Basic Intravenous Therapy

90-95% of patients in the hospital receive some type of intravenous therapy.

This presentation will enhance your knowledge of how to care for them.
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Vein Anatomy and Physiology

Veins are unlike arteries in that they are 1)superficial, 2) display dark red blood at skin surface and 3) have no pulsation
Vein Anatomy

Tunica Adventitia - Tunica Media - Tunica Intima - Valves

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Tunica Adventitia
the outer layer of the vessel

Connective tissue Contains the arteries and veins supplying blood to vessel wall

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the middle layer of the vessel

Tunica Media

Contains nerve endings and muscle fibers The vasoconstrictive response occurs at this layer

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Tunica Intima
the inner layer of the vessel
One No

layer of endothelials

nerve endings

Surface

for platelet aggregation w/trauma and recognition of foreign object at this level begins here

PHLEBITIS

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present in MOST veins

Valves

Prevent backflow and pooling

More in lower extremities and longer vessels Vein dilates at valve attachment

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Veins of the Upper Extremities

Digital Vessels
-Along lateral aspects fingers, infiltrate easily, painful, difficult to immobilize and should be your LAST RESORT

Metacarpal Vessels
-Located between joints and metacarpal bones (act as natural splint) -Formed by union of digital veins
Digital

-Geriatric patients often lack enough connective / adipose tissue and skin turgor to use this area successfully
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Veins of the Upper Extremities

Cephalic (Interns Vein)

-Starts at radial aspect of wrist -Access anywhere along entire length (BEWARE of radial artery/nerve)

Medial Cephalic (On ramp to Cephalic Vein)

-Joins the Cephalic below the elbow bend -Accepts larger gauge catheters, but may be a difficult angle to hit and maintain

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Veins of the Upper Extremities

Basilic - Originates from the ulner side of

the metacarpal veins and runs along the medial aspect of the arm. It is often overlooked becauses of its location on the back of the arm, but flexing the elbow/bending the arm brings this vein into view

Medial Basilic - Empties into the Basilic vein running parallel to tendons, so it is not always well defined. Accepts larger gauge catheters. - BEWARE of Brachial Artery/Nerve
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Purposes of IV Therapy

To provide parenteral nutrition To provide avenue for dialysis/apheresis To transfuse blood products To provide avenue for hemodynamic monitoring To provide avenue for diagnostic testing To administer fluids and medications with the ability to rapidly/accurately change blood concentration levels by either continuous, intermittent or IV push method.
Types of Peripheral Venous Access Devices
Butterfly

(winged) or Scalp vein needles (SVN) not recommended for non compliant patient as it can easily penetrate the vein wall causing extravasation. We use these

frequently for phlebotomy

Safety

Over the needle catheters (ONC) - PROTECTIV -ACUVANCE

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Starting a Peripheral IV

Finding a vein can be challenging

- Go by feel, not by sight. Good veins are bouncy to the touch, but are not always visible. - Use warm compresses and allow the arm to hang dependently to fill veins. - A BP cuff inflated to 10mmHg below the known systolic pressure creates the perfect tourniquet. Arterial flow continues with maximum venous constriction. - If the patient is NOT allergic to latex, using a latex tourniquet may provide better venous congestion - Avoid areas of joint flexion - Start distally and use the shortest length/smallest gauge access device that will properly administer the prescribed therapy (BE AWARE: Blood flow in the lower forearm and hand is 95ml/min)

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IV Start Pain Management

One of the most frequent contributors to patient dissatisfaction is painful phlebotomy and IV starts

Use 25-27g insulin syringe to create a wheal similar to a TB skin test on top of or just to side of vein with 0.1 -0.2 ml normal saline or 1% xylocaine without epinephrine

Topical anesthesia cream (ie EMLA) may be applied to children>37 weeks gestation 1 hr. prior to stick. It might be a good idea to anesthetize a couple of sites
Have the patient close their fist (NO PUMPING) prior to stick Make sure the skin surface cleansing agent (alcohol/chlorhexidine) is dry prior to stick. Drawing this into the vein may stimulate the vasoconstrictive action of the tunica media layer
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Flushing Peripheral IVs

Use prefilled saline and heparin flush syringes located in PYXIS
Heparin flush concentrations available: -100u/ml (5ml in a 10ml syringe) -10u/ml (2ml in a 3ml syringe)

Flushing intervals and amounts

- Peds: q 6hrs.
<22ga 1ml 0.9%NS followed by 1ml heparinized (10units/ml) saline

w/1ml. 0.9%NS [3ml heparinized saline for OB]

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- Adults: q 8hrs

Dressing/Bag Changes
Physician orders are required if a peripheral catheter is left in the same site for more than 3 days. It is best to have the pharmacy add medications to the infusion bags under laminare flow to reduce contamination

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Central Venous Catheters

Percutaneous Insertion Location MD @ bedside w/xray confirmation Visible externally. Enters subclavian, ext. juglar,or int. juglar vein near clavicular area Polyurethane $200-$400 2-3 Tunneled MD in OR under fluoroscopy Visible ext. usually midway bet. clavicle and nipple. Tunneled under skin & threaded through subclavian or IJ Silicone $3500-$5000 2-3 PICCs MD/trained RN @bedside w/x-ray confirmation Visible externally around antecubital fossa, upper arm or neck Implanted Ports MD in OR under fluoroscopy Completely internal. Titanium or plastc port is implanted in a surgically created pocket and catheter is threaded into subclavian or int. juglar vein. Access is through skin into self sealing port using special non coring needle Silicone catheter. Port is titanium or plastic w/self sealing diaphragm $3500-$5000 1-2 Dialysis MD in OR under fluoroscopy Visible externally. Arm or leg placement

Material/Cost

Silicone / polyurethane $350-$500 1-2

Various materials

Lumen

2-3

Sutured
Duration Flushes

Yes/entire life
Short term 4-10 days 5-10ml NaCl after use and daily

Yes, until internal Dacron cuff healed

Long term 5-10ml NaCl after use and daily

No
Long term 5-10ml NaCl after use and daily

Yes
Long term 10ml NaCl followed by 4.5ml heparinized saline (adults-100units/ml; peds-10units/ml) after ea. use or monthly if not accessed Bard, Accces Port-A-Cath

Yes
Mid term Done ONLY by IV team or dialysis nurses

Brands/ Names Discontinue

Arrow Howe, Triple Lumen, Subclavian, IJ MD or speically trained RN @ bedside

Hickman, Broviac

PICC, PIC, EDPC, Arrow Howe, Gesco, PASV Specially trained RN @ bedside

Bard, Tesio, Vescath, Quinton MD in OR

MD in OR

MD in OR

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Central Venous Catheter Sites

PICC (Peripherally inserted Central Catheter)

Percutaneous(Subclavian)

Implanted Port (single or double lumen) Tunnelled (Hickman)

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Percutaneous (IJ-Int. Jugular)

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CVC Care/Maintenance

Percutaneous Flush after each access or daily for catheters>21ga, q 6 hrs <21 ga -adults: 10ml saline - peds/neonates: 5ml saline (preservative free for infants <1yr) Transparent dressing change q 7 days & prn
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Tunneled

PICC

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CVC Care/Maintenance

Flush after each use and weekly while accessed;

monthly when not acessed

- 10ml saline (preservative free for pts. <1yr)

- followed by 4.5ml-5ml heparinized saline 100units/ml for adults 10units/ml for peds

Implanted Port

Transparent dressing/ access needle change q 7days

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Monitor and document site condition:

Hourly for peds

Site Care

Q 2 hr for adult
* Indicates complication: Infiltration Phlebitis Thrombosis Cellulitis Septicemia

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Infiltration/Extravasation
The most common cause is damage to the wall during insertion or angle of placement.

STOP INFUSION and treat as indicated by Pharmacy, Medication package insert or drug reference book.

Notify MD and document

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Phlebitis/Thrombophlebitis
Chemical
- Infusate chemically erodes internal layers. Warm compresses may help while the infusate is stopped/changed. Anti-inflammatory and analgesic medications are often used no matter what the cause

Mechanical
- Caused by irritation to internal lumen of vein during insertion of vascular access device and usually appears shortly after insertion. The device may need to be removed and warm compresses applied
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Bacterial
- Caused by introduction of bacteria into the vein. Remove the device immediately and treat w/antibiotics. The arm will be painful, red and warm; edema may accompany
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Cellulitis

Inflammation of loose connective tissue around insertion site.

- Caused by poor insertion technique - Red swollen area spreads from insertion site outwardly in a diffuse circular pattern - Treated w/antibiotics

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Septicemia/Pulmonary Edema/ Embolism

Septicemia

- Severe infection that occurs to a system or entire body

- Most often caused by poor insertion technique or poor site care - Discontinue device immediately, culture and treat appropriately

Pulmonary edema- caused by rapid infusion

Pulmonary embolism - Caused by any free floating substances that
require thrombolytic therapy for several months. Increased risk w/lower ext. Air embolism- caused by air injected into IV system. Keep insertion site below level of heart

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Troubleshooting

Vascular access device will not flush/cant draw blood

- Evaluate for kink in tubing or catheter tip against vein wall.

Vascular access device (VAD) leaking when flushed

- Verify that hub access cap is connected correctly

Patient complains of pain while VAD being flushed

- Assess for infiltration

VAD broken
- PICCs may be repaired. All other devices must be replaced

Call IV therapy team member for any concerns or questions.

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Policy notes
KVO ra te :

RNs and LPNs can start peripheral IVs after initial training and observation by preceptor LPNs CANNOT infuse blood products or high risk IV medications.

Adu lt s - 10 m l/h r P edia t r ics - 2-3 m l/h r Neon a t es - 0.5-1 m l/h r

On ly u n til ra te o rd e r re c e iv e d

Ve rific a tio n re qu ire d fo r: In su lin H epa r in P ot a ssiu m Digoxin Ch em ot h er a py

LP Ns ca n n ot pu sh IV m edica t ion s

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IV Medication Administration
Many medications require patient monitoring that cannot be done on units where the nurse/patient ratios are greater than 1:2 A patient can be moved to a unit where the ratio is appropriate for invasive/frequent monitoring or another nurse can be brought to care for the patient during the med administration
All Med ica t ion s Ca n n ot Be Ad m in is t er ed on All U n it s
Ge n e r a l Ca r e U n i t s : Ca n give m ed s r equ ir in g on ly ba s ic p h ys ica l a s s es s m en t d a t a S t e p d o w n U n i t s : Ca n give m ed s t h a t r equ ir e m or e in va s ive or fr equ en t m on it or in g t h a n is a va ila ble on gen er a l ca r e u n it s In t e n s i v e Ca r e U n i t s : Ca n give m ed s t h a t r equ ir e m or e in va s ive or fr equ en t m on it or in g t h a n is a va ila ble on t h e St ep d own u n it s .

www.mc.vanderbilt.edu/pharmacy/ivroom/IV MedAdm061003.pdf

VANDERBILT URL LINK FOR IV MEDICATIONS:

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IV Medication Administration
Sample page from the Pharmacy med administration web site

See APPROVED FOR section. You will find if the medication can be administered on your unit.
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www.ins1.org

Infusion Nurses Society (INS)

Professional Organization that sets the standards of care for clinicians practicing in the field of infusion therapy. Standards set by INS are reflected in our policies and procedures related to infusion therapy for health care providers. In a court of law, the standards set by the INS are used to assess the infusion clinicians performance.
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