IV ACCESSDR.R.MANJUNATHCHIEF PHYSICIAN

VIKRAM HOSPITALMYSORE

Indications 

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

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)

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.

Intravenous Cannulas

• Over-the-needle catheter • Hollow-needle catheter • Plastic catheter inserted through a hollow needle

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

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.

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.

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.

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.

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.

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)

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.

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 PlacementProper 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.

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)   

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.

Inability to advance catheter

EARLY COMPLICATIONS

Infiltration | Arterial Placement | Air Embolism | Catheter Fracture & Embolism

Infiltration and ExtravasationInfiltration 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)

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.

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)

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. 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

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)

•Utilizing a septic technique•Using of alcohol or iodine prior to insertion•Securing catheter appropriately•Avoiding lower extremity insertion sites

•Inspecting for thrombophlebitis daily•Replacing catheters every 72 hours•Avoiding unnecessary tubing changing•Replacing dressings as needed.

Thrombophlebitis can be prevented by following these recommendations (Tagalakis 2002):

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.

THANK YOUDR.R.MANJUNATH