chapter 6 venous access. chapter goal understand basic principles of venous access & iv...

Chapter 6

Venous Access

Chapter Goal

Understand basic principles of venous access & IV therapy, as well as relate importance of employing appropriate BSI precautions when employing these precautions

Learning Objectives

Describe indications, equipment needed, techniques used, precautions, & general principles of: Peripheral venous cannulation Obtaining blood sample External jugular cannulation Disposal of contaminated items & “sharps”

Introduction

Intravenous (IV) cannulation Placement of catheter into vein Used to administer:

• Blood• Fluids• Medications

Used to obtain blood samples Medical direction or standing orders typically

required

Introduction

Indications: Cardiac disease Hypoglycemia Seizures Shock

• Hypovolemic shock—to counter blood loss • Medical emergencies—to establish route for medication

administration • Administer drugs in prehospital setting• Precautionary measure

Introduction

Precautions: Bleeding Infiltration Infection

Contraindications: Sclerotic veins Burned extremities Do not delay transport to start IV

Introduction

Body substance isolation precautions Substances potentially infected with

• Hepatitis B virus (HBV)• Human immunodeficiency virus (HIV)

Wash hands:• Before & after• Immediately on contact

Wear gloves, gown, mask, eye protection HBV vaccine

Introduction

Needle stick injuries 600,000 to 800,000 per year

• Hepatitis C & AIDS Devices to help reduce risk

• Needleless systems—no needle • Needle safety systems—built-in physical attribute

Passive & active devices• Active device requires activation• Passive device does not

Introduction

Rules for avoiding injuries: Use alternatives Assist in selecting & evaluating devices Use safety devices provided Proper handling, disposal, use of barriers Avoid recapping, bending, breaking, recapping needles Avoid separating from syringe, manipulating by hand Safe handling & disposal Dispose of used needles promptly Report injuries Tell employer about hazards Attend training

Introduction

IV supplies & equipment IV solution Administration set Extension set Needles, catheters Gloves, gown, goggles Tourniquet Tape, dressing Antibiotic swabs, ointment Gauze dressings Syringes Vacutainer Blood tubes Armboards

Introduction

IV Solutions Solutions & osmotic pressure

• Described by tonicity • Isotonic solution• Hypotonic solution• Hypertonic solution

Crystalloids • Normal saline • Lactated Ringer’s

Introduction

Crystalloids Dissolved ions cross cell

membrane Sodium chloride 0.9%

solution/lactated Ringer’s solution

5% dextrose in water (D5W)

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Intravenous Solutions

Intravenous solutions come in four different types. Crystalloids Colloids Blood Oxygen carrying fluids


Crystalloid solutions move quickly across cell membranes. Colloid solutions do not, and therefore remain in the intravascular space for longer periods.


Solutions and osmotic pressure Isotonic solution: a solution that has an osmotic

pressure equal to the osmotic pressure of normal body fluid

Hypotonic solution: a solution that has an osmotic pressure less than that of normal body fluid

Hypertonic solution: a solution that has an osmotic pressure greater than that of normal body fluid

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Intravenous Solutions—Solutions and Osmotic Pressure Crystalloids

Dissolving crystals such as salts and sugars in water creates crystalloid solutions.

They contain no proteins or other high-molecular-weight solutes.

When introduced into the circulatory system, the dissolved ions cross the cell membrane quickly, followed by the IV solution water. • Crystalloid solutions remain in the intravascular

space for only a short time before diffusing across the capillary walls into the tissues.

• It is necessary to administer 3 L of IV crystalloid solution for every 1 L of blood lost (3:1 ratio) when treating patients who have experienced hypovolemic shock.

Intravenous Solutions—Solutions and Osmotic Pressure

Crystalloids Normal saline and lactated Ringer's solution are

examples of crystalloids One L of lactated Ringer's solution contains:

• 130 mEq of sodium (Na+)• 4 mEq of potassium (K+) • 3 mEq of calcium (Ca2+) • 109 mEq of chloride ions (Cl–) • 28 mEq of lactate


Crystalloids One L of normal saline contains:

• 154 mEq of sodium ions (Na+) • 154 mEq of chloride ions (Cl–)

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5% dextrose in water (D5W)

It is a glucose solution that is isotonic in the

container but hypotonic after it enters the

circulatory system.

In the past, D5W was a mainstay in the

management of medical emergencies.

The AHA Advanced Cardiac Life Support

Guidelines for cardiac arrest no longer list D5W as

the preferred solution.

Patients who survive are reported to have poor

neurological outcomes when they have increased

glucose levels.


Numerous other crystalloid solutions are also available. Hypertonic solutions

• 5% dextrose in 0.9% saline • 5% dextrose in 0.45% saline (half-normal saline)• 5% dextrose in lactated Ringer's solution• 3% sodium chloride• 7.5% sodium chloride• 10% dextrose in water


Hypotonic solutions 0.45% saline (half-normal saline) 0.33% sodium chloride 2.5% dextrose in water


Colloids Colloids contain large molecules such as protein

that do not readily pass through the capillary membrane. They remain in the intravascular space for extended periods.

The presence of the large molecules in colloids results in an osmotic pressure that is greater than the osmotic pressure of interstitial and intracellular fluids.

This difference in pressure pulls fluid from the interstitial and intracellular spaces into the intravascular space.

Colloids are often referred to as volume expanders.


Colloids Because colloids are expensive, have short half-

lives, and often require refrigeration, they are not commonly used in the prehospital setting

Common colloids include:• Blood derivatives

Plasma protein fraction (plasmanate) Salt poor albumin

• Artificial colloids Dextran Hetastarch (Hespan)

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IV Solution Containers IV bags Solutions used in the prehospital

setting are typically contained in a

clear plastic or vinyl bag that

collapses as it empties. The size of the IV bag varies

depending on its use. Smaller bags (100 to 250 mL) are

used in the management of medical

emergencies and drug

administration. Larger bags (1000 mL) are used in

the management of trauma

emergencies or when the patient has

experienced volume loss.

Introduction

Sodium Chloride 0.9% solution & Lactated Ringer’s solution Recommended IV use in prehospital setting Used to:

• Expand intravascular volume • Replace extracellular fluid losses • Administer with blood productsonly solution

5% dextrose in water (D5W) Was mainstay in management of medical emergencies

• In cardiac arrestno longer considered preferred • Slightly aciditic • Local EMS protocols will dictate

Copyright © 2007, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Fluid Contents

Sodium Chloride 0.9% Solution Sodium and Chloride

Lactated Ringer’s Solution Lactate, Potassium, Sodium, Chloride, Calcium

5% dextrose in water (D5W) Dextrose and Water

Introduction

IV solution containers Size of bag varies

Introduction

IV solution containers 2 ports at bottom of bag Labeled with:

• Contents• Expiration date

Introduction

Administration set Clear plastic tubing Range from 60–110 inches

Introduction

Piercing spike

IntroductionMicrodrip Macrodrip

Introduction

Rates for administering IV fluids Medical emergencies—TKO rate (8-15 gtts/min.) Trauma—based on patient’s response

Introduction

Changing philosophy for hypovolemic shock —no clear rule Shock, external bleeding uncontrolled—only

enough to maintain BP Uncontrolled internal bleeding—surgical

intervention Regardless of flow rate—limited to 2–3 L

Introduction

Injection port

Introduction

Connector ends

Introduction

Blood tubing Some EMS systems use in patients with hypovolemia EMTs who work in critical care areas 2 types of blood tubing

• Y-tubing • Straight tubing

Introduction

Volume control Volutrol chamber

• For specific amount of fluid to be administered

• Pediatrics• Renal failure• Administer precise

medications

Equipment

Needle/Catheter

Equipment

Protected Needles Shielding/Retracting Self-blunting

IV Catheter Size Outside diameter is “gauge” Larger gauge number—

smaller diameter Large diameter—greater

fluid flow Color-coded system

Equipment

Choosing best size over-the-needle catheter Smaller-sized devices are better

• Except for volume replacement• Causes less injury• Allows greater blood flow

Large-bore catheters• Shock• Cardiac arrest• Viscous medications• Life-threatening emergencies—rapid fluid replacement• Minimum 18-gauge catheter—patients requiring blood

Catheter’s length—longer catheter = slower rate

Equipment

Other supplies & materials Latex, rubber or nonlatex gloves Tourniquet Alcohol preparations Sterile dressings Adhesive tape Commercial transparent dressings Armboards 10 or 35-mL syringe or Vacutainer Assorted blood collection tubes

Equipment

Intermittent infusion device Eliminates need for IV bag & administration Keeps access device sterile Self-sealing Constant venous access—not continuous infusion

Equipment

IV solution warming devices Temperature of IV fluids vary Infusion < normal body temperature Appliances designed to:

• Maintain IV fluid at normal body temperature • Prevent overheating

Hot sack

Peripheral Venous Cannulation

Veins have 3 layers—Tunica intima, Tunica media, Tunica adventitia


Skin has 2 layers Epidermis

• Outermost layer • Protective covering • Varies in thickness

Dermis • Highly vascular &

sensitive• Many capillaries • Thousands of nerve

fibers


Noncritical patients Distal veins on dorsum of

hands and arms In Indiana, a jugular vein

is considered to a peripheral vein


Noncritical patients Use vein with these

characteristics:• Fairly straight• Easily accessible• Well-fixed—not rolling• Feels springy


Sites to be avoided:

Sclerotic veins Veins near joints Areas where arterial pulse is palpable Veins near injured areas Veins near edematous extremities


Sites used in cardiac arrest: Peripheral veins of antecubital fossa

• Largest• Most visible• Most accessible

Distal veins are least desirable• Blood flow markedly diminished • Difficult or impossible to cannulate


Other sites External jugular vein Peripheral leg veins Intraosseous

Performing IV Cannulation

Insert spiked piercing end of administration set into tubing of IV bag

Squeeze drip chamber to fill halfway


Place tourniquet 6 inches above venipuncture site

Make slip knot with tourniquet


Complete band placement

Use povidone-iodine (use protocol) or alcohol wipe to cleanse site


Pull skin taut; bevel of needle should be facing up

Penetrate vein either from top or side


Watch for blood in flashback chamber

Advance needle until tip of catheter is sufficiently within vein

Slide catheter into vein until hub rests against skin


Remove needle from vein & catheter

Properly dispose of used needle



Draw sample of blood

Release tourniquet


Open IV control valve; ensure IV fluid is flowing properly

Secure catheter & tubing with tape/commercial device


After venipuncture is performed: Confirm needle placement Blood may not flow back If infiltration occurs

• Remove & discard catheter • Place dressing on venipuncture site • Attempt venipuncture at another site

Other methods of determining proper placement of catheter• Lower IV bag below IV site • Palpating vein above IV site• Palpating tip of catheter in vein• Aspirating blood with 10-mL syringe

Peripheral IV Access



Using an armboard Can be avoided—choose site away from flexion areas May be necessary when:

• Venipuncture device inserted near joint • Venipuncture device inserted in dorsum of hand• Used along with restraints


Regulating fluid flow rates Primary aspect Too fast or too slow—cause complications Adjust according to protocol Formula Flow rate established—check on ongoing basis

Procedures for Regulating Flow Rates

Regulating fluid flow rates (cont.) The formula below can be used to calculate IV solution drip

rates per minute.

volume to be infused (in milliliters) × drip factor (in drops per milliliter) = flow rate (in drops per minute)

time of infusion (in minutes)

Procedures for Regulating Flow Rates

volume to be infused (in milliliters) × drip factor (in drops per milliliter) = flow rate (in drops per minute)

time of infusion (in minutes)

Infuse 150ml of NS using a Marco over 1 hr.

(150ml x 15gtts)/60 min. = 2250/60 = 37.5 gtts/min


Regulating fluid flow rates Factors that can cause flow rate to vary

• Vein spasm• Vein pressure changes• Patient movement• Manipulations of clamp • Bent, kinked tubing• IV fluid viscosity• Height of infusion bag• Type of administration set• Size & position of venous access device


Regulating fluid flow rates Assess flow rate more frequently

• Critically ill patients• Condition can be exacerbated by fluid overload• Pediatric patients• Elderly patients• Patients receiving drug that can cause tissue damage if

infiltration occurs


Document Date/time Type/amount of solution Type of device used Venipuncture site Number of attempts &

location for each IV flow rate Adverse reactions &

actions taken Name/identification

number of person initiating infusion

When IV Fluid Does Not Flow



Complications Pain Catheter shear Circulatory overload Cannulation of artery Hematoma or infiltration Local infection Air embolism Pyrogenic reaction

Intermittent Infusion Device

Prime device with dilute heparin/saline solution

Cannulate vein

Intermittent Infusion Device

Connect intermittent device to hub of IV catheter

Connect saline/heparin-filled syringe to access port Slowly aspirate until

blood is seen Inject 3–5mL dilute

heparin/saline

Changing IV Bag

Typically occurs when directed to continue IV after bag is empty

Steps Remove cover from IV tubing port Occlude flow Remove spike Insert spike into new IV bag Open roller clamp to appropriate flow rate

Discontinuing IV Line

Close flow control valve completely

Do not disturb catheter—remove dressing

Hold 2 × 2 dressing above site to stabilize tissue while withdrawing catheter

Remove catheter by pulling straight back

To prevent blood loss Cover site with 2 × 2 dressing Hold against puncture site until bleeding stopped Tape dressing in place

Using IV Protective Devices

Penetrate skin, vein with over-the-needle device

Slide catheter forward into vein while withdrawing needle

Using IV Protective Devices

Clicks into place once plastic guard reaches end

Separate plastic guard from catheter hub

Needle is retracted fully within protective sheath

External Jugular Vein Cannulation

Benefits Fairly easy to cannulate Fluids & meds quickly reach central circulation & heart

Disadvantages Hard to access when managing patient’s airway Vein can “roll” Vein can be positional Extremely painful

Complications Same as with other veins Risk of puncturing thoracic cavity Structures can be damaged by accidental misplacement

External Jugular Vein Cannulation

Anatomy of surrounding area Proper IV cannulation

Elderly Patients

Prominent veins—less resistant skin

Difficult to stabilize vein

Veins fragile

Remove tourniquet quickly

Smaller, shorter venipuncture devices work best

Seizing or Moving Patients or Patients in Transport

Steady extremity

Look for biggest vein

Penetrate during period of less movement.

Hold little & ring fingers against patient’s extremity

Once in—slide catheter in quickly

Seizing or Moving Patients or Patients in Transport

Once in place—do not let go

Use extra tape to secure cannula

Use armboard or splint

Wrap tubing & extremity proximal to site

Summary

IV cannulation—placement of catheter into vein for purpose of administering blood, fluids, or medications &/or obtaining venous blood specimens

Placement of IV line should not significantly delay transporting critically ill or injured patients to hospital

Recommended IV solutions for use in prehospital setting— normal saline (0.9%) & lactated Ringer’s solution

Crystalloid solutions quickly diffuse out of circulatory system

2 most common types of administration sets—microdrip, macrodrip

Summary

Most commonly, plastic over-the-needle catheters are used in prehospital setting

Noncritical patients—distal veins of dorsal aspect of hand & arms preferred

Cardiac arrest—veins of antecubital fossa

Patients in whom cannulating vein is difficult Obese persons Patients in shock or cardiac arrest Chronic mainline drug users Elderly patients Small children

Summary

When equipment selected—IV fluid checked Right fluid Not outdated Clear Bag has no leaks

Continually employ infection control procedures

Release tourniquet once IV tubing is connected

Continually monitor patient for signs of improvement & signs of circulatory overload

All IV techniques share number of complications Oh Yea . .

Questions?

chapter 6 venous access. chapter goal understand basic principles of venous access & iv...

Documents

iv slide

introduction precautions

training slide

w slide

venous access slide

introduction crystalloids

introduction indications

introduction rules