Peripheral IV insertion Scott and White Indications for IV Therapy Establish or maintain a fluid or electrolyte balance Administer continuous or intermittent medication Administer bolus medication Administer fluid to keep vein open (KVO) Administer blood or blood components Indications for IV Therapy Administer intravenous anesthetics Maintain or correct a patient's nutritional state Administer diagnostic reagents Monitor hemodynamic functions Procedures Gather supplies IV cannula IV tubing IV fluid or Heparin lock Steel Needles Butterfly catheter. They are named after the wing-like plastic tabs at the base of the needle. They are used to deliver small quantities of medicines, to deliver fluids via the scalp veins in infants, and sometimes to draw blood samples (although not routinely, since the small diameter may damage blood cells). These are small gauge needles (i.e. 23 gauge). Steel Needles Over the Needle Catheter Gauges Catheters (and needles) are sized by their diameter, which is called the gauge. The smaller the diameter, the larger the gauge. Therefore, a 22-gauge catheter is smaller than a 14-gauge catheter. To deliver large amounts of fluid or viscous solutions such as blood and blood components, you should select a large vein and use a 20 gauge or less. To administer medications, an 20 –22 gauge or in a smaller vein will do. The smaller the catheter, the less the irritation to the vein. Gauges Approach to Patient Introduce yourself to the patient Assess the patient identification Assess alertness and attitude of patient Explain to the patient and/or family the need for the procedure Explain to the patient and/or family the steps in the procedure Methods Raise the bed/ gurney sufficiently high that you can work in good light without hurting your back. If the intended site is distal, kneel or seat yourself so that you can work closely and steadily. Vein Selection Veins of the hand 1. Digital Dorsal Veins 2. Dorsal Metacarpal Veins 3. Dorsal Venous Network 4. Cephalic Vein 5. Basilic Veins Vein Selection 1. 2. 3. 4. 5. 6. Cephalic Vein Median Cubital Vein Accessory Cephalic Vein Basilic Vein Cephalic Vein Median Antebrachial Vein Vein Selection Try to cannulate the most distal veins first. If for example, the antecubital veins are ruined as a result of failed cannulation attempts, this can cause problems in the event of a successful cannulation further down. Any drugs or fluids put through the cannula may extravasate at the failed cannula site Inappropriate sites Edematous areas Hematomas Scarred areas Arms with cannulas, fistulas or vascular grafts Universal Precautions If the IV cannot be started with gloves on, ---it cannot and should not be started. Protect yourself with adequate body-substance isolation at all times. Glasses, goggles, or splash shields, may also be worn. ALL patients must be considered infective at all times. It is NOT ACCEPTABLE to compromise precautions for any reason [this includes tearing off a finger tip of one's glove to permit palpation]. Methods Occlude Venous Flow Apply tourniquet 4-6 inches above the insertion site. Veins may also be distended by placing the limb in a dependent position, applying a warm pack in addition to the tourniquet, or applying a blood pressure cuff. The tourniquet or blood pressure cuff should not obstruct arterial flow. Apply Tourniquet Methods Prep The Skin Alcohol Scrub Use vigorous circular motion. Allow the skin to dry. This procedure defats the skin. Clean with alcohol Methods Povidone Iodine Scrub Using a circular motion, work from the center of the insertion site outwards. Allow to dry for two minutes. If the patient is allergic to iodine preparations use a vigorous two minute alcohol scrub. Venipuncture Hold the skin taut and anchor the vein with the thumb of your free hand. Avoid recontamination of the area. Lower the hub of the needle close to the skin and align needle for insertion. Insert the needle, bevel up, into the skin and subsequently into the vein. The free hand is used to stabilize the vein while the needle is being introduced. If the needle is in the vein, blood return will be visible in the flashback chamber. Venipuncture Venipuncture-Side Technique for skin puncture at the side of the selected vein. The needle should puncture the skin to one side of the vein about 1/2 to one inch below where the needle will enter the vein. Pierce the skin at a 45 angle along side of the vein. Once through the skin, insert the needle into the vein nearly parallel to the vessel (10-20 angle). Venipuncture-Over Technique for skin puncture directly over the selected vein. The needle should puncture the skin at a 45 angle directly over the selected vein. Once through the skin, decrease the angle to about 10-20 and enter the vein. Methods After the needle has entered the vein, proceed to slowly advance the needle approximately 1/2 inch. Carefully withdraw the needle about 1/2 inch while continuing to advance the catheter. Inserting cannula Method Apply pressure to the vein just above the tip of the catheter to obstruct blood flow. Remove the introducer needle. Connect the catheter to IV tubing or to “heparin” lock. Method Release the tourniquet Cover the insertion site with a transparent occlusive dressing, tape securely,label. Begin IV fluid or flush “Heparin” lock Remember that IV catheter site rotation is recommended every 72 hours, unless you are using extended dwell catheters. Remove tourniquet Unsuccessful If you are unsuccessful in entering the vein and there is no flashback, then slowly withdraw the catheter, without pulling all the way out, and carefully watch for the flashback to occur Unsuccessful If you are still not within the vein, then advance it again in a 2nd attempt to enter the vein. While withdrawing always stop before pulling all the way out to avoid repeating the painful initial skin puncture. Unsuccessful If after several manipulations the vein is not entered, then release the tourniquet, place a gauze over the skin puncture site, withdraw the catheter and tape down the gauze. Try again at another site.