Venipuncture & Peripheral IV Insertion

1. Venipuncture & Peripheral IV Insertion By Prof. Unn Hidle & Prof. Pat Dillon Updated Spring, 2010

2. Available on Blackboard:Professor Hidle’s skills videos1) Intravenous cannulization2) Venous access

3. Clinical indications • Venipuncture: • Blood tests • Monitoring blood levels • Peripheral IV: • Fluid maintenance (decreased/absent PO, NG or GT intake) • Fluid boluses for dehydration • Nutritional supplementation (TPN, lipids • Administration of medications/treatments • Blood transfusions

4. Selecting anatomical sites: Venipuncture and PIV insertion The site chosen for venipuncture varies with the client’s age, the length of time the infusion is to run, the type of solution used, and the condition of veins. In general, for adults, veins in the hand and are commonly used, while for infants, veins in the scalp and dorsal foot veins may be used. Larger veins are preferred for infusion that need to be given rapidly and for solution that could be irritating.

5. Assessing for suitable veins • Vein patency (scar tissue): Veins that have previously been used for IV insertion may have been damaged by phlebitis, infiltration or sclerosis • “Rolling veins” : Highly visible veins and “popping up” – tends to roll away from the needle • Skin turgor (dehydration): Veins less palpable and access more difficult • Edema: Veins less palpable • Fistulas/shunts

6. The site selected depends on accessibility and convenience • Consider the child’s developmental, cognitive, and mobility needs • For veins in the extremities, it is best to start with the most distal sites. • If the vein is damaged, using distal sites initially preserves access to the vein in proximal sites

7. Anatomical Sites

10. Median cubital vein – usually saved for PICC line insertion; inconvenient in children as it limits motility • Basilic vein • Cephalic vein • Medial antebrachial vein • Dorsal hand veins • Scalp veins – used for infants • Dorsal foot veins – used for infants

11. Anatomical sites in Infants

12. Blood Drawing in Infants • The recommended location for blood collection on a newborn baby or infant is the heel. • The diagram below indicates in green the proper area to use for heel punctures for blood collection. • Pre-warm the infant's heel (42 C for 3 to 5 minutes - may use “infant heel warmer”). • Clean the site with an alcohol sponge. • Hold the baby's foot firmly to avoid sudden movement. • Using a sterile blood lancet and clean gloves, ONLY puncture appropriate region & do not use previous puncture site. • Wipe away the first drop of blood. • Do not use excessive pressure or heavy massaging because the blood may become diluted with tissue fluid AND damage to RBC can occur and affect blood test results.

13. IV Consideration in Children • Most infants have 1-2 possible IV sites on each hand, arm, and foot and 4-8 sites on the scalp. • Although scalp IV are easily accessible, they are used only when attempts at other sites have failed • Superficial scalp veins have no valves and fluid can be infused in either direction

14. A rubber band is used from brow to occiput as a tourniquet when needed. • It is often difficult to distinguish a scalp vein from an artery, even when palpating for pulsation • Catheter in scalp should be inserted pointing downwards toward the heart

15. Accessing Veins • Extremity veins may be difficult to locate as they are small and there is more subcutaneous fat. • Warm compress, running warm water over the extremity, &/or holding the limb in a dependent position below body level will aide in visualization and palpation • Use tourniquet with caution as it may cause added venous pressure in fragile veins to “blow” when punctured, causing a hematoma

16. Preparing the child and caretakers • Natural anxiety --- prepare them: HOW? • Consider developmental age/stage • Use play • Demonstrate (i.e. doll) • Let the child have some control in the situation (i.e. handle equipment, clean with alcohol wipe, assisting taping)

17. Stay away from “safe places” – i.e. playroom- use treatment room instead. • Keep in mind that children often “loose control” without expecting to do so • Teaching child and care-takers: pre-and–post-procedure, care of IV site, signs of infection, infiltration, etc.

18. Equipment needed(will go over in demonstration) • Gloves • Alcohol wipes • Betadine (if blood culture is needed) • Tourniquet • Angiocatheter or butterfly needle • IV tubing and IV solution (primed) • NS for injection • 3cc or 5cc syringe with needle • Tape &/or dressing material (Opsite, Tegaderm, gauze) • Support board/arm-board if indicated • Protective cover for butterfly needle

20. IV Guard Pediatric Site Cover Posey IV Shield

21. Procedure for IV insertion and securing the site • PIV insertion • Catheter hub should be firmly secured at the puncture site with transparent dressing or clear, non-allergenic tape • Never encircle extremity with tape • Also use extreme caution with Ace bandage, stretch bandages and gauze – Roll; don’t stretch too tightly. • I.V. cover (house) as a protective devise • Immobilizers such as arm-boards, splints and elbow restraints are controversial. • If restraints are used, frequently check the IV site, remove at intervals, passive/active ROM.

22. TROUBLESHOOTING GUIDELINES: 1. IF AN INCOMPLETE COLLECTION OR NO BLOOD IS OBTAINED: The needle should form a 15 to 30 degree angle with the surface of the arm Adjust the angle (the bevel may be against the vein wall). Change the position of the needle. Move it forward (it may not be in the lumen). • Loosen the tourniquet. It may be obstructing blood flow. • Try another tube. There may be no vacuum in the one being used. • Re-anchor the vein. Veins sometimes roll away from the point of the needle and puncture site. or move it backward (it may have penetrated too far).

23. TROUBLESHOOTING GUIDELINES: 3. OTHER PROBLEMS 2. IF BLOOD STOPS FLOWING INTO THE TUBE: • A hematoma forms under the skin adjacent to the puncture site - release the tourniquet immediately and withdraw the needle. Apply firm pressure. The vein may have collapsed; re-secure the tourniquet to increase venous filling; if not effective – REMOVE ! ALSO, the needle may have pulled out of the vein when switching tubes. Hold equipment firmly when changing tubes! The blood is bright red &/or pulsating (arterial) rather than venous. Apply firm pressure for more than 5 minutes.

24. The “gentler” IV • Remember, children are as scarred of IV removal as they are of insertion! • Use EMLA cream pre-IV insertion - (lidocaine 2.5% and prilocaine 2.5%) is an emulsion mixture of lidocaine and prilocaine in a ratio of 1:1 • “Hurricane” spray (Benzocaine: local also in Baby Oragel for teething and Vagisil for diaper rash). • Use adhesive tape remover (wash off immediately to protect the skin from irritation) • Remove Tegaderm in a correct manner

25. Benzocaine (Hurricane Spray) - ALERT • Health professionals should be aware that potentially uncontrollable doses can be administered due to the design of the delivery device causing symptoms of benzocaineinduced methemoglobinemia. • Methemoglobinemia is a high methemoglobin = IRON blood level • This results in decreased O2 carrying capacity of RBC. • Antidote = methylene blue 50 mg IV. • The spray is not a metered dose product and as such each actuation does not deliver a specific dose per actuation. • The instructions provided by the manufacturer for safe application appear ONLY on the canister’s cap and not on the canister’s container label. • Until alternatives to this treatment regimen are implemented facilities should proactively report to FDA’s MedWatch reporting system any problems associated with Benzocaine (Hurricane Spray) use.

26. Complications • Infection : • Local infection (cellulitis) at the IV site insertion may present with edema, erythema spreading along vein (phlebitis), warmth (inflammation). • A much more serious infection is a systemic infection in which pyrogenic substances in either the infusion solution or the IV administration set can induce a febrile reaction and septicemia. More common in immunocompromised patients.

27. Infiltration: • More difficult to detect in infants and small children than in adults. • A good blood return is not always an indicator of infiltration. • Flush the catheter and observe the site for discoloration (blanching or redness), pain, tenderness, and edema or not any exudate or drainage and increase in skin or basal temperatures.

28. Hematoma: • Results when blood leaks into tissues surrounding the IV insertion site. • Leakage can result from perforation of the opposite vein wall during venipuncture, the needle slipping out of the vein, and insufficient pressure applied to the site after removing the needle or cannula. • S/S include ecchymosis, immediate swelling at the site and the leakage of blood at the site. • Treat with ice X 24 hours, then warm compresses to increase absorption

29. Phlebitis: • Inflammation of a vein related to a chemical or mechanical irritation or both. • It is characterized by reddened, warm area around the insertion site or along the vein and swelling. • Increased risk with increased time IV is left in place, fluid composition, medication, size of the cannula, ineffective filtration and microorganism. • Discontinue IV and restart it at another site. • Apply warm, moist compress to the affected site.

30. Tissue injury / extravasation: • Infiltration of a vesicant solution or medication into the surrounding tissue (VESICANTS – chemotherapy -and other medications such as dopamine, calcium preparation). • Blistering, inflammation, and necrosis of tissue can occur. • Stop infusion, notify physician and administer / apply antidote prescribed. If not available, ICE!!! • Sometimes IV remains in place not to worsen the extravasation.

31. Local allergy: • Always ask prior to IV insertion if there are any allergies to iodine/seafood (betadine preparation), alcohol or latex

32. Clotting and obstruction / embolization: • Blood clots may form in the IV line as a result of kinked IV tubing, a very slow infusion rate, an empty IV bag, or failure to flush the IV line after intermittent medication or solution administrations. • The signs include decreased flow rate and blood backflow into the IV tubing. • Nursing Interventions: • Never force a clotted IV line, irrigate or milk it. • Stop the IV line and restart in another site.

33. Air embolism: • Very rare, but may occur with cannulation of central veins. • Manifestation of air embolism include dyspnea and cyanosis, hypotension, weak rapid pulse, loss of consciousness and chest, shoulder, and low back pain. • Nursing Interventions: includes immediately clamping the cannula, placing the patient ion the left side in the Trendenlenburg position, assessing VS and breath sounds and administering O2.

34. Venous Spasm • A sudden involuntary contraction of a vein or an artery resulting in temporary cessation of blood flow through a vessel. • Can be spontaneous, or resulting from high osmolarity (Dextrose > 12.5%) or high/low ph, viscous or cold fluids, rapid infusion, cannula too large, vaso-vagal response to anxiety or pain and some drugs (Diazepam, Nafcillin, Phenytoin, Potassium Cl, Propofol and Vancomycin). • Signs/symptoms: sharp pain at the IV site that travels up the arm, which is caused by a piercing stream of fluid that irritates or shocks the vein wall; slowing of the infusion • Nursing – Prevention: Use a large vein and a small gauge catheter to allow for unrestricted blood flow.

35. Peripheral Nerve Palsy: • Limitation in the use of the limb following IV insertion in that periphery. • Compression of nerves and blood vessels within an enclosed space leading to impaired blood flow and muscle and nerve • Causes: tight wrapping with tape or bandaging, edema/cellulitis, infiltration, and hematoma. • Nerve, tendon, ligament or limb damage can lead to loss of function or amputation. • Nursing Intervention/Prevention: Assess for pulses, elevate extremity immediately and report! • Compartment Syndrome:

36. Points to Remember: • Areas to be avoided when choosing a site: • Extensive scars from burns and surgeryIt is difficult to puncture the scar tissue and obtain a specimen. • Upper extremity on the side of a previousmastectomyTest results may be affected because of lymphedema and the area is highly susceptible to infection. • HematomaMay cause erroneous test results and risk of infection. If another site is not available, collect the specimen distal to the hematoma.

37. Points to remember • Intravenous therapy (IV) / blood transfusions Fluid may dilute the specimen, so collect from the opposite arm of the IV infusion if possible. Otherwise, satisfactory samples may be drawn below the IV by following these procedures: • Turn off the IV for at least 2 minutes before venipucture. • Apply the tourniquet below the IV site. Select a vein other than the one with the IV. • Perform the venipucture. Draw 5 ml of blood and discard before drawing the specimen tubes for testing. • Cannula/fistula/saline lockHospitals have special policies regarding these devices. In general, blood should not be drawn from an arm with a fistula or cannulawithout consulting the attending physician. • Edematous extremitiesTissue fluid accumulation alters test results and risk infection.

38. How to best prevent complication of infection (cellulitis)?

39. HANDWASHING! • HANDWASHING! • HANDWASHING! • HANDWASHING!

40. VENIPUNCTURE COLLECTION TUBES

41. Collection Tubes • Color-coded stoppers indicate type of additive • Additives include anticoagulants such as oxalates, citrates, ethylenediaminetetra acetic acid (EDTA), and heparin. • BLOOD CULTURES are drawn in small speciment bottles before any other blood specimens . • RED Tubes contain NO ADDITIVES !

42. LABORATORY TUBE COLORS • RED: NO ADDITIVE. Serum is obtained in clotted blood for chemistry (electrolytes, proteins, enzymes, lipids, hormones), drug monitoring, radioimmunioassay (RIA), serology and blood bank.

43. LABORATORY TUBE COLORS • GRAY: ADDITIVE is OXALATE. Plasma and blood specimens are collected for glucose testing.

44. LABORATORY TUBE COLORS • BLUE: ADDITIVE is CITRATE. Plasma-blood specimens are collected for coagulation studies (prothrombin time [PT], activated partial thromboplastin time [APTT], partial trhromboplastin time [PTT]) and hemoglobin.

45. LABORATORY TUBE COLORS • LAVENDER: ADDITIVE is EDTA. Plasma and blood specimens are collected for hematology (CBC), platelet count and certain chemistry.

46. LABORATORY TUBE COLORS • GREEN: ADDITIVE is HEPARIN. Plasma-blood specimens are for arterial blood gases, Lupus erthematosus (LE), and sometimes electrolytes and hormones (usually red top).

47. IMPORTANT NOTE! Tubes with additives must be thoroughly mixed (Tip upside down and back). Erroneous test results may be obtained when the blood is not thoroughly mixed with the additive.

48. ORDER OF COLLECTING BLOOD • Blood cultures (sterile) – use Betadine to clean the area • Chemistry (red top) = no additives which may be a source of contamination • CBC (lavender) • PT/PTT (blue) • Others or follow specific lab instructions

49. IV FLUID RATE CALCULATION In PEDIATRICS

50. Maintenance Fluids: Hourly Rate • First 10 kg: X 4 ml/h • 2nd 10 kg (11-20 kg): X 2 ml/h • Thereafter (21 kg and up): 1 ml/h • Example: • What is the maintenance IV fluid rate (1X maintenance) for a child who weighs 35kg?