Venipuncture

AEGD Lecture
 Venipuncture
• A technique separate and distinct from IV sedation
• NOT difficult to perform correctly
• important to become proficient
• route of drug administration not only for IV sedation, but
also for emergency drugs, ACLS, etc.
 Venipuncture
• In Theory:
• May be performed in any vein of sufficient size to
accommodate catheter
• In Practice:
• usually confined to a superficial vein in an upper
extremity
• other areas used if veins of arms are inadequate or in
situations in which arm is unavailable for use
 Venipuncture: Anatomy
• Venous circulation
• potential IV sites
• Arterial circulation
• often in close proximity to veins
• knowing where NOT to start an IV is important
 Venipuncture: Anatomy

• Blood to right upper

limb:
• leaves aortic arch
through brachiocephalic
trunk
• divides into the right
common carotid and the
right subclavian arteries
Venipuncture: Anatomy
• Blood to left upper limb
• subclavian artery is a
direct branch of the
aortic arch
 Venipuncture: Anatomy
• Subclavian artery:
• enters the axilla as the
axillary artery

• axillary artery enters the

arm as the brachial
artery
 Venipuncture: Anatomy
• one inch below
antecubital fossa the
brachial artery bifurcates
into the radial and ulnar
arteries
• travel distally and
terminate in palm as an
arterial arch
 Venipuncture: Anatomy
• Location of arteries important
• In antecubital fossa:
• brachial artery often located just deep to the median
cephalic vein (usually the most prominent vein)
• On ventral wrist
• radial artery quite superficial laterally
• ulnar artery deeper on medial
 Venipuncture: Anatomy
• Venous return from upper limb
• Blood from digits and palm drain into the dorsal venous
network on dorsum of hand
• Two major veins arise from this network:
• cephalic vein - from radial network (lateral)
• basilic vein - from ulnar network (medial)
 Venipuncture: Anatomy
• The cephalic and basilic veins ascend the forearm
• joined by the median cephalic and median basilic veins
medially (which are bridged by the median vein)
• continue to ascend superiorly to drain into the axillary
vein => subclavian vein => brachiocephalic vein =>
superior vena cava
 Venipuncture: Anatomy
• Veins of upper limb may be divided into…
• Deep veins:
• accompany arteries within their fascial sleeve
• run in pairs on either side of arteries
• Superficial veins:
• lie outside the fascial sleeve of arteries
• the veins selected for most venipunctures
 Venipuncture: Anatomy

• Upper limb
• provides four distinct areas for venipuncture:
• Dorsum of hand
• Wrist
• Forearm (No)
• Antecubital fossa
• medial
• lateral
 Dorsum of Hand
• Advantages:
• few, if any, superficial
arteries
• veins are very superficial
• forms flat, non-
articulating surface
• immobilization of limb
not necessary
 Dorsum of Hand
• Disadvantages
• veins often smaller in size
• can be mobile, prone to “roll”
• can be controlled to some degree:
• Having patient hold tight fist during attempt
• Holding traction on the vein by pulling the skin of the dorsum
toward the knuckles
• Use of a vein bifurcation, if present
• more painful than other sights???
 Wrist
• various unnamed veins on dorsum
• large vein on radial (lateral) aspect of wrist = “resident’s
vein”
• excellent site, but…
• often mobile, prone to “roll”
• tendons deep; can be painful if vein missed deep
• ventral wrist: “don’t even go there”
• veins too small
• nerves, arteries, tendons prevalent in area
Wrist
 Forearm

• Basilic vein medially

• Cephalic vein laterally
• Median vein centrally
• Large veins
• Less prone to roll
• No need for immobilization
of site
• Devoid of any arteries or
nerves superficially
• But…not always visible
 Antecubital Fossa
• Antecubital Fossa
• relatively large targets
• medial
• basilic
• median basilic*
• median vein
• median cephalic
• cephalic
• lateral

 usually most prominent

 Antecubital Fossa
• Important structures deep, medially
• biceps tendon
• median cutaneous nerve of the forearm
• bicipital aponeurosis
• immediately deep to bicipital aponeurosis:
• median nerve
• brachial artery

• Lateral much safer

 Antecubital Fossa
• Advantages:
• large, immobile veins
• anatomically safe, laterally
• Disadvantages:
• veins sometimes not visible
• medial aspect should be avoided due to important
structures
• area requires immobilization for IV
 Venipuncture
• Selection of site
• avoid veins that are:
• tortuous
• scarred
• inflamed, sore
• choose veins that are:
• unused
• uninflamed
• easily visible
• straight
Utilizing Traction
 Venipuncture
• Preferred sites:
• areas that allow freedom of movement
• ie - not “positional”
• dorsum of hand
• forearm
• wrist, antecubital fossa usually require some sort of immobiliation
or strict positioning
• can increase patient discomfort
• can compromise reliability of IV
• increases potential for IV failure, infiltration
 Venipuncture: Complications
• Non-running IV infusion
• Infusion bag not adequately elevated
• Bevel of needle against wall of vein
• Tourniquet left on arm
• Vein not cannulated = infiltration
• never reliably established
• cannula dislodged
 Venipuncture: Complications

• Infiltration
• IV fluid deposited into tissues surrounding a vessel
• should be just IV fluid
• can be drug if infiltration not recognized before drugs
given
 Venipuncture: Complications
• Infiltration
• Prevention
• careful venipuncture technique
• careful verification of adequate IV flow
• Causes
• catheter dislodgement…
• site not appropriately immobilized
• catheter not securely taped
• vein never effectively cannulated
 Venipuncture: Complications

• Infiltration
• Recognition
• painless, colorless swelling around site of IV
• skin around site will be cool
• Management
• IMMEDIATELY stop flow of IV fluid
• remove catheter, apply pressure to site
• Elevation of extremity
 Infiltration (Continued)
• Apply moist heat and elevate extremity above level of heart (for
many cases this simple treatment is all that is required)
• If irritating drugs have extravasated, then consider infiltrate 1%
plain lidocaine (Xylocaine) at the site, if needed for pain
 Venipuncture: Complications
• Hematoma
• The infiltration of blood from a perforated vessel into the
surrounding interstitial space
• When cannulation successful, the catheter itself acts an
obturator, sealing the vessel
• more friable veins (elderly) may allow leakage around the
catheter
 Venipuncture: Complications
• Hematoma
• Occur mainly at two times
• When IV initiated
• vessel damaged during IV attempt
• catheter becomes dislodged immediately after start
• After IV removed
• inadequate pressure to area following d/c of IV
 Venipuncture: Complications
• Hematoma
• Management
• remove tourniquet!
• remove needle/catheter
• apply digital pressure for two minutes
• followed by gauze taped under pressure
• may want to advise patient to apply ice for first few few hours
postoperatively
• vasoconstriction
• analgesia
• advise patient to expect bruising of area
 IV Complications

• Air Embolism
• infusion of air bubble trapped in IV tubing
• small air bubble infusions not usually a problem in adults
• children - DIFFERENT MATTER
• even small air bubbles can potentially create problems
 IV Complications

• Air Embolism
• Prevention
• take care to remove ALL air from IV tubing
• Management
• geared toward preventing air from entering pulmonary and
cerebral circulation
• position patient on left side (prevents air from entering
pulmonary circulation)
• head down (prevents air from entering cerebral circulation)
 IV Complications
• Overhydration
• Not a problem for most healthy adult patients
• Two groups to be concerned about:
• CHF, CAD patients
• fluid overload may overwhelm heart’s ability to handle volume and
exacerbate CHF symptoms
• small children
• smaller capacity!
• Can create fluid overload more easily
• Prevention: Pediatric IV infusion sets
 IV Complications
• Extravascular Drug Administration
• Can create three problems:
• Pain/discomfort
• at infiltration site, transient and remains localized
• Delayed absorption of drug
• need to consider delayed and prolonged effects of drugs
• Local tissue damage
• can create vasoconstriction in area which may lead to necrosis if severe
enough (very rare)
• not all drugs are irritating to tissue
• diazepam/pentobarbital/propofol ARE!
 IV Complications
• Extravascular Drug Administration
• Cause:
• unrecognized catheter dislodgement from vein/infiltration
• Recognition:
• be able to recognize signs of catheter dislodgment/infiltration
• patient complains of intense pain on injection
• lack of expected response to drug
• resistance noted on injecting drug
 IV Complications
• Extravascular Drug Administration
• Management - small amount
• remove catheter and apply pressure to area
• prevents hematoma formation
• disperses drug over larger tissue area
• Management - larger amount
• perform above, then…
• inject 1% procaine/lidocaine, approx. 10cc over area as infiltration
• produces profound vasodilation
• may obviate some of the discomfort
 IV Complications
• Extravascular Drug Administration
• Management (cont.)
• Patient may require longer time for monitoring and
recovery due to prolonged effect of drug administered
subcutaneously
 IV Complications

• Intraarterial Drug Administration

• Should never happen!
• Intraarterial catheterization should be recognized and
treated appropriately
• bright red, forceful flash in angiocath chamber
• pulsatile retrograde flow in IV tubing
• intense pain on insertion of IV
• No harm done up to this point
 IV Complications
• Intraarterial Drug Injection
• Recognition
• Patient will complain of severe pain
• Pulse points distal to site may be diminished
• Loss of normal skin color distal to site
• Extremity distal will be cool
• Problem
• chemical endarteritis
• results in thrombosis and ischemia distal to site
• can lead to gangrenous necrosis and loss of limbs
 IV Complications
• Intraarterial Drug Injection
• Management
• LEAVE NEEDLE IN PLACE!
• Provides route for administration of…
• 1% Procaine/lidocaine, 2-10cc
• Profound vasodilator - prevents/breaks vasospasm
• Anesthetic to decrease pain
• Acidic (pH = 5) to counteract alkalinity of meds such as pentobarbital
• Acts as diluent
• Consult vascular surgery
 IV Complications
• Local venous complications
• Phlebitis = inflammation of vein
• Thrombophlebitis = thrombus formation in vein as a
result of inflammation
• Phlebothrombosis = presence of clot in vein unassociated
with with inflammation
 IV Complications
• Thrombophlebitis
• most common with IV sedation
• edema
• inflammation
• tenderness to vein
• delayed onset (24-48 hours)
• Treatment
• NSAIDS
• Elevation and limited activity
• Heat
• Antibiotics?
Venipuncture: Armamentarium
Venipuncture: Armamentarium
Venipuncture: Armamentarium
Venipuncture: Armamentarium
Venipuncture: Technique
Venipuncture: Technique
Venipuncture: Technique
Venipuncture: Technique
Venipuncture: Technique
Venipuncture: Technique