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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:
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Peripheral venous cannulation
Obtaining blood sample
External jugular cannulation
Disposal of contaminated items & “sharps”
Introduction
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Intravenous (IV) cannulation
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Placement of catheter into vein
Used to administer:
• Blood
• Fluids
• Medications
Used to obtain blood samples
Medical direction or standing orders typically
required
Introduction
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Indications:
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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
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Precautions:
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Bleeding
Infiltration
Infection
Contraindications:
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Sclerotic veins
Burned extremities
Do not delay transport to start IV
Introduction
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Body substance isolation precautions
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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
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Needle stick injuries
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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
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Rules for avoiding injuries:
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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
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IV supplies & equipment
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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
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IV Solutions
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Solutions & osmotic pressure
• Described by tonicity
• Isotonic solution
• Hypotonic solution
• Hypertonic solution
Crystalloids
• Normal saline
• Lactated Ringer’s
Introduction
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Crystalloids
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Dissolved ions cross cell
membrane
Sodium chloride 0.9%
solution/lactated Ringer’s
solution
5% dextrose in water
(D5W)
Intravenous Solutions
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Intravenous solutions come in four different
types.
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Crystalloids
Colloids
Blood
Oxygen carrying fluids
Copyright line.
Intravenous Solutions
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Crystalloid solutions
move quickly across
cell membranes.
Colloid solutions do
not, and therefore
remain in the
intravascular space
for longer periods.
Intravenous Solutions
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Solutions and osmotic pressure
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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
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Dissolving crystals such as salts and sugars in
water creates crystalloid solutions.
They contain no proteins or other high-molecularweight 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
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Crystalloids
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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
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Crystalloids
 One L of normal saline contains:
• 154 mEq of sodium ions (Na+)
• 154 mEq of chloride ions (Cl–)
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Intravenous Solutions—Solutions and Osmotic
Pressure
5% dextrose in water (D5W)
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It is a glucose solution that is isotonic in the
container but hypotonic after it enters the
circulatory system.
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In the past, D5W was a mainstay in the
management of medical emergencies.
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The AHA Advanced Cardiac Life Support
Guidelines for cardiac arrest no longer list D5W as
the preferred solution.
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Patients who survive are reported to have poor
neurological outcomes when they have increased
glucose levels.
Copyright line.
Intravenous Solutions—Solutions
and Osmotic Pressure
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Numerous other crystalloid solutions are also
available.
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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
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Hypotonic solutions
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0.45% saline (half-normal saline)
0.33% sodium chloride
2.5% dextrose in water
Intravenous Solutions—Solutions and Osmotic
Pressure
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Colloids
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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
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Colloids
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Because colloids are expensive, have short halflives, and often require refrigeration, they are not
commonly used in the prehospital setting
Common colloids include:
• Blood derivatives
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Plasma protein fraction (plasmanate)
Salt poor albumin
• Artificial colloids
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Dextran
Hetastarch (Hespan)
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IV bags
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Solutions used in the prehospital
setting are typically contained in a
clear plastic or vinyl bag that
collapses as it empties.
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The size of the IV bag varies
depending on its use.
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Smaller bags (100 to 250 mL) are
used in the management of medical
emergencies and drug
administration.
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Larger bags (1000 mL) are used in
the management of trauma
emergencies or when the patient has
Copyright line.
experienced volume loss.
IV Solution Containers
Introduction
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Sodium Chloride 0.9% solution & Lactated Ringer’s
solution
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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 (D5W)
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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
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Sodium Chloride 0.9% Solution
Sodium and Chloride
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Lactated Ringer’s Solution
Lactate, Potassium, Sodium, Chloride, Calcium
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5% dextrose in water (D5W)
Dextrose and Water
Introduction
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IV solution containers
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Size of bag varies
Introduction
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IV solution containers
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2 ports at bottom of bag
Labeled with:
• Contents
• Expiration date
Introduction
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Administration set
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Clear plastic tubing
Range from 60–110 inches
Introduction
Piercing spike
Introduction
Microdrip
Macrodrip
Introduction
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Rates for administering IV fluids
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Medical emergencies—TKO rate (8-15 gtts/min.)
Trauma—based on patient’s response
Introduction
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Changing philosophy for hypovolemic shock
—no clear rule
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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
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Blood tubing
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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
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Volume control
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Volutrol chamber
• For specific amount of
fluid to be administered
• Pediatrics
• Renal failure
• Administer precise
medications
Equipment
Needle/Catheter
Equipment
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Protected Needles
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Shielding/Retracting
Self-blunting
IV Catheter Size
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Outside diameter is “gauge”
Larger gauge number—
smaller diameter
Large diameter—greater
fluid flow
Color-coded system
Equipment
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Choosing best size over-the-needle catheter
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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
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Other supplies & materials
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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
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Intermittent infusion device
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Eliminates need for IV bag & administration
Keeps access device sterile
Self-sealing
Constant venous access—not continuous infusion
Equipment
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IV solution warming devices
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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
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Veins have 3 layers—Tunica intima, Tunica media,
Tunica adventitia
Peripheral Venous Cannulation
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Skin has 2 layers
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Epidermis
• Outermost layer
• Protective covering
• Varies in thickness
Dermis
• Highly vascular &
sensitive
• Many capillaries
• Thousands of nerve
fibers
Peripheral Venous Cannulation
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Noncritical patients
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Distal veins on dorsum of
hands and arms
In Indiana, a jugular vein
is considered to a
peripheral vein
Peripheral Venous Cannulation
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Noncritical patients
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Use vein with these
characteristics:
• Fairly straight
• Easily accessible
• Well-fixed—not rolling
• Feels springy
Peripheral Venous Cannulation
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Sites to be avoided:
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Sclerotic veins
Veins near joints
Areas where arterial pulse is palpable
Veins near injured areas
Veins near edematous extremities
Peripheral Venous Cannulation
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Sites used in cardiac arrest:
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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
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Other sites
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External jugular vein
Peripheral leg veins
Intraosseous
Performing IV Cannulation
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Insert spiked piercing
end of administration
set into tubing of IV bag
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Squeeze drip chamber
to fill halfway
Performing IV Cannulation
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Place tourniquet 6
inches above
venipuncture site
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Make slip knot with
tourniquet
Performing IV Cannulation
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Complete band
placement
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Use povidone-iodine
(use protocol) or alcohol
wipe to cleanse site
Performing IV Cannulation
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Pull skin taut; bevel of
needle should be facing
up
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Penetrate vein either
from top or side
Performing IV Cannulation
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Watch for blood in
flashback chamber
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Advance needle until tip
of catheter is sufficiently
within vein
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Slide catheter into vein
until hub rests against
skin
Performing IV Cannulation
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Remove needle from
vein & catheter
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Properly dispose of
used needle
Copyright © 2007, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Performing IV Cannulation
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Draw sample of blood
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Release tourniquet
Performing IV Cannulation
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Open IV control valve;
ensure IV fluid is
flowing properly
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Secure catheter &
tubing with
tape/commercial device
Performing IV Cannulation
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After venipuncture is performed:
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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
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Using an armboard
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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
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Regulating fluid flow rates
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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
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Regulating fluid flow rates (cont.)
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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
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Regulating fluid flow rates
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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
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Regulating fluid flow rates
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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
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Document
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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
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Complications
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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
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Cannulate vein
Intermittent Infusion Device
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Connect intermittent
device to hub of IV
catheter
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Connect saline/heparinfilled syringe to access
port
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Slowly aspirate until
blood is seen
Inject 3–5mL dilute
heparin/saline
Changing IV Bag
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Typically occurs when directed to continue IV
after bag is empty
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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
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Close flow control valve completely
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Do not disturb catheter—remove dressing
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Hold 2 × 2 dressing above site to stabilize tissue while
withdrawing catheter
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Remove catheter by pulling straight back
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To prevent blood loss
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Cover site with 2 × 2 dressing
 Hold against puncture site until bleeding stopped
 Tape dressing in place
Using IV Protective Devices
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Penetrate skin, vein
with over-the-needle
device
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Slide catheter forward
into vein while
withdrawing needle
Using IV Protective Devices
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Clicks into place once
plastic guard reaches
end
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Separate plastic guard
from catheter hub
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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
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Complications
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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
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Prominent veins—less
resistant skin
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Difficult to stabilize vein
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Veins fragile
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Remove tourniquet quickly
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Smaller, shorter
venipuncture devices work
best
Seizing or Moving Patients or
Patients in Transport
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Steady extremity
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Look for biggest vein
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Penetrate during period of
less movement.
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Hold little & ring fingers
against patient’s extremity
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Once in—slide catheter in
quickly
Seizing or Moving Patients or
Patients in Transport
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Once in place—do not let go
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Use extra tape to secure
cannula
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Use armboard or splint
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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
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Cardiac arrest—veins of antecubital fossa

Patients in whom cannulating vein is difficult
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Obese persons
Patients in shock or cardiac arrest
 Chronic mainline drug users
 Elderly patients
 Small children
Summary
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When equipment selected—IV fluid checked

Right fluid
 Not outdated
 Clear
 Bag has no leaks
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Continually employ infection control procedures
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Release tourniquet once IV tubing is connected
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Continually monitor patient for signs of improvement & signs of
circulatory overload
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All IV techniques share number of complications Oh Yea . .
Questions?