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February 17, 2010 SURGERY 4 Shifting Dr. Mata

IV CANNULATION
IV THERAPY, VENIPUNCTURE Tunica Intima
 the inner layer of the vessel
Basic Intravenous Therapy  One layer of endothelial
 90-95% of patients in the hospital receive some type of  No nerve endings
intravenous therapy.  Surface for platelet aggregation w/trauma and recognition
 This presentation will enhance your knowledge of how to of foreign object at this level
care for them  PHLEBITIS begins here

Indications for IV Therapy Valves

 Establish or maintain a fluid or electrolyte balance  present in MOST veins
 Administer continuous or intermittent medication  Prevent backflow and pooling
 Administer bolus medication  More in lower extremities and longer vessels
 Administer fluid to keep vein open (KVO) (Old Skool!)  Vein dilates at valve attachment
 Administer blood or blood components
 Administer intravenous anesthetics Veins of the Upper Extremities
 Maintain or correct a patient's nutritional state  Digital Vessels
 Administer diagnostic reagents o Along lateral aspects fingers, infiltrate easily,
 Monitor hemodynamic functions painful, difficult to immobilize and should be
your LAST RESORT
Vein Anatomy and Physiology
 Veins are unlike arteries in that they are 1)superficial, 2)  Metacarpal Vessels
display dark red blood at skin surface and 3) have no o Located between joints and metacarpal bones
pulsation (act as natural splint)
 Vein Anatomy o Formed by union of digital veins
o Tunica Adventitia o Geriatric patients often lack enough connective /
o Tunica Media adipose tissue and skin turgor to use this area
o Tunica Intima successfully
o Valves

 Cephalic (Intern’s Vein)

Tunica Adventitia o Starts at radial aspect of wrist
 the outer layer of the vessel o Access anywhere along entire length
 Connective tissue (BEWARE of radial artery/nerve)
 Contains the arteries and veins supplying blood to vessel
wall  Medial Cephalic (“On ramp” to Cephalic Vein)
o Joins the Cephalic below the elbow bend
Tunica Media o Accepts larger gauge catheters, but may be
 the middle layer of the vessel a difficult angle to hit and maintain
 Contains nerve endings and muscle fibers
 The vasoconstrictive response occurs at this layer

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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)

Gauges
 Basilic  Needles & Catheters are sized by diameters which are
o Originates from the ulner side of the called gauges.
metacarpal veins and runs along the medial  Smaller diameter = larger gauge
aspect of the arm. It is often overlooked  IE: 22-gauge catheter is smaller than a 14-gauge
becauses of its location on the “back” of the  Larger diameter = more fluid able to be delivered
arm, but flexing the elbow/bending the arm  If you need to deliver a large amount of fluid, typically 14-
brings this vein into view or 16-gauge catheters are used.

 Medial Basilic Choosing Fluids & Catheters

o Empties into the Basilic vein running parallel  Crystalloid Fluids
to tendons, so it is not always well defined. o Volume replacement and  CO/BP
Accepts larger gauge catheters. o Isotonic
o BEWARE of Brachial Artery/Nerve o No proteins
o Moves into tissue over short time
Equipment and Supplies
 Fluids  Colloid Fluids
o Normal Saline o Large proteins
(0.9% NaCl) o Remain in vascular space
o Lactated Ringers o Blood replacement products
(LR or RL) o Plasma Substitutes (Hypertonic)
o 5% Dextrose in Water  Dextran
(D5W)  Hetastarch
o Other
(D5 1/2 NS)  Catheters
o Over the needle preferred (or IO in peds)
 Supplies o Size depends on patient’s needs and vein size
o IV Catheters o Large gauge and short length for volume
 Over the needle catheter replacement
 Thru the needle catheter
 Hollow needle / Butterfly needles  Vein Selection
 Intraosseous needle o For most patients, choose most distal
o Hand, forearm, antecubital space, and external
Types of IV Needles jugular
 Steel needles: Butterfly catheters, named for the plastic o Normal Anatomy provides clues to locations
tabs that look like wings. Used for small quantities of o avoid injury, fistula, mastectomy side
medicine, infants, and to draw blood although the small
size of the catheter can damage blood cells. Usually small Theory of Fluid Flow
4
gauge needles.  Flow = diameter / length
 Over-the-needle catheters: Peripheral-IV catheters are o Larger catheters = higher flow
usually made of various types of Teflon or silicone o Short catheters = somewhat higher flow
materials which determines how long the catheter can  Other factors affecting flow
remain in your vein. These typically need to be replaced o Tubing length
about every 1 to 3 days. o Size of Vein
 Inside-the-needle catheters: Larger than Over-the-needle o Temperature and viscocity of fluid
catheters, typically used for central lines. o Warm fluids flow better than cold

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Tips on Increasing Flow o If the patient is NOT allergic to latex, using a
 Use a large vein latex tourniquet may provide better venous
o Large AC preferred for cardiac arrest, trauma, congestion
adenosine & D50 administration o Avoid areas of joint flexion
 Use a short, large bore catheter o Start distally and use the shortest
1/4
o 1 ” 14 g length/smallest gauge access device that will
 Use short tubing with large drip set properly administer the prescribed therapy
o Macrodrip (10 gtts/ml) and NO extension set (BE AWARE: Blood flow in the lower forearm and hand is 95ml/min)
 Use warm fluid with pressure infuser
Selection of an insertion point.
Venipuncture Procedure: Tips  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.

 Talk to your patient l

 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
 Clean insertion site and surrounding field with solution of
chlorhexidine in ethyl alcohol or isopropyl alcohol
Starting a Peripheral IV
 Wait 3-4 minutes till aseptic solution evaporates.
 Finding a vein can be challenging
 Don’t allow contamination of insertion site.
o Go by “feel”, not by sight. Good veins are
 Put the tight tourniquet above insertion site
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.

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  Withdraw the needle completely
 Press a finger on the vein above the insertion point to
 Hold the cannula firmly with three points grip
avoid blood spillage
 Such grip minimizes the risk of contamination and
ensures correct positioning between the needlepoint
and the catheter tip.

 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

 Remove the luer lock plug by pushing the needle to

the waste container
 Close the cannula with the luer lock plug.

 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 Cannula fixation
 Withdraw the needle partially to avoid exit through  Fix the cannula to the patient skin with proper
the posterior vein wall. Firmly hold the flash chamber dressing.
and advance the catheter off the needle into the vein.  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 o Neonate (umbilical vein)
irritation of the vein  Any drug or fluid that can be given IV may be given by the
 Check the correct placement of the catheter by IO route
injecting about 5 ml of sterile physiological saline.  Little interference during Resuscitation
 Record date and time of insertion

Potential IV sites
 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

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  Indications
preparation o Required drug or fluid resuscitation due to an
immediate life-threat (e.g. CPR, Shock)
IV Start Pain Management o At least 2 unsuccessful peripheral IV attempts
 One of the most frequent contributors to patient  Contraindications
dissatisfaction is painful phlebotomy and IV starts o Placement in or distal to a fractured bone/pelvis
 Use 25-27g insulin syringe to create a wheal similar to a TB o Placement at a burn site (relative)
skin test on top of or just to side of vein with 0.1 -0.2 ml o Placement in a leg with a missed IO attempt
normal saline or 1% xylocaine without epinephrine o ↑ difficulty in patients > 6 years of age
 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

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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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