This document provides information about intravenous (IV) access including indications, types of IV access, IV administration sets, cannulas, and considerations for successful IV placement. It discusses peripheral and central venous access, as well as PICC lines. It describes sets for fluid and blood administration and how to confirm proper IV placement. It also outlines complications including infiltration, arterial placement, air embolism, catheter fracture, infection, thrombophlebitis, and needlestick injuries. Proper patient positioning, gathering supplies, predicting difficult access, using vasodilation techniques, and universal precautions are emphasized for successful IV access.

1. IV ACCESS
DR.R.MANJUNATH
CHIEF PHYSICIAN
VIKRAM HOSPITAL
MYSORE

2. Indications
Fluid and blood replacement
Drug administration
Obtaining venous blood specimens for lab
analysis
“Stab wound” specimen

3. Types of IV Access
Peripheral venous access
Central venous acces,
Veins located deep in the body
Internal jugular, subclavian, femoral
Peripherally inserted central catheter (PICC
lines)

5. IV Administration Sets
Macrodrip —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.

6. Intravenous Cannulas
• Over-the-needle catheter
• Hollow-needle catheter
• Plastic catheter inserted through a hollow needle

8. IV ACCESS
Successful completion of any procedure requires careful preparation. Attention
to patient positioning and a prior collection of needed equipment is mandatory.
Additionally, predicting difficult access and the use of techniques to aid
vasodilation will greatly facilitate successful cannulation.
The use of topical anesthetics may be useful in some populations, especially in
pediatric patients

9. PATIENT POSITIONING
As with any procedure, positioning of both the patient and the performer should be
optimized. The patient should be seated or in a reclining position for comfort and
safety. Immobilize the extremity, particularly for pediatric or uncooperative patients.
Keep the extremity in full extension to make the vein taut, and place the intended
cannulation site in a dependant position to engorge the vein.

10. MISE-EN-PLACE
In French, and in cooking, this means to lay out all of your expected ingredients and
equipment ahead of time (Prior to beginning the procedure, gather all the
required equipment), prepared and within reach. It is often beneficial to have a
selection of IV catheters available as well as extra blood tubes, tape, etc., should
additional supplies be required.

11. 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 conditions
When presented with these situations, using the vasodilating techniques below may
facilitate cannulation. If you are unsuccessful, Alternative Techniques may be
required.

12. 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 patient
hold the extremity in a dependent fashion will also help to engorge the vessel.
Lenhardt and associates showed in a randomized trial that actively warming patient's
hands with a warming mitt prior to cannulation reduced the time needed to complete
the procedure and increased success rates. (Lenhardt, 2002) While these warming mitts
will not likely be available at your institution, cheap and conveinent alternatives (such as
having the patient hold the hand in a bowl of warm water, or applying a heating blanket
or hot-water bottle) will likey have the same effect.

13. TOPICAL ANESTHESIA
While anesthesia is not routinely utilized for intravenous cannulation, its use should be
considered in special situations. Topical anesthetics are often used for venepuncture on
children, 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 then
covered with an occlusive dressing such as Tegaderm. While it provides excellent
anesthesia, it must remain on the skin for 60 minutes prior to the procedure to achieve
maximum tissue preparation. (Wong) EMLA is extremely safe to use, but it should not be
left on for more than two hours. Cases of methemoglobinemia have been reported
(Hahn; Jakobson), however these are exceedingly rare and in most cases involved large
doses 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 body
without collateral circulation (such as the fingers, toes, ears and penis) because the
epinephrine can cause local tissue ischemia. This is more of a concern when LET is used
on lacerations. (Wheaton)

14. EXPLAIN THE PROCEDURE
Explain 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 the
cannulation.
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 injury
should the patient faint during the procedure.

15. TROUBLESHOOTING
Peripheral venous catheterization is a relatively safe procedure. Many of the
complications 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 Placement
Proper IV placement is confirmed by a smooth saline flush without evidence of
extravasation into the subcutaneous tissues. The ability to draw blood provides further
confimation but is not a requirement since blood flow may be obstructed by a valve or
from vein collapse due to suction.

16. It can be difficult at times to confirm that an intravenous catheter is actually within the
lumen. Backflow of blood into the intravenous tubing upon the application of negative
pressure (e.g. withdrawing on a syringe attached to the catheter) is not a reliable
indicator, as the tip of the catheter may be partially in and partially out of the vessel
lumen. Conversely, the absence of backflow does not necessarily indicate catheter
malposition, as the tip of the needle may intraluminal but adjacent to a valve or vessel
wall.
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)

17. Inability to advance catheter
Occasionally it will be difficult to advance the catheter into the vein, despite a good
flashback of blood during initial venepuncture. This can occur due to a venous valve, or
to a tortuous vein. The catheter should never be forced into the vein, and this is likely to
damage 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 and
advance the catheter. If unsuccessful, traction can be reduced (or even released) and
further attempts at advancement can be pursued.
"Float" the catheter in. If the catheter can be partially advanced but meets resistance
before 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 and
opens valves.) Excessive pressure should not be used in order to prevent infiltration.

18. EARLY COMPLICATIONS
Infiltration | Arterial Placement | Air Embolism | Catheter Fracture & Embolism
Infiltration and Extravasation
Infiltration of the IV occurs when the tip becomes dislodged from the vessel lumen. This complication
should be suspected when the intravenous fluid flows poorly, if the line is difficult to flush, if the
automated 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 as
norepinephrine or dopamine extravasate into local tissues from an infiltrative line, severe tissue
necrosis may result. This can be treated by injecting five cc phentolamine mixed with five cc of saline
into the subcutaneous tissues with a small gauge needle. (Liu 2004)

19. Arterial Placement
Peripheral catheters may accidentally be inserted into arteries instead of veins. This would
occur most commonly in the antecubital fossa, with the catheter entering the brachial
artery instead of the median cubital or basilic vein. Arterial cannulation is distinguished by
arterial flow (pumping) of blood, which will also be a bright scarlet red if patient is not
hypoxic. In this situation phlebotomy may still be performed but the catheter should
subsequently be removed. Pressure should be placed over the site for one full minute,
longer if patient is coagulopathic.

20. Air embolism
Air embolism is more commonly seen with central venous catheters, however may also
occur with peripheral catheters. If air is introduced into the vascular system, it may
accumulate and cause complications such as blockage of the right side of the vascular
system (i.e. venous) leading to outflow obstruction of the right ventricle and
pulmonary arteries.
Possible symtpoms include impaired gas exchange, hypotension, and circulatory
collapse. (Breen 2000, Feied 2002) Left-sided (arterial) obstruction may also occur, if an
atrial or ventricular septal defect is present. Obstruction of the coronary or cerebral
arteries by air can lead to myocardial infarction and acute stroke, respectively. (Breen
2000, Shockley 2002)

21. 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)

22. 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)

23. LATE COMPLICATIONS
Infection | Thrombophlebitis | Phlebitis Infection
The peripheral venous catheter should be removed at once if infection is suspected. the
decision to begin antibiotics must be made on an individual basis. Antibiotics with activity
against gram positive organisms (such as first-generation cephalosporins, penicillin, or
vancomycin) should be initiated if there is evidence of systemic infection or spreading local
infection.
Catheter related infections are best controlled by meticulous attention to sterility and
preparation 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 alcohol
prep simply not effective. Iodine-based solutions are more effective than alcohol, and
should be used if the patient is not allergic to iodine. These preps are most effective if
allowed to dry on the skin for at least 30 seconds. (Weinstein

24. Peripheral venous thrombophlebitis,
an extremely common complication, is heralded by pain, erythema, swelling, and a palpable cord
along the course of the cannulated vein. Thrombophlebitis is caused by local damage to the venous
wall, and resultant inflammation and thrombus formation. (Tagalakis 2002)
There are multiple risk factors for the development of thrombophlebitis. The length of duration of
cannulation is proportional to the risk of thrombophlebitis. Catheters placed in the veins that
overlay joints are more likely to cause thrombophlebitis, as motion of the joint can cause frictional
trauma between the endothelium and the catheter. Stagnant blood flow in the lower extremities
makes veins in this location more likely to develop thrombophlebitis. Numerous intravenous fluid
solutions, such as potassium chloride, barbiturates, phenytoin, and chemotherapeutic agents, are
known to cause endothelial damage and inflammation. Finally, poor technique and multiple
attempts lead to vascular damage and thrombophlebitis. (Tagalakis 2002, Weinstein 2001)
Should thrombophlebitis developed, the intravenous catheter should be removed immediately. The
most circumstances, no treatment is needed other than elevation of the extremity and the
application of warm compresses. Antibiotics may be required if there is evidence of surrounding
infection. (Weinstein 2001)

25. 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.

26. Needlestick injuries to health-care workers and other hospital employees is
commonplace. It is estimated that over 800,000 needlestick injuries occur each year in
United States hospitals. (Tan 2001
UNIVERSAL PRECAUTIONS Appropriate Universal Precautions should always be
maintained to protect the patient, the person performing the procedure, and other
individuals 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 sharps
disposal and the correct usage of safety features.

27. THANK YOU
DR.R.MANJUNATH