Basic Intravenous Therapy

1. 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.

2. 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

3. Tunica Adventitiathe outer layer of the vessel • Connective tissue • Contains the arteries and veins supplying blood to vessel wall

4. Tunica Mediathe middle layer of the vessel • Contains nerve endings and muscle fibers • The vasoconstrictive response occurs at this layer

5. Tunica Intimathe inner layer of the vessel • One layer of endothelials • No nerve endings • Surface for platelet aggregation w/trauma and recognition of foreign object at this level • PHLEBITIS begins here

6. Valvespresent in MOST veins • Prevent backflow and pooling • More in lower extremities and longer vessels • Vein dilates at valve attachment

7. 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 -Geriatric patients often lack enough connective / adipose tissue and skin turgor to use this area successfully Digital

8. Veins of the Upper Extremities • Cephalic (Intern’s 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

9. 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

10. 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 ®

11. 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)

12. 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

13. Flushing Peripheral IV’s • 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 - Adults: q 8hrs w/1ml. 0.9%NS [3ml heparinized saline for OB]

14. 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

15. Central Venous Catheters

16. Central Venous Catheter Sites Percutaneous(Subclavian) PICC (Peripherally inserted Central Catheter) Implanted Port (single or double lumen) Percutaneous (IJ-Int. Jugular) Tunnelled (Hickman)

17. CVC Care/Maintenance Tunneled 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 PICC

18. 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 • Transparent dressing/ access needle change q 7days Implanted Port

19. Site Care • Monitor and document site condition: • Hourly for peds • Q 2 hr for adult • * Indicates complication: • Infiltration • Phlebitis • Thrombosis • Cellulitis • Septicemia

20. 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

21. 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 • 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 • 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

22. 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

23. 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

24. Troubleshooting • Vascular access device will not flush/can’t 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 - PICC’s may be repaired. All other devices must be replaced Call IV therapy team member for any concerns or questions.

25. Policy notes RN’s and LPN’s can start peripheral IV’s after initial training and observation by preceptor LPN’s CANNOT infuse blood products or high risk IV medications.

26. VANDERBILT URL LINK FOR IVMEDICATIONS:www.mc.vanderbilt.edu/pharmacy/ivroom/IVMedAdm061003.pdf 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

27. 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.

28. 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 clinician’s performance.