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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: 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 (D5W) 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-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 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 (D5W) It is a glucose solution that is isotonic in the container but hypotonic after it enters the circulatory system. In the past, D5W was a mainstay in the management of medical emergencies. The AHA Advanced Cardiac Life Support Guidelines for cardiac arrest no longer list D5W 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 halflives, 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 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 Copyright line. experienced volume loss. IV Solution Containers 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 productsonly solution 5% dextrose in water (D5W) Was mainstay in management of medical emergencies • In cardiac arrestno 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 (D5W) 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 Introduction Microdrip 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/heparinfilled 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 . . 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