VASCULAR ACCESS DEVICES

VASCULAR ACCESS DEVICES Carlos Smith, MBA, MSN.Ed, RN – CCRN WebRN Corporation © 2022 All Rights Reserved

DEFINITION A vascular access procedure involves the insertion of a flexible and sterile thin plastic tube, or catheter, into a blood vessel to provide an effective method of drawing blood or delivering medications, blood products, or nutrition into a patient's bloodstream over a period of weeks, months or even years. 2

TYPES OF VASCULAR ACCESS • Peripheral Intravenous Catheterization • Midline Peripheral Catheterization • Central Venous Catheterization • Arteriovenous Fistula/Graft • Arterial Catheterization • Intraosseous Cannulation 3

1. PERIPHERAL INTRAVENOUS CATHETERIZATION

DEFINITION 5 • Peripheral line placement, also referred to as peripheral intravenous catheterization, is the insertion of an indwelling single-lumen plastic conduit across the skin into a peripheral vein • Such devices may be referred to as peripheral IV lines, cannulas, or catheters BD INSYTE AUTOGUARD: Shielded IV Catheter https://www.bd.com/a/79062

INDICATION • They allow fluids, medications and other therapies such as blood products to be introduced directly into the cardiovascular system, bypassing other barriers to absorption and reaching most target organs very quickly • Lines are also commonly used for phlebotomy at the time of insertion (before administration of drugs or fluids which would dilute or contaminate the blood samples) • Once inserted, a well-functioning line can remain in use for several days if required, obviating the need for repeated needle insertion into the patient should ongoing treatment be needed 6

WHY VEINS NOT ARTERIES? • IVs are always placed in veins, not arteries, allowing the medication to move through the bloodstream to the heart • Veins are close to the surface of the skin whereas arteries are deeper • The walls of veins are thinner than arteries • The blood pressure in veins is less than that in arteries 7

SITE OF INSERTION 8

PREFERRED SITE • The non-dominant upper extremity is commonly chosen, because of comfort, reduced risk of dislodgement, and lower incidence of thrombosis or thrombophlebitis • Cannulation of the veins of the feet is not ideal. Insertion can be quite painful and the catheter may cause more discomfort • Additionally, IV catheters placed in the feet are more likely to become infected, to not flow properly and more likely to produce phlebitis 9

PREFERRED SITE Prefe•••••rreDIRFSdsituilsevalnsteansaaisdnlsnysastd:rtnuaoedpimgsnaphoplltiintnti-tetlbesranched (venous valves are commonly near branching points) 10

SITES OF INSERTION Dorsal Digital veins Dorsal Metacarpal Dorsal Venous veins plexus Cephalic vein Basilic vein QUIZLET: HAND VEINS https://quizlet.com/451936971/hand-veins-diagram/ 11

SITES OF INSERTION Cephalic vein Median cubital Accessory cephalic vein vein Basilic vein Median vein IV Initiation Tips https://nurseconnect.tumblr.com/post/18 5357327004/iv-initiation-tips 12

SITE OF INSERTION Lesser saphenous vein Greater saphenous vein Dorsal venous arch SCIENCE PHOTO LIBRARY: Foot Anatomy https://www.sciencephoto.com/media/1137805/vi ew/foot-anatomy-illustration 13

SITE OF INSERTION Frontal veins Occipital vein https://www.olchc.ie/Healthcare- Superficial Professionals/Nursing-Practice- temporal vein Guidelines/Intravenous- Cannulation-.pdf Posterior auricular vein 14

INTRAVENOUS CATHETER 15

IV CATHETER GAUGES Always select the smallest gauge peripheral catheter that will accommodate the prescribed therapy and patient need. The required size depends on: • What will be infused, for example: colloid, crystalloid, blood products or medications • The rate the infusion is to run 16

IV CATHETER SIZES COLOR GAUGE EXTERNAL LENGTH WATER RECOMMENDED SIZE DIAMETER (mm) FLOW RATE USES (mL/min) (mm) 14G 2.1 mm 45 mm 240 Trauma, Rapid blood transfusion, ORANGE mL/min Surgery 16G 1.8 mm 45 mm 180 Rapid fluid replacement, mL/min Trauma, Rapid blood transfusion GRAY 17

IV CATHETER SIZES COLOR GAUGE EXTERNAL LENGTH WATER RECOMMENDED SIZE DIAMETER (mm) FLOW RATE USES (mL/min) (mm) 18G 1.3 mm 32 mm 90 mL/min Rapid fluid replacement, GREEN Trauma, Rapid blood transfusion Most infusions, Rapid fluid 20G 1.1 mm 32 60 mL/min replacement, Trauma, Routine mm blood transfusion PINK 18

IV CATHETER SIZES COLOR GAUGE EXTERNAL LENGTH WATER RECOMMENDED USES SIZE DIAMETER (mm) FLOW RATE (mL/min) (mm) 22G 0.9 mm 25 mm 36 mL/min Most infusions, Neonate, Pediatric, BLUE Older adults, Routine blood transfusion 24G 0.7 mm 19 mm 20 mL/min Most infusions, Neonate, Pediatric, YELLOW Older adults, Routine blood transfusion, Neonate or Pediatric blood transfusion 19

IV CATHETER SIZES COLOR GAUGE EXTERNAL LENGTH WATER RECOMMENDED SIZE DIAMETER (mm) FLOW RATE USES (mL/min) (mm) 26G 0.6 mm 19 mm 13 mL/min Pediatrics, Neonate PURPLE References: Infusion Therapy Standards of Practice Jan/Feb 2016 https://www.bd.com/infusion/products/ivcatheters/iagbc/videos/pdfs/iagbc_wp3.pdf 2 *varies by specific catheter and manufacturer 20

PREPARING FOR INSERTION

PREPARING FOR INSERTION A. GATHER SUPPLIES • Sterile disposable gloves • Appropriate size Bag of IV fluid • Non-latex tourniquet • Sterile bandage or dressing • Gauze • Alcohol wipes • Medical tape • Sharps container • Sterile pad or paper Wikihow.com 22

PREPARING FOR INSERTION B. CHOOSE A SUITABLE GAUGE CATHETER Wikihow.com • Catheters come in different sizes called 23 gauges • The larger gauge needle you use, the higher the maximum flow rate of the fluid entering into the vein • Choose a size that can easily fulfill the purpose of the procedure but is not oversized

PREPARING FOR INSERTION C. INTRODUCE YOURSELF • Introduce yourself to the patient and explaining the procedure that's about to occur • Verify your patient’s identity before starting any procedure 24

PREPARING FOR INSERTION D. PUT ON STERILE GLOVES Wikihow.com • Inserting an IV pierces the skin and introduces foreign equipment directly into the bloodstream • To avoid the risk of a dangerous infection, it's important to wash your hands and dry them with a clean paper towel before beginning, then put on sterile gloves before you handle your equipment and touch the patient 25

PREPARING FOR INSERTION E. PREPARE THE IV TUBING • Prime the IV tubing by suspending the IV bag from an elevated stand, filling the tubing with saline solution, and checking for any bubbles • Clamp the tubing so that the solution doesn't drip onto the floor 26

PREPARING FOR INSERTION E. PREPARE THE IV TUBING • Be sure to remove any bubbles from the tubing by gently tapping, squeezing, or flushing them out of the line o Injecting air bubbles into a patient's bloodstream can cause a serious condition called an embolism • A dated and signed sticker should then be placed on both the IV tubing and the IV bag Medidose.com 27

PREPARING FOR INSERTION F. LOOK FOR PROMINENT VEINS • Examine the individual's veins in the selected area. You want to make sure that they have suitable veins for insertion o ADULTS: upper extremities that aren’t near joints and are furthest from the body o CHILDREN: the scalp, hand, or foot Wikihow.com 28

PREPARING FOR INSERTION G. APPLY TOURNIQUET • The tourniquet should be applied approximately 4 – 6 inches above the insertion site to dilate the vein • Check for a distal pulse. If there is no pulse, the tourniquet is too tight and is occluding the arterial blood flow. Remove the tourniquet immediately and reapply Wikihow.com 29

PREPARING FOR INSERTION H. PALPATE THE VEIN IF NECESSARY Wikihow.com • Lightly palpate vein with your index and 30 middle fingers, while stretching it to prevent rolling. If the vein feels hard or rope‐like, select another site • If the vein is easily palpable, but not sufficiently dilated, have patient open and close fist a few times or try tapping the vein to make it dilate

PREPARING FOR INSERTION I. DISINFECT THE IV SITE • Apply the antiseptic to the site with friction for 30-60 seconds, and then allow the site to air dry for up to one minute. This will help prevent the risk of infection and reduce stinging Wikihow.com • If the area is really covered in hair, you may need to shave it. This will help you to identify the vein, get a clear aim at it, and it will help when cleaning the area 31

INSERTING THE NEEDLE J. PREPARE NEEDLE FOR INSERTION Wikihow.com • Make sure you are using a new, unopened needle that is still in its sterile package • Remove needle from package and ensure that catheter is able to unhook from needle 32

INSERTING THE NEEDLE K. INSERTION • The correct angle will depend on the size of the device and the depth of the vein. If you are trying to access a small, superficial vein, you should use a small catheter (with a gauge of 22-24) and insert at an angle of 10°-25° Wikihow.com • For a deeper vein, use a larger catheter and insert at an angle of 30°-45° • Make sure you insert the needle bevel up 33

INSERTING THE NEEDLE L. ADVANCE THE PLASTIC PIECE OF THE CANNULA • The needle should now be held stationary while the plastic component of the cannula is advanced another 2-3 mm into the vein. The goal is to get the plastic sheath into the vein, and keep it there, while the needle is removed Wikihow.com • Keep advancing the plastic component of the cannula until the plastic tube is fully inserted 34

INSERTING THE NEEDLE M. ADVANCE THE CANNULA UNTIL YOU ACHIEVE FLASHBACK • Hold the cannula in the front of its wings with your pointer and middle finger and in the back with your thumb. Advance it slowly into the skin until blood enters the base of the cannula ( flashback ) Wikihow.com • Once flashback occurs, reduce the angle of the needle to avoid puncturing the posterior wall of the vein 35

INSERTING THE NEEDLE N. RELEASE THE TOURNIQUET Wikihow.com • Remove the tourniquet from the patient's arm. Remove the needle from the base of the cannula, leaving the plastic component in sight • Remove the protective cover from the end of the primed IV tubing and carefully insert it into the catheter hub • Secure it in the catheter by screwing and locking in place 36

INSERTING THE NEEDLE O. STABILIZE • Secure the IV against the patient's skin • Place a piece of tape over the catheter hub, then make a loop in the catheter tubing and tape this down with a second piece of tape over the first Wikihow.com • Place a label with the date and time of insertion on the IV dressing 37

INSERTING THE NEEDLE P. DRESSING THE SITE • The IV site should be dressed according to the facility policy and procedure; generally by either using a transparent semi‐ permeable membrane dressing or a gauze dressing Wikihow.com • A transparent semi‐permeable membrane dressing is recommended over gauze because gauze can obscure the visualization of the IV site 38

INSERTING THE NEEDLE Q. DISPOSE ALL NEEDLES PROPERLY • The needles used to start an IV qualify as medical sharps and need to placed in a well- marked sharps container immediately after use Wikihow.com 39

MAINTAINING AN IV LINE

FLUSHING OF IV LINE • If the cannula is accessed intermittently for the administration of medications or fluids, the cannula should be flushed prior to infusion or at least once a shift • Sterile 0.9% sodium chloride for injection should be used to flush a catheter • A minimum of 2 ml normal saline flush is recommended • Use 10ml syringe for flushing to avoid excessive pressure and catheter rupture. Syringes with an internal diameter smaller than that of a 10mL syringe can produce higher pressure in the lumen and rupture the catheter 41

FLUSHING OF IV LINE • Use aseptic non touch techniques including cleaning the access port (scrub the hub) with a dual disinfectant agent vigorously for at least 15 seconds and allowing to dry prior to accessing the system • Flush in a pulsatile (push-pause) motion • Flush catheters: o Immediately after placement o Prior to and after fluid infusion or injection o Prior to and after blood drawing 42

CHANGE OF DRESSING • Indications for dressing change: when it becomes insecure or if there is blood or fluid leakage under the dressing • Carefully remove the old dressing, holding the cannula in place at all times • Take the opportunity to Wikihow.com thoroughly inspect the site of entry of the cannula for any sign of infection • Skin preparation using alcohol in 2% chlorhexidine is the preferred solution for dressings 43

CHANGE OF DRESSING • Cleanse the area around the catheter insertion site including under the hub using a pattern which will ensure entire area is covered • Cover the cannula insertion site with sterile transparent semipermeable, occlusive dressing (e.g. Tegaderm ) placed using an aseptic non touch technique over the catheter. This will allow continuous observation of the site and to help stabilize and secure the catheter 44

CHANGING OF IV BAGS AND LINES No additives in BAG CHANGE IV LINE CHANGE infusion Every 7 days Every 7 days Every 24 hours in Additives in neonates infusion Lipid or lipid Every 24 hours Every 7 days containing parenteral Every 24 hours Every 24 hours nutrition Blood products Every 4 hours Up to 12 hours 45

COMPLICATIONS 46

COMPLICATIONS 1. PHLEBITIS • Phlebitis is the inflammation of a vein. If it is associated with clot formation as well it is known as thrombophlebitis • S/SX: redness, swelling, pain, and edema at the insertion site and/or along the vein • CAUSE: poor blood flow around the venipuncture device, friction from catheter movement in the vein, clotting at the catheter tip • TREATMENT: removal of the catheter, application of heat and analgesia 47

COMPLICATIONS 2. INFILTRATION • Infiltration is the inadvertent leakage of a non vesicant solution into surrounding tissue • S/SX: cool skin Peripheral IV Failure temperature at the IV site, https://lineusmed.com/iv-complications skin that looks blanched, taut, or stretched, edema, discomfort; tenderness, change in quality and flow of the infusion, or IV fluid leaking from the insertion site 48

COMPLICATIONS 2. INFILTRATION • CAUSE: Catheter dislodgement, improper insertion of the IV catheter, damage or swelling of the vein, clot formation in the vein, or when the cannula punctures or erodes through the opposite wall of the vein • TREATMENT: immediately stopping the infusion, elevation of the limb, application of heat or cold (depending on the infusate), dressing the old site and restarting the IV 49

COMPLICATIONS 3. HEMATOMA • S/SX: tenderness at the site, a bruise may be evident at the site, and the infusion will not flow • CAUSE: Hematomas occur when blood leaks into the extravascular space • TREATMENT: The IV catheter must be 50 removed and restarted elsewhere. Additionally, you should apply pressure until the bleeding stops and warm soaks to aid in the absorption of the blood IV therapy https://quizlet.com/420015285/nur-224-iv- therapy-flash-cards/