Chapter 6 Venous Access.

Name: Chapter 6 Venous Access.
Uploaded: 2017-07-13T19:09:19+00:00
Duration: PTM29S52
Channel: Donovan Gradin
Description: Chapter 6 Venous Access.

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: Contraindications: 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 Crystalloids
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.

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

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.

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

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

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.

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

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

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.

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 Solution Containers
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 experienced volume loss. Copyright line.

Copyright © 2007, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
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 (D5W) 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.

Lactate, Potassium, Sodium, Chloride, Calcium
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

Introduction Volume control chamber IV tubing

Equipment Needle/Catheter

Equipment Protected Needles IV Catheter Size 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

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

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

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

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

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

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

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

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

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

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

Draw sample of blood Release tourniquet

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

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

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

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

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

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

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

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

Drawing Blood Acquire blood samples for analysis
Commonly use in field setting Draw samples immediately after venipuncture Blood-drawing equipment

Drawing Blood Variety of sizes & types Several colors & patterns
During manufacture—vacuum created Filled by drawing blood from vein with syringe Tube filled completely Tube labeled Stored in plastic “zip-lock” bag

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

Preparing Volume Control Setups
Open upper control valve Open bottom flow clamp

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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