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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.

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Presentation on theme: "Chapter 6 Venous Access. Chapter Goal  Understand basic principles of venous access & IV therapy, as well as relate importance of employing appropriate."— Presentation transcript:

1 Chapter 6 Venous Access

2 Chapter Goal  Understand basic principles of venous access & IV therapy, as well as relate importance of employing appropriate BSI precautions when employing these precautions

3 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”

4 Introduction  Intravenous (IV) cannulation  Placement of catheter into vein  Used to administer: Blood Blood Fluids Fluids Medications Medications  Used to obtain blood samples  Medical direction or standing orders typically required

5 Introduction  Indications:  Cardiac disease  Hypoglycemia  Seizures  Shock Hypovolemic shock—to counter blood loss Hypovolemic shock—to counter blood loss Medical emergencies—to establish route for medication administration Medical emergencies—to establish route for medication administration Administer drugs in prehospital setting Administer drugs in prehospital setting Precautionary measure Precautionary measure

6 Introduction  Precautions:  Bleeding  Infiltration  Infection  Contraindications:  Sclerotic veins  Burned extremities  Do not delay transport to start IV

7 Introduction  Body substance isolation precautions  Substances potentially infected with Hepatitis B virus (HBV) Hepatitis B virus (HBV) Human immunodeficiency virus (HIV) Human immunodeficiency virus (HIV)  Wash hands: Before & after Before & after Immediately on contact Immediately on contact  Wear gloves, gown, mask, eye protection  HBV vaccine

8 Introduction  Needle stick injuries  600,000 to 800,000 per year Hepatitis C & AIDS Hepatitis C & AIDS  Devices to help reduce risk Needleless systems—no needle Needleless systems—no needle Needle safety systems—built-in physical attribute Needle safety systems—built-in physical attribute  Passive & active devices Active device requires activation Active device requires activation Passive device does not Passive device does not

9 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

10 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

11 Introduction  IV Solutions  Solutions & osmotic pressure Described by tonicity Described by tonicity Isotonic solution Isotonic solution Hypotonic solution Hypotonic solution Hypertonic solution Hypertonic solution  Crystalloids Normal saline Normal saline Lactated Ringer’s Lactated Ringer’s

12 Introduction  Crystalloids  Dissolved ions cross cell membrane  Sodium chloride 0.9% solution/lactated Ringer’s solution  5% dextrose in water (D 5 W)

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

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

15 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

16 Copyright line. 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. 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. 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.

17 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+) 130 mEq of sodium (Na+) 4 mEq of potassium (K+) 4 mEq of potassium (K+) 3 mEq of calcium (Ca2+) 3 mEq of calcium (Ca2+) 109 mEq of chloride ions (Cl–) 109 mEq of chloride ions (Cl–) 28 mEq of lactate 28 mEq of lactate

18 Intravenous Solutions—Solutions and Osmotic Pressure  Crystalloids  One L of normal saline contains: 154 mEq of sodium ions (Na+) 154 mEq of sodium ions (Na+) 154 mEq of chloride ions (Cl–) 154 mEq of chloride ions (Cl–)

19 Copyright line. 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.

20 Intravenous Solutions—Solutions and Osmotic Pressure  Numerous other crystalloid solutions are also available.  Hypertonic solutions 5% dextrose in 0.9% saline 5% dextrose in 0.9% saline 5% dextrose in 0.45% saline (half-normal saline) 5% dextrose in 0.45% saline (half-normal saline) 5% dextrose in lactated Ringer's solution 5% dextrose in lactated Ringer's solution 3% sodium chloride 3% sodium chloride 7.5% sodium chloride 7.5% sodium chloride 10% dextrose in water 10% dextrose in water

21 Intravenous Solutions—Solutions and Osmotic Pressure  Hypotonic solutions  0.45% saline (half-normal saline)  0.33% sodium chloride  2.5% dextrose in water

22 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.

23 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 Blood derivatives  Plasma protein fraction (plasmanate)  Salt poor albumin Artificial colloids Artificial colloids  Dextran  Hetastarch (Hespan)

24 Copyright line. 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.

25 Introduction  Sodium Chloride 0.9% solution & Lactated Ringer’s solution  Recommended IV use in prehospital setting  Used to: Expand intravascular volume Expand intravascular volume Replace extracellular fluid losses Replace extracellular fluid losses Administer with blood products  only solution 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 In cardiac arrest  no longer considered preferred Slightly aciditic Slightly aciditic Local EMS protocols will dictate Local EMS protocols will dictate Copyright © 2007, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

26 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

27 Introduction  IV solution containers  Size of bag varies

28 Introduction  IV solution containers  2 ports at bottom of bag  Labeled with: Contents Contents Expiration date Expiration date

29 Introduction  Administration set  Clear plastic tubing  Range from 60–110 inches

30 Introduction Piercing spike

31 Introduction Microdrip Macrodrip

32 Introduction  Rates for administering IV fluids  Medical emergencies—TKO rate (8-15 gtts/min.)  Trauma—based on patient’s response

33 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

34 Introduction Injection port

35 Introduction Connector ends

36 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 Y-tubing Straight tubing Straight tubing

37 Introduction  Volume control  Volutrol chamber For specific amount of fluid to be administered For specific amount of fluid to be administered Pediatrics Pediatrics Renal failure Renal failure Administer precise medications Administer precise medications

38 Introduction  Volume control chamber IV tubing

39 Equipment Needle/Catheter

40 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

41 Equipment  Choosing best size over-the-needle catheter  Smaller-sized devices are better Except for volume replacement Except for volume replacement Causes less injury Causes less injury Allows greater blood flow Allows greater blood flow  Large-bore catheters Shock Shock Cardiac arrest Cardiac arrest Viscous medications Viscous medications Life-threatening emergencies—rapid fluid replacement Life-threatening emergencies—rapid fluid replacement Minimum 18-gauge catheter—patients requiring blood Minimum 18-gauge catheter—patients requiring blood  Catheter’s length—longer catheter = slower rate

42 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

43 Equipment  Intermittent infusion device  Eliminates need for IV bag & administration  Keeps access device sterile  Self-sealing  Constant venous access—not continuous infusion

44 Equipment  IV solution warming devices  Temperature of IV fluids vary  Infusion < normal body temperature  Appliances designed to: Maintain IV fluid at normal body temperature Maintain IV fluid at normal body temperature Prevent overheating Prevent overheating  Hot sack

45 Peripheral Venous Cannulation  Veins have 3 layers—Tunica intima, Tunica media, Tunica adventitia

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

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

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

49 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

50 Peripheral Venous Cannulation  Sites used in cardiac arrest:  Peripheral veins of antecubital fossa Largest Largest Most visible Most visible Most accessible Most accessible  Distal veins are least desirable Blood flow markedly diminished Blood flow markedly diminished Difficult or impossible to cannulate Difficult or impossible to cannulate

51 Peripheral Venous Cannulation  Other sites  External jugular vein  Peripheral leg veins  Intraosseous

52 Performing IV Cannulation  Insert spiked piercing end of administration set into tubing of IV bag  Squeeze drip chamber to fill halfway

53 Performing IV Cannulation  Place tourniquet 6 inches above venipuncture site  Make slip knot with tourniquet

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

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

56 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

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

58 Performing IV Cannulation  Draw sample of blood  Release tourniquet

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

60 Performing IV Cannulation  After venipuncture is performed:  Confirm needle placement  Blood may not flow back  If infiltration occurs Remove & discard catheter Remove & discard catheter Place dressing on venipuncture site Place dressing on venipuncture site Attempt venipuncture at another site Attempt venipuncture at another site  Other methods of determining proper placement of catheter Lower IV bag below IV site Lower IV bag below IV site Palpating vein above IV site Palpating vein above IV site Palpating tip of catheter in vein Palpating tip of catheter in vein Aspirating blood with 10-mL syringe Aspirating blood with 10-mL syringe

61 Peripheral IV Access Copyright © 2007, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

62 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 near joint Venipuncture device inserted in dorsum of hand Venipuncture device inserted in dorsum of hand Used along with restraints Used along with restraints

63 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

64 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) time of infusion (in minutes)

65 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) 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

66 Performing IV Cannulation  Regulating fluid flow rates  Factors that can cause flow rate to vary Vein spasm Vein spasm Vein pressure changes Vein pressure changes Patient movement Patient movement Manipulations of clamp Manipulations of clamp Bent, kinked tubing Bent, kinked tubing IV fluid viscosity IV fluid viscosity Height of infusion bag Height of infusion bag Type of administration set Type of administration set Size & position of venous access device Size & position of venous access device

67 Performing IV Cannulation  Regulating fluid flow rates  Assess flow rate more frequently Critically ill patients Critically ill patients Condition can be exacerbated by fluid overload Condition can be exacerbated by fluid overload Pediatric patients Pediatric patients Elderly patients Elderly patients Patients receiving drug that can cause tissue damage if infiltration occurs Patients receiving drug that can cause tissue damage if infiltration occurs

68 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

69 When IV Fluid Does Not Flow Copyright © 2007, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

70 Performing IV Cannulation  Complications  Pain  Catheter shear  Circulatory overload  Cannulation of artery  Hematoma or infiltration  Local infection  Air embolism  Pyrogenic reaction

71 Intermittent Infusion Device  Prime device with dilute heparin/saline solution  Cannulate vein

72 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

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

74 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

75 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

76 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

77 Using IV Protective Devices  Penetrate skin, vein with over-the-needle device  Slide catheter forward into vein while withdrawing needle

78 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

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

80 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

81 External Jugular Vein Cannulation Anatomy of surrounding area Proper IV cannulation

82 Elderly Patients  Prominent veins—less resistant skin  Difficult to stabilize vein  Veins fragile  Remove tourniquet quickly  Smaller, shorter venipuncture devices work best

83 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

84 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

85 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

86 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

87 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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89 Questions?


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