IV ACCESSDR.R.MANJUNATH CHIEF PHYSICIANVIKRAM HOSPITAL MYSORE
Indications Fluid and blood replacementDrug administrationObtaining venous blood specimens for lab analysis“Stab wound” specimen
Types of IV Access Peripheral venous accessCentral venous acces,Veins located deep in the bodyInternal jugular, subclavian, femoralPeripherally inserted central catheter (PICC lines)
IV Administration SetsMacrodrip —10 gtts = 1 ml, for giving large amounts of fluid.Microdrip —60 gtts = 1 ml, for restricting amounts of fluid.Blood tubing— has a filter to prevent clots from blood products from entering the body.Measured volume —delivers specific volumes of fluids.IV extension tubing —extends original tubing.Electromechanical pump tubing —specific for each pump.Miscellaneous —some sets have a dial that can set the flow rates.
Intravenous Cannulas• Over-the-needle catheter• Hollow-needle catheter• Plastic catheter inserted through a hollow needle
IV ACCESSSuccessful completion of any procedure requires careful preparation. Attentionto patient positioning and a prior collection of needed equipment is mandatory.Additionally, predicting difficult access and the use of techniques to aidvasodilation will greatly facilitate successful cannulation.The use of topical anesthetics may be useful in some populations, especially inpediatric patients
PATIENT POSITIONINGAs with any procedure, positioning of both the patient and the performer should beoptimized. The patient should be seated or in a reclining position for comfort andsafety. Immobilize the extremity, particularly for pediatric or uncooperative patients.Keep the extremity in full extension to make the vein taut, and place the intendedcannulation site in a dependant position to engorge the vein.
MISE-EN-PLACEIn French, and in cooking, this means to lay out all of your expected ingredients andequipment ahead of time (Prior to beginning the procedure, gather all therequired equipment), prepared and within reach. It is often beneficial to have aselection of IV catheters available as well as extra blood tubes, tape, etc., shouldadditional supplies be required.
PREDICTING DIFFICULT ACCESS AND PROMOTING VASODILATION Difficult Access Conditions that may predict difficult access include:•Dehydration/intravascular depletion•Chronic illness with venous scarring from frequent IV access•IV drug use with venous scarring•Obesity•Significant edema•Tortuous, fragile vessels due to advanced age•Thin vessel walls due to age, steroid use, certain disease conditionsWhen presented with these situations, using the vasodilating techniques below mayfacilitate cannulation. If you are unsuccessful, Alternative Techniques may berequired.
Tourniquets should always be used when drawing blood or starting an IV. The tourniquet prevents venous return of blood, causing the vessel to dilate. If a suitable vein is not identified after the application of a tourniquet, having the patienthold the extremity in a dependent fashion will also help to engorge the vessel.Lenhardt and associates showed in a randomized trial that actively warming patients hands with a warming mitt prior to cannulation reduced the time needed to completethe procedure and increased success rates. (Lenhardt, 2002) While these warming mittswill not likely be available at your institution, cheap and conveinent alternatives (such ashaving the patient hold the hand in a bowl of warm water, or applying a heating blanketor hot-water bottle) will likey have the same effect.
TOPICAL ANESTHESIAWhile anesthesia is not routinely utilized for intravenous cannulation, its use should beconsidered in special situations. Topical anesthetics are often used for venepuncture onchildren, to reduce anxiety and pain. (Arrowsmith)EMLA (eutectic mixture of local anesthetics) cream contains 2.5% lidocaine and 2.5% prilocaine. It is applied as a thick dollop of cream to the area of venepuncture, and thencovered with an occlusive dressing such as Tegaderm. While it provides excellentanesthesia, it must remain on the skin for 60 minutes prior to the procedure to achievemaximum tissue preparation. (Wong) EMLA is extremely safe to use, but it should not beleft on for more than two hours. Cases of methemoglobinemia have been reported(Hahn; Jakobson), however these are exceedingly rare and in most cases involved largedoses of EMLA which were in contact with the skin for an extended period of time.LET (lidocaine 4%, epinephrine 0.1%, tetracaine 0.5%) can also be used in a similar fasion to EMLA. It too is generally safe, however should not be used on areas of the bodywithout collateral circulation (such as the fingers, toes, ears and penis) because theepinephrine can cause local tissue ischemia. This is more of a concern when LET is usedon lacerations. (Wheaton)
EXPLAIN THE PROCEDUREExplain the procedure to the patient.Tell the patient that the procedure may be mildy painful, but is brief.Ask that he / she hold the extemity completely still until the completion of thecannulation.Take time to answer any questions that the patient might have.The patient should be laying in the bed, with the opposite bed rail up, to prevent injuryshould the patient faint during the procedure.
TROUBLESHOOTING Peripheral venous catheterization is a relatively safe procedure. Many of thecomplications listed below are more common with central venous catheters. However, knowledge of these complications is essential in order to recognize problems when they occur.Confirmation of PlacementProper IV placement is confirmed by a smooth saline flush without evidence ofextravasation into the subcutaneous tissues. The ability to draw blood provides furtherconfimation but is not a requirement since blood flow may be obstructed by a valve orfrom vein collapse due to suction.
It can be difficult at times to confirm that an intravenous catheter is actually within thelumen. Backflow of blood into the intravenous tubing upon the application of negativepressure (e.g. withdrawing on a syringe attached to the catheter) is not a reliableindicator, as the tip of the catheter may be partially in and partially out of the vessellumen. Conversely, the absence of backflow does not necessarily indicate cathetermalposition, as the tip of the needle may intraluminal but adjacent to a valve or vesselwall.The most reliable method to confirm intraluminal placement, and to exclude infiltration, is to apply tourniquet proximal to the catheter site tight enough to restrict venous flow. A catheter in the appropriate position will cease to flow in this situation, whereas an infiltrated line may continue to flow. (Weinstein 2001)
Inability to advance catheterOccasionally it will be difficult to advance the catheter into the vein, despite a goodflashback of blood during initial venepuncture. This can occur due to a venous valve, orto a tortuous vein. The catheter should never be forced into the vein, and this is likely todamage the vessel and cause infiltration. Several tricks are available in this situation:Vary the amount of traction placed on the vein. First, try to pull the vein a bit tauter andadvance the catheter. If unsuccessful, traction can be reduced (or even released) andfurther attempts at advancement can be pursued."Float" the catheter in. If the catheter can be partially advanced but meets resistancebefore insertion is completed, infusing saline through the line (via a flush or IV fluids)during advancement may facilitate passage. (The fluids act to distend the vessel andopens valves.) Excessive pressure should not be used in order to prevent infiltration.
EARLY COMPLICATIONSInfiltration | Arterial Placement | Air Embolism | Catheter Fracture & EmbolismInfiltration and ExtravasationInfiltration of the IV occurs when the tip becomes dislodged from the vessel lumen. This complicationshould be suspected when the intravenous fluid flows poorly, if the line is difficult to flush, if theautomated pump sounds an alarm, or if the patient complains of pain. (Liu 2004, Weinstein 2001)Infiltration can become a serious situation if toxic fluids are being administered through the line.These include hypertonic agents, cytotoxic agents, and vasopressors. Vasopressors, such asnorepinephrine or dopamine extravasate into local tissues from an infiltrative line, severe tissuenecrosis may result. This can be treated by injecting five cc phentolamine mixed with five cc of salineinto the subcutaneous tissues with a small gauge needle. (Liu 2004)
Arterial Placement Peripheral catheters may accidentally be inserted into arteries instead of veins. This wouldoccur most commonly in the antecubital fossa, with the catheter entering the brachialartery instead of the median cubital or basilic vein. Arterial cannulation is distinguished byarterial flow (pumping) of blood, which will also be a bright scarlet red if patient is nothypoxic. In this situation phlebotomy may still be performed but the catheter shouldsubsequently be removed. Pressure should be placed over the site for one full minute,longer if patient is coagulopathic.
Air embolismAir embolism is more commonly seen with central venous catheters, however may alsooccur with peripheral catheters. If air is introduced into the vascular system, it mayaccumulate and cause complications such as blockage of the right side of the vascularsystem (i.e. venous) leading to outflow obstruction of the right ventricle andpulmonary arteries.Possible symtpoms include impaired gas exchange, hypotension, and circulatorycollapse. (Breen 2000, Feied 2002) Left-sided (arterial) obstruction may also occur, if anatrial or ventricular septal defect is present. Obstruction of the coronary or cerebralarteries by air can lead to myocardial infarction and acute stroke, respectively. (Breen2000, Shockley 2002)
Air embolism(contd)• While it is classically taught that 5 ml / kg of air is needed to produce an "air lock" of the right ventricle and pulmonary artery, circulatory collapse has been reported with as little as 20cc of air. Should signicant air embolization occur, the patient should be placed in a left lateral recumbent position to trap the air in the right atrium. Available interventions include aspiration via a central venous catheter, hyperbaric treatment, and in severe cases, thoractomy. (Feied 2002)• To prevent air embolism, all tubing should be flushed prior to utilization. Additionally, all connections must be tight, and fluid bags should not be allowed to completely empty before replacement. If this occurs, the line should be removed from the catheter and re-flushed. (Weinstein 2001)
Catheter fracture and embolism Catheter embolism is a rare complication of peripheral intravenous catheters. If the tip of the synthetic catheter is sheared off, it may potentially embolize and travel proximally in the circulation. This sequence of events occurs when the needle is withdrawn from the catheter and then reinserted. Therefore, once the needle is removed it should never be reinserted. (Weinstein 2001) Catheter embolism carries a high complication rate (up to 49%), and fluoroscopic catheterization and retrieval of the foreign body is usually recommended. (Roye 1996)
LATE COMPLICATIONS Infection | Thrombophlebitis | Phlebitis Infection The peripheral venous catheter should be removed at once if infection is suspected. thedecision to begin antibiotics must be made on an individual basis. Antibiotics with activityagainst gram positive organisms (such as first-generation cephalosporins, penicillin, orvancomycin) should be initiated if there is evidence of systemic infection or spreading localinfection.Catheter related infections are best controlled by meticulous attention to sterility andpreparation during insertion. Alcohol preps are adequate only if done appropriately (i.e.applied with a moderate amount of friction for one minute.) A quick swipe with an alcoholprep simply not effective. Iodine-based solutions are more effective than alcohol, andshould be used if the patient is not allergic to iodine. These preps are most effective ifallowed to dry on the skin for at least 30 seconds. (Weinstein
Peripheral venous thrombophlebitis, an extremely common complication, is heralded by pain, erythema, swelling, and a palpable cordalong the course of the cannulated vein. Thrombophlebitis is caused by local damage to the venouswall, and resultant inflammation and thrombus formation. (Tagalakis 2002)There are multiple risk factors for the development of thrombophlebitis. The length of duration ofcannulation is proportional to the risk of thrombophlebitis. Catheters placed in the veins thatoverlay joints are more likely to cause thrombophlebitis, as motion of the joint can cause frictionaltrauma between the endothelium and the catheter. Stagnant blood flow in the lower extremitiesmakes veins in this location more likely to develop thrombophlebitis. Numerous intravenous fluidsolutions, such as potassium chloride, barbiturates, phenytoin, and chemotherapeutic agents, areknown to cause endothelial damage and inflammation. Finally, poor technique and multipleattempts lead to vascular damage and thrombophlebitis. (Tagalakis 2002, Weinstein 2001)Should thrombophlebitis developed, the intravenous catheter should be removed immediately. Themost circumstances, no treatment is needed other than elevation of the extremity and theapplication of warm compresses. Antibiotics may be required if there is evidence of surroundinginfection. (Weinstein 2001)
Thrombophlebitis can be prevented by following these recommendations (Tagalakis 2002): •Utilizing a septic technique •Inspecting for thrombophlebitis •Using of alcohol or iodine prior to daily insertion •Replacing catheters every 72 hours •Securing catheter appropriately •Avoiding unnecessary tubing •Avoiding lower extremity insertion changing sites •Replacing dressings as needed.
Needlestick injuries to health-care workers and other hospital employees iscommonplace. It is estimated that over 800,000 needlestick injuries occur each year inUnited States hospitals. (Tan 2001UNIVERSAL PRECAUTIONS Appropriate Universal Precautions should always bemaintained to protect the patient, the person performing the procedure, and otherindividuals involved in all aspects of care (i.e. housekeeping staff who clean the room).This includes handwashing, the use of gloves and other protective barriers, proper sharpsdisposal and the correct usage of safety features.