1. Venipuncture DMI 63 Kyle Thornton

2. Disclaimer This is intended to be a step by step process It is completely from memory If I forgot something, I’ll slip it in on our next meeting

3. Injecting Contrast? What do you need to know? Is there an order? What are the 5 rights of medication What is the pt’s renal function? Does the patient have allergies? Does the patient take any medications that are incompatible with IV contrast? What is IV contrast? What emergency meds do I need? What gauge needle should I use? Where is a good injection site? What else do I need? What can go wrong?

4. Is there an order? Orders will vary A contrast study is ordered as w/contrast or Enhanced For example:  Abdomen w/contrast  or  Chest enhanced If order states unenhanced or w/out contrast No venipuncture necessary MD will make that determination

5. What are the 5 rights of medication The right patient The right medication The right route The right amount The right time

6. What is the pt’s. renal function? How do we find out this information? We could ask but  How many pt’s. actually know their renal function  so… We need lab values: Should be within at least 72 hours Most hospitals require:  Creatinine: app. 0.6 – 1.2 mg/dl  Source: http://www.medicinenet.com/creatinine_blood_test/page2.htm  eGfr: UCSF value; > 60  Textbook mentions BUN, but this generally isn’t requested  Normal BUN value is about 7 – 20mg/dl  Source: http://www.lifeoptions.org/kidneyinfo/labvalues.php

7. What is creatinine? Waste product made from protein breakdown Reasons for elevation: Muscle breakdown HIV medications Impaired renal function

8. What is eGfr? More accurate than creatinine Indicates rate at which kidneys are filtering wastes from blood Source: http://www.lifeoptions.org/kidneyinfo/labvalues.php

9. Is an elevated creatinine and low eGfr a deal breaker? Not always Is it known that the pt. has renal disease? Is the pt. on dialysis? When is the next scheduled dialysis? Can the pt. be pre-hydrated prior to the study Hydration provided by:  Sodium bicarbonate – IV  Mucomyst - Oral

10. Does the pt. have allergies? Are allergies a deal breaker? Depends… Is there an alternative study? Can the pt. tolerate pre-medication?  UCSF Pre-medication protocol for contrast allergies:  12 hours before test:  50mg. Prednisone or 32 Medrol  2 hours before test:  50mg. Prednisone or 32 mg. Medrol  300mg. Tagamet or 150 mg. Zantac  50mg. Benadryl

11. Does the pt. have allergies Warning! Pre-medication does not mean there won’t be a reaction It reduces the likelihood

12. Does the pt. take any medications that are incompatible with contrast? Insulin dependent diabetics and oral medication Glucophage, Glucovance, aka Metformin Must be suspended for 48 hours after contrast administration

13. What is IV contrast? An iodinated medium bound in either an organic or inorganic compound Organic: Non-ionic Characteristics:  Low osmolarity = 290 – 884  About 1.1 to 3X that of blood  Blood is app. 280 – 303  Iodine content = 320 – 370  Does not dissociate into component molecules  Remains intact  Side effects less likely  For more information, go to:  http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=17432

14. Omnipaque: a commonly used brand of contrast

15. What is IV contrast? Ionic Characteristics High osmolar value  580 – 2100 Iodine content  300 – 370 Dissociates into component molecules  Reactions and side effects more likely  N/V highly likely!

16. What emergency meds do I need? An emergency medication box will generally contain: Steroid – counteract inflammatory response Antihistamine – counteract histamine release Vasodilator – increase blood pressure

17. Don’t forget! Did you screen for pregnancy? Did the pt. have a similar exam recently? Should wait at least 12 hours between contrast injections Did you screen for allergies? Did you screen for other medications?

18. If the patient has an existing IV access port… You must make sure it is functioning Wash your hands Put on gloves Examine site Check tubing connections Clean the port of the connecting tubing w/rubbing alcohol Draw back on syringe Check for blood flow into tubing Flush w/saline by hand Observe flush Test power inject with saline at same rate/pressure as planned contrast infusion If in doubt, don’t infuse contrast Ask MD or RN to examine site Restart IV access if necessary

19. What type of needle do I need? Butterfly versus Angiocath Butterfly Needle is attached to tubing Good for hand injections Not suitable for the power injector Angiocath Needle is sheathed within a clear plastic catheter After venipuncture, needle is removed, catheter remains in vein Requires tubing to be attached  Good for long term IV solution therapy  Suitable for the power injector  Often used with a saline lock

20. What gauge of needle do I need? For power injector, the lowest practical gauge should be used Often injections are delivered at a rate of 3 – 5ml/sec at 300 – 350 PSI The faster the injection rate, and the greater the pressure, the lower the gauge should be 16 or 18 Slower injection rates and lower PSI may use higher gauges 20 – 22  Should not be > 20

21. Where is a good injection site? Injection site depends upon: The type of solution to be administered The duration of the administration IV contrast is short duration The antecubital fossa is ideal Veins are larger and more accessible Able to withstand greater pressure

22. Where is a good injection site? Vein v. artery If there’s a pulse, don’t go there CRT’s are limited to upper extremity Hand veins (dorsal venous arch and superficial dorsal veins) are difficult to stick and hurt Anterior wrist veins (radial) are difficult to stick and hurt Antecubital veins are best, but If you miss, you need to go to the other arm

23. Where is a good injection site? Forearm and antecubital veins Basilic Courses medial side of arm  Follows ulna and medial humerus Medial Medial through the forearm Joins median cubital at antecubital fossa Cephalic Courses lateral side of arm Follows radius and lateral humerus

24. What else do I need? Hand wash Gloves Cleansing solution Tourniquet Tape or tegaderm Tubing Towel Arm board Saline

25. Inserting the venipuncture device Wash your hands – sing happy birthday to yourself twice Put on gloves Apply tourniquet Cleanse the site – sing happy birthday to yourself twice Put on new gloves Perform the venipuncture Watch for backflow of blood If it’s bright red and seems to come out with pressure – STOP!

26. Inserting the venipuncture device If dark and oozing, continue Attach tubing and secure Loosen tourniquet Inject saline – about 10cc It’s a good idea to hand inject saline first then,  Inject saline using the power injector at the same rate and pressure as the contrast injection  If that’s all good,  Inject the contrast as the protocol directs

27. Before you inject… Did you check the order? Did you observe the 5 rights of medication? Did you check renal function? Did you screen for allergies? Did you screen for pregnancy? Do you have all your supplies? Is your IV site functioning? Did you test with saline?

28. Injecting Remove tourniquet Observe infusion Palpate infusion site to ensure contrast is flowing If not, stop injection immediately Assure patient, who is probably feeling hot flashes! Usually ceases in a couple of minutes

29. What can go wrong? Angiocath disconnects from tubing Contrasts goes everywhere Infiltration This is much worse! In case of infiltration Stop infusion immediately Call a physician or nurse Apply ice (UCSF protocol) Await further orders

30. D/C’ing the IV If the study is complete No further IV access is needed DC the IV You will need: Gauze Bandage Sharps container

31. D/C’ing the IV Remove the tape Have the gauze ready Remove the venipuncture device in one movement Press the gauze on the wound Elevate the extremity Hold pressure for about a minute Check the site Apply a bandage Check the site again Check the site one more time before pt. leaves

32. If you’re not DC’ing the IV Flush tubing w/saline to remove all contrast, blood, etc. Clamp tubing off If you paused an existing infusion: Flush the tubing w/saline Reconnect tubing with infusion Resume pump if applicable