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 (D 5 W)

Intravenous Solutions

 Intravenous solutions come in four different types.  Crystalloids  Colloids  Blood  Oxygen carrying fluids Copyright line.

Intravenous Solutions

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

Intravenous Solutions

 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

 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. Copyright line.

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

Intravenous Solutions —Solutions and Osmotic Pressure

 Crystalloids  One L of normal saline contains: • • 154 mEq of sodium ions (Na+) 154 mEq of chloride ions (Cl –)

Intravenous Solutions —Solutions and Osmotic Pressure  5% dextrose in water (D 5 W)  It is a glucose solution that is isotonic in the container but hypotonic after it enters the circulatory system.  In the past, D 5 W was a mainstay in the management of medical emergencies.  The AHA Advanced Cardiac Life Support Guidelines for cardiac arrest no longer list D 5 W as the preferred solution.

 Patients who survive are reported to have poor neurological outcomes when they have increased glucose levels. Copyright line.

Intravenous Solutions —Solutions and Osmotic Pressure

 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

Intravenous Solutions —Solutions and Osmotic Pressure

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

 Intravenous Solutions —Solutions and Osmotic Pressure 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.

Intravenous Solutions —Solutions and Osmotic Pressure

 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)

  IV bags Solutions used in the prehospital IV Solution Containers 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. Copyright line.

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 products  only solution  5% dextrose in water (D 5 W)  Was mainstay in management of medical emergencies • In cardiac arrest  no 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 (D 5 W) 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

Microdrip

Introduction

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

Peripheral Venous Cannulation

 Skin has 2 layers   Epidermis • • • Outermost layer Protective covering Varies in thickness Dermis • Highly vascular & sensitive • • Many capillaries Thousands of nerve fibers

Peripheral Venous Cannulation

 Noncritical patients  Distal veins on dorsum of hands and arms  In Indiana, a jugular vein is considered to a peripheral vein

Peripheral Venous Cannulation

 Noncritical patients  Use vein with these characteristics: • • • • Fairly straight Easily accessible Well-fixed —not rolling Feels springy

Peripheral Venous Cannulation

 Sites to be avoided:  Sclerotic veins  Veins near joints  Areas where arterial pulse is palpable  Veins near injured areas  Veins near edematous extremities

Peripheral Venous Cannulation

 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

Peripheral Venous Cannulation

 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

Performing IV Cannulation

 Place tourniquet 6 inches above venipuncture site  Make slip knot with tourniquet

Performing IV Cannulation

 Complete band placement  Use povidone-iodine (use protocol) or alcohol wipe to cleanse site

Performing IV Cannulation

 Pull skin taut; bevel of needle should be facing up  Penetrate vein either from top or side

Performing IV Cannulation

 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

Performing IV Cannulation

 Remove needle from vein & catheter  Properly dispose of used needle Copyright © 2007, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Performing IV Cannulation

 Draw sample of blood  Release tourniquet

Performing IV Cannulation

 Open IV control valve; ensure IV fluid is flowing properly  Secure catheter & tubing with tape/commercial device

Performing IV Cannulation

 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

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

Performing IV Cannulation

 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

Performing IV Cannulation

 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

Performing IV Cannulation

 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

Performing IV Cannulation

 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

Performing IV Cannulation

 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

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

Performing IV Cannulation

 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?