ed.). St. Louis: Mosby, 1992. Villote, A. IV Therapy Learning Package for Markham Stouffville Hospital. Markham, ON: Markham Stouffville Hospital, 1989. York County Hospital. IV Cannulation Workbook For R.N.’s. Newmarket, ON: York County Hospital, 1992. Interesting Online Resources www.ivteam.com/ www.springnet.com/ce/p004a.htm www.springnet.com/ce/edce1a.htm www.baxter.com/doctors/iv_therapies/education/iv_therapy_CE/Basic_One/BasicOne.ht ml#tech York Region Base Hospital Program Page 19

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