Vascular AccessMary Corcoran RN, BSN, MICN

Peripheral Access

Peripheral Access is obtained using Aseptic technique

Initial insertion attempts should begin distally and progress up the extremity◦ If the situation and pt vasculature allow

During resuscitation peripheral access is preferred to eliminate interruption in chest compression for central line insertion

Proximal veins may be used when giving medication with extremely short half life, or for rapid fluid or CT contrast infusion ◦ Adenosine

Scalp Veins have no valves and are easily visible on infants- allowing infusion in both directions

Tips and Tricks

Infiltration of fluid or medication (can cause necrosis with certain meds)

Phlebitis Embolism

◦ Of blood, air, or catheter fragments Infection Cellulitis Needle stick and blood exposure for

RN

Potential Complications

In ER- anywhere you can find a vein◦ Arms, legs, Neck, Abdomen,

Hands, Feet, Breasts etc… Most Common are

◦ Hands, A/C (antecubital), Forearms, and EJ’s (external Jugular)

Just make sure to always point toward the heart

**note: check with your facility for specific locations and protocols

Location

Size and Type of cath are determined by urgency of need, patient size and vasculature◦ Larger Diameter (12,14,16,18g)- used for rapid

fluid, drug, or blood infusion◦ Smaller Catheter (20,22,24g)- are used for routine

vascular access, and patients with smaller veins

Catheter Selection

IV Insertion

Central Venus Access

Subclavian Vein- under the clavicle

Internal Jugular- also under the clavicle

Femoral Vein- In the groin

Where are they placed?

Why do we place them?

Short Term Long Term

When all other peripheral access is unavailable

When condition is unstable and requires hemodynamic monitoring (eg CVP)

Prolonged IV Therapy◦ TPN, extended Abx

therapy, or caustic medication administration Vancomycin

Debilitating diseases

◦ AIDS, Cancer

Central Line Insertion

Non tunneled Tunneled Implanted

Example PICC- Peripherally Inserted Central Catheters

Broviac Port-a-Cath, norport, lifeport

Characteristics Single or Multi-Lumen

Single or Multi- Lumen w/ cuff

Implanted in chest wall

Advantages Easy removal and placement

Unlimited use, painless access

Less trauma to body image, minimal infection

Disadvantages Activity Restriction, dislodges easily

Mental and Physical Requirements for self care

High Insertion Costs, more painful

Venus Access Devices

Intraosseous Infusion

Inserted in to the bone marrow, blood can be drawn from the marrow, and fluids, medication, and blood infused through the marrow

Used on adults and pediatric patients

When all else fails…

Anterior Tibia, Medial Malleolus, Sternum, Distal Femur, Humerus, or Iliac Crest

Where do we place them?

You Tube Video for Humeral IO, staring someone familiar…..

Sternal IO insertion- only done in military currently

Fluid and Blood Replacement

Example Uses

Isotonic 0.9% Normal Saline (NS),Lactated Ringers

Expands intravascular volume, used for hydration, and maintenance fluid

Hypotonic NS 0.45%NS 0.2%Dextrose 5% in Water (D5W)

Shifts H2O intracellular, assessing renal patients,and mixing medications

Hypertonic D5% in NSD10% in NS

D10% in WaterD10% in 0.45%NSD20% in Water

Shifts intra cell fluid to extracellular, used in too much hypotonic solution administration

Maintenance to promote diuresis

Maintenance IV Fluid

Whole Blood◦ Unfiltered and carries significant risks of

infection and transmission, is expensive, and not readily available

PRBC’s (Packed Red Blood Cells)◦ Are used most often for blood replacement

FFP (Fresh Frozen Plasma)◦ Contains Clotting Factors

Albumin (5% isoonocoit, 25% isotonic “salt poor”)◦ Used as volume expander when risk of

interstitial edema is great (pulmonary/cardiac disease)

Blood Administration

Blood Compatibility Patient Compatible Transfusion

Type A A or AB Plasma

Type B A or O RBC’s

Type AB AB Plasma; A, B, AB or O RBC’s

Type O A, B, AB or O Plasma; O RBC’s

Rh- Must Receive Rh- Blood

Rh+ Can Receive Rh- Blood or Rh+ Blood

O- Universal Doner for RBC’s

AB+ Universal Doner for Plasma

*caution in pregnant mothers/females

Transfusion Reactions Hemolytic

◦ Cause- Blood Incompatibility◦ Prevention- Type and Crossmatch, infuse first

50cc slowly◦ Assessment- Fever, Chills, Dyspnea, Tachypnea,

fever, olguria, hematuria, chest tightness Collect blood and urine

◦ Intervention- Discontinue Immediately FATALITY may occur after 100cc, start NS or LR, consider diuretics, and monitor BUN, Creatinine

Transfusion Reaction Allergic

◦ Cause- Antibody Reaction to allergens◦ Prevention- Screen donors for allergy; administer

antihistamines (Benadryl) prior to transfusion◦ Assessment- Chills, hives, wheezing, vertigo,

Anaphlaxis, dyspnea, bronchospasm and generlized edema

◦ Intervention- Stop Infusion, give antihistamines, epi, NS or LR

Transfusion Reactions Circulatory overload

◦ Cause-infusion of large amounts of blood, especially to elderly, or cardiac hx

◦ Prevention- Infuse Slowly; check drip rate and frequency

◦ Assessment- Pulmonary Crackles, Cough, dyspnea, pulmonary edema, increased CVP

◦ Intervention- Stop infusion, treat pulmonary edema

Transfusion Reaction Hypocalcaemia

◦ Cause-Precipitate from acid citrate dextrose calcium dilution with massive transfusions

◦ Prevention- use blood immediately

◦ Assess- Numbness, and tingling to extremities

◦ Intervention- Stop infusion, give Calcium

Hyperkalemia◦ Cause- Hemolysis of

red blood cells Release Potassium

◦ Prevention- Use blood immediately

◦ Assess- Nausea, Vomiting, Muscle weakness, bradycardia

◦ Intervention- stop Infusion