practice and care of iv line

8/17/2019 Practice and Care of IV Line

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Practice and Care Peripheral iv line

The 4th Symposium on Critical Care

and Emergency Medicine,

Medan.

Hasanul Arifin

Fluid Therapy Course ‘Skill Station”

Kamis , 08 Mei 2008, 15.00-17.00 wib


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Anatomy and physiology

• Superficial veins of the upper limbs are usuallyselected for peripheral cannulation

(Dougherty1999).

• Cannulation of the lower limbs is associated withan increased risk of venous thromboembolism

(Scales 1999).


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• Skin is composed of two main layers:

Epidermis (skin surface): approximately 1mm thickcontaining sensory nerve endings.

Dermis (beneath the epidermis): thicker than the

epidermis, composed of collagenous and elasticconnective tissue and containing fat, blood and lymph

vessels, nerves, hair follicles, sweat glands and

sebaceous glands.


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• Ageing alters the structure and appearance of the skin.The dermal layers become thinner and there is lesssubcutaneous tissue to support the blood vessels.

• The veins of older people are often easier to seebecause of the reduction in subcutaneous tissue,particularly on the dorsum of the hand.

• The vessels are also more mobile, more fragile and often

tortuous and thrombosed (Dougherty 1999). The dorsumof the hand should be avoided in older people


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Psychology• Fears and phobias (needle phobia)

• Pain during cannulation• Palpating and cleaning the skin (trigger

memories of previous experiences)

• Reduce a patient’s anxiety by :

• Deep breathing and relaxation

• Topical anaesthetic agents


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Consent• Consent is necessary at every stage of a

patient’s treatment.• Written consent is considered good practice

before invasive procedures and for procedures

that involve risk, for example, operations andcytotoxic drug regimens.

• Verbal consent is considered adequate for

procedures with a low level of risk, for example,

cannulation.


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Consent

• Consent is only valid if it is given voluntarily and

accompanied by an adequate explanation,which allows the patient to make an informed

choice to accept or reject a proposed treatment

• Before peripheral cannulation it is important toprovide an explanation of the reason for

cannulation, duration of the intended therapy

and associated risks, for example bruising.


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IndicationCannulation may be used

• To administer drugs.• To maintain correct hydration (fluid infusion)

• Transfusion of a blood component.

• Parenteral nutrition


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Vein Selection


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Vein Selection

• The veins of the antecubital fossa are

usually easily visualised, palpated andaccessed because of their superficialnature and size.

• However, their position over the flexorsurface of the elbow makes these veinsprone to mechanical phlebitis, and thecannula prone to failure from kinking ordislodgement.


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Vein Selection

• A cannula should not be placed in areas

of localised oedema, dermatitis, cellulitis,arteriovenous fistulae, wounds, skin

grafts, fractures, stroke, planned limb

surgery and previous cannulation.

• The patient may prefer the non-dominant

limb to be selected for cannulation topromote independence and comfort


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Vein Selection

• Both upper limbs should be inspected to

identify possible veins for cannulation.• Potential veins can then be palpated to

assess their condition.• An ideal vein is ‘soft and bouncy’ when

palpated.

• Veins that are tender, thrombosed or hard

should be avoided


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Device selection

• It is important to select the correct

vascular access device for the patient’s

specific clinical situation

• PUR (polyurethane), modern, softer,

cause less intimal damage and are kinkresistant which reduces the incidence of

cannula failure

• PVC, Teflon, older materials are more

rigid, higher incidence of thrombophlebitis.


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Device selection• Generally, the smallest gauge of cannula should

be selected for the prescribed therapy.• This helps to prevent damage to the vessel

intima and ensures that there is adequate blood

flow past the cannula.• Small gauge cannulae usually provide a

sufficiently high flow rate to deliver most

therapies, and reduce the risks of mechanical

and chemical phlebitis


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equipment• Infusion standart

• Fluid (RL, NaCl, etc)

• Infusion tubing

• The following equipment for cannulation should

be assembled and placed on a clean tray:• cannula, antiseptic, sterile gauze, sterile saline

flush, single or multiway adapter (primed with

sterile saline) with integral ‘needle-less’ device,sterile moisture-permeable transparent dressing,

tape, and a small sharps’ container.


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Theoretical Maximum Flow Rates

Colour Gauge Flow

Yellow 24G 13 ml/min

Blue 22G 30 ml/min

Pink 20G 55 ml/min

Green 18G 80-100 ml/min

White 17G 135 ml/min

Grey 16G 180 ml/min

Orange or Brown 14G 270 ml/min


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Site preparation

• Topical anaesthetic agents can reduce the

pain of cannulation.• Emla® cream has to be applied two hoursbefore cannulation, which is not always

practical, and the associatedvasoconstriction may complicatecannulation

• Ametop® is a good alternative: it iseffective after ten minutes and has mildvasodilatory effects.


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Cannulation procedure


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Cannulation procedure


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COMPLICATIONS.

• Haematoma.• Infiltration or “ tissueing” .

• Thromboembolism.• Air Embolism.

• Phlebitis and Septicemia.


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COMPLICATIONS.

• Haematoma, is a collection of blood, it can be formed

following leakage of blood from the vein into the

tissues surrounding the insertion site. It can occur asa result of failure to puncture the vein properly

during cannula insertion.

• Infiltration or “tissueing” occurs when the infusateenters the subcutaneous tissue rather than the vein.

• Thromboembolism, occurs when a blood clot on the

catheter or vein wall becomes detached and iscarried by the venous flow to the heart and

pulmonary circulation.


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COMPLICATIONS.• Air Embolism, is a possible hazard during all forms of

I.V. therapy. In peripheral cannulation, however, the risk

of air embolism is limited by the positive peripheralpressure (3-5 cm H2O).

• Phlebitis and Septicemia. Phlebitis is an inflammation ofthe vein and can be due to chemical or mechanicalirritation, or infection. A thrombus can form in associationwith the inflammation resulting in thrombophlebitis. Of allthe factors affecting the development of phlebitis such as

catheter size, Venepuncture site etc the duration of thecannulation and the types of fluids administered are themost important.


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Replacement of CathetersPeripheral Venous Catheters

Scheduled replacement of intravascular catheters has beenproposed as a method to prevent phlebitis and catheterrelated

infections. Studies of short peripheral venous catheters

indicate that the incidence of thrombophlebitis and bacterial

colonization of catheters increases when catheters are left inplace >72 hours. However, rates of phlebitis are

not substantially different in peripheral catheters left in place

72 hours compared with 96 hours. Because phlebitis

and catheter colonization have been associated with an

increased risk for catheter-related infection, short peripheral

catheter sites commonly are rotated at 72–96-hour intervals to reduce

both the risk for infection and patient discomfort

associated with phlebitis.


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Summary• This article provides an overview of theknowledge and skills required for peripheral

venous cannulation, including anatomy andphysiology, psychology, consent, veinselection, device selection, infection control,

insertion technique, device securement,sharps’disposal and the prevention andmanagement of complications.

• A period of supervision and assessment ofcompetency is required to consolidate thistheoretical knowledge.


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