February 17, 2010


SURGERY 4 Shifting


Dr. Mata

Basic Intravenous Therapy  90-95% of patients in the hospital receive some type of intravenous therapy.  This presentation will enhance your knowledge of how to care for them Indications for IV Therapy  Establish or maintain a fluid or electrolyte balance  Administer continuous or intermittent medication  Administer bolus medication  Administer fluid to keep vein open (KVO) (Old Skool!)  Administer blood or blood components  Administer intravenous anesthetics  Maintain or correct a patient's nutritional state  Administer diagnostic reagents  Monitor hemodynamic functions Vein Anatomy and Physiology  Veins are unlike arteries in that they are 1)superficial, 2) display dark red blood at skin surface and 3) have no pulsation  Vein Anatomy o Tunica Adventitia o Tunica Media o Tunica Intima o Valves

Tunica Intima  the inner layer of the vessel  One layer of endothelial  No nerve endings  Surface for platelet aggregation w/trauma and recognition of foreign object at this level  PHLEBITIS begins here Valves    

present in MOST veins Prevent backflow and pooling More in lower extremities and longer vessels Vein dilates at valve attachment

Veins of the Upper Extremities  Digital Vessels o Along lateral aspects fingers, infiltrate easily, painful, difficult to immobilize and should be your LAST RESORT  Metacarpal Vessels o Located between joints and metacarpal bones (act as natural splint) o Formed by union of digital veins o Geriatric patients often lack enough connective / adipose tissue and skin turgor to use this area successfully

Tunica Adventitia  the outer layer of the vessel  Connective tissue  Contains the arteries and veins supplying blood to vessel wall Tunica Media  the middle layer of the vessel  Contains nerve endings and muscle fibers  The vasoconstrictive response occurs at this layer

Cephalic (Intern’s Vein) o Starts at radial aspect of wrist o Access anywhere along entire length (BEWARE of radial artery/nerve) Medial Cephalic (“On ramp” to Cephalic Vein) o Joins the Cephalic below the elbow bend o Accepts larger gauge catheters, but may be a difficult angle to hit and maintain

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Supplies (cont’d) o Infusion Sets  10 or 15 gtt/cc (large/macro drip)  60 gtt/cc (small/micro drip)  “Select-3” o Alcohol and Betadine o Restricting Band o “Tegaderm” / “Venigard” o Tape o Armboard (optional) o Labels o Saline Lock (optional)

Basilic o

Gauges  Originates from the ulner side of the metacarpal veins and runs along the medial aspect of the arm. It is often overlooked becauses of its location on the “back” of the arm, but flexing the elbow/bending the arm brings this vein into view    

Needles & Catheters are sized by diameters which are called gauges. Smaller diameter = larger gauge IE: 22-gauge catheter is smaller than a 14-gauge Larger diameter = more fluid able to be delivered If you need to deliver a large amount of fluid, typically 14or 16-gauge catheters are used.

Medial Basilic o Empties into the Basilic vein running parallel to tendons, so it is not always well defined. Accepts larger gauge catheters. o BEWARE of Brachial Artery/Nerve

Choosing Fluids & Catheters  Crystalloid Fluids o Volume replacement and  CO/BP o Isotonic o No proteins o Moves into tissue over short time  Colloid Fluids o Large proteins o Remain in vascular space o Blood replacement products o Plasma Substitutes (Hypertonic)  Dextran  Hetastarch Catheters o Over the needle preferred (or IO in peds) o Size depends on patient’s needs and vein size o Large gauge and short length for volume replacement Vein Selection o For most patients, choose most distal o Hand, forearm, antecubital space, and external jugular o Normal Anatomy provides clues to locations o avoid injury, fistula, mastectomy side

Equipment and Supplies  Fluids o Normal Saline (0.9% NaCl) o Lactated Ringers (LR or RL) o 5% Dextrose in Water (D5W) o Other (D5 1/2 NS)  Supplies o IV Catheters  Over the needle catheter  Thru the needle catheter  Hollow needle / Butterfly needles  Intraosseous needle

Types of IV Needles  Steel needles: Butterfly catheters, named for the plastic tabs that look like wings. Used for small quantities of medicine, infants, and to draw blood although the small size of the catheter can damage blood cells. Usually small gauge needles.  Over-the-needle catheters: Peripheral-IV catheters are usually made of various types of Teflon or silicone materials which determines how long the catheter can remain in your vein. These typically need to be replaced about every 1 to 3 days.  Inside-the-needle catheters: Larger than Over-the-needle catheters, typically used for central lines.

Theory of Fluid Flow 4  Flow = diameter / length o Larger catheters = higher flow o Short catheters = somewhat higher flow  Other factors affecting flow o Tubing length o Size of Vein o Temperature and viscocity of fluid o Warm fluids flow better than cold

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Tips on Increasing Flow  Use a large vein o Large AC preferred for cardiac arrest, trauma, adenosine & D50 administration  Use a short, large bore catheter 1/4 o 1 ” 14 g  Use short tubing with large drip set o Macrodrip (10 gtts/ml) and NO extension set  Use warm fluid with pressure infuser Venipuncture Procedure: Tips

If the patient is NOT allergic to latex, using a latex tourniquet may provide better venous congestion o Avoid areas of joint flexion o Start distally and use the shortest length/smallest gauge access device that will properly administer the prescribed therapy (BE AWARE: Blood flow in the lower forearm and hand is 95ml/min) Selection of an insertion point.  Evaluate the patient veins.  Select the vein and point of insertion remembering: o cannula should be positioned at the opposite side of body in respect to the planned surgery o the median cavitalvein should be reserved for blood sampling o the sites previously irritated by injection or cannulation should be avoided o the insertion site should be easily approached and the presence of cannula should not create patient discomfort. Preparation of puncture site  Explain to the patient the procedure and purpose of cannulation.  Clean the hands.  Clean the skin surrounding the cannula insertion site with soap or detergent solution for example the site at the hand palm, the palm and forearm. The similar field in a case of other selected site.


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Talk to your patient Prepare & Assemble equipment ahead of time or direct this task Inspect fluid date, appearance, and sterility Flush air from tubing Select the most distal site if at all possible o antecubital o saphenous o external jugular Flush air from tubing Select the most distal site if at all possible o antecubital o saphenous o external jugular Remove needle & place in sharps Check for adequate flow RECHECK drip rate


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Starting a Peripheral IV  Finding a vein can be challenging o Go by “feel”, not by sight. Good veins are bouncy to the touch, but are not always visible. o Use warm compresses and allow the arm to hang dependently to fill veins. o A BP cuff inflated to 10mmHg below the known systolic pressure creates the perfect tourniquet. Arterial flow continues with maximum venous constriction.

Clean insertion site and surrounding field with solution of chlorhexidine in ethyl alcohol or isopropyl alcohol Wait 3-4 minutes till aseptic solution evaporates. Don’t allow contamination of insertion site. Put the tight tourniquet above insertion site

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Hold the cannula firmly with three points grip Such grip minimizes the risk of contamination and ensures correct positioning between the needlepoint and the catheter tip.

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Withdraw the needle completely Press a finger on the vein above the insertion point to avoid blood spillage

The needle must never be reinserted while the catheter is in the vein. This may sever the catheter

Insert the cannula into the vein at a low angle. Entry the needle into the vein is indicated by the presence of blood in flashback chamber

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Remove the luer lock plug by pushing the needle to the waste container Close the cannula with the luer lock plug.

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Advance the cannula a few millimeters further into the vein, which insures that catheter tip also enters the vein. Avoid touch contamination by holding the hub by the wing or protection cap Withdraw the needle partially to avoid exit through the posterior vein wall. Firmly hold the flash chamber and advance the catheter off the needle into the vein.

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Cannula fixation Fix the cannula to the patient skin with proper dressing. Fixation of the cannula should not affect blood flow around the catheter and should prevent movements

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of the cannula which can result in mechanical irritation of the vein Check the correct placement of the catheter by injecting about 5 ml of sterile physiological saline. Record date and time of insertion

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o Neonate (umbilical vein) Any drug or fluid that can be given IV may be given by the IO route Little interference during Resuscitation

For medicine administration and cannula cleaning the injection port can be used. Port not in use must remain covered by protection cap. For repeated injections at short intervals the syringe can be left in the port

Potential IV sites

Removal of the cannula.  Wash the hands.  Remove all the tape and I.V. dressing.  Hold a piece of dry sterile cotton gauze over the insertion site.  Remove the cannula.  Apply pressure immediately for 2-3 minutes to stop leakage of blood.  Apply suitable dressing if necessary.  Inspect the removed cannula if the catheter is complete and undamaged.  The scissors must not be used in the whole process of preparation IV Start Pain Management  One of the most frequent contributors to patient dissatisfaction is painful phlebotomy and IV starts  Use 25-27g insulin syringe to create a wheal similar to a TB skin test on top of or just to side of vein with 0.1 -0.2 ml normal saline or 1% xylocaine without epinephrine  Topical anesthesia cream (ie EMLA) may be applied to children>37 weeks gestation 1 hr. prior to stick. It might be a good idea to anesthetize a couple of sites  Have the patient close their fist (NO PUMPING) prior to stick  Make sure the skin surface cleansing agent (alcohol/chlorhexidine) is dry prior to stick. Drawing this into the vein may stimulate the vasoconstrictive action of the tunica media layer Intraosseous (IO) Infusion & Vascular Access  Common IV sites for Pediatric patients o Peripheral extremities (hand, wrist, dorsal foot, antecubital) o Peripheral other (external jugular, scalp, intraosseous

Indications o Required drug or fluid resuscitation due to an immediate life-threat (e.g. CPR, Shock) o At least 2 unsuccessful peripheral IV attempts Contraindications o Placement in or distal to a fractured bone/pelvis o Placement at a burn site (relative) o Placement in a leg with a missed IO attempt o ↑ difficulty in patients > 6 years of age

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Intraosseous (IO) Infusion  Procedure o Same as peripheral IV o Place leg on firm surface. Locate landmarks o Grasp the thigh and knee. Do not place hand behind insertion site. o Palpate landmarks and identify site of insertion. o Clean site if time permits o Insert needle at 90° angle. Apply pressure with firm twisting motion. o Stop advancing once needle resistance is decreased o Remove stylet. o Inject saline. Check for resistance or soft tissue swelling. o Connect infusion set o Stabilize  Considerations o Gravity flow of IV fluids will typically be ineffective. Use pressure bags if continuous infusion is required o Fluid is best administered as a syringe bolus using an extension set or T-connector o PROTECT YOUR IO SITE!

Potential Complications o Sepsis (infection) o Hematoma o Cellulitis o Thrombosis o Phlebitis o Catheter fragment embolism o Infiltration o Air embolism Intravenous Piggy Back Medications o Purpose o To administer intermittent IV drugs that cannot be mixed with the primary solution o To administer different IV drugs at different times o To maintain peak levels of a medication in the blood stream o Primary line to saline lock o Obtain primary tubing  Determine amount of fluid to prime tubing o Clamp tubing o Spike medication container o Fill chamber o Prime tubing

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