Peripheral IVs

1. Peripheral IVs

2. Pediatric Challenges • Smaller Veins • Active • Challenging • Need an assistant • All ages • Scared of shots

3. VASCULAR ACCESS DEVICE (VAD) SELECTION ALGORITHM Expected duration >1 month? NO YES Determine length of therapy and need for vascular access Determine length of therapy 0-5 days 7-30 days 1 month-1 year > 1 year Is Infusate appropriate for peripheral IV * Choose PICC, Tunneled CVC or Port (See Notes) Choose Tunneled CVC or Port (See Notes) • * Infusate appropriate for peripheral IV: • < 500 mOsm/L • pH 5-9 • Non irritant, non vesicant or vesicant YES NO Using assessment tool is there adequate vascular integrity? OTHER DECISIONS TO BE MADE WHEN SELECTING VAD: • Consider the need for single vs. multi-lumen CVC, and select the least number of lumens to deliver the required therapy. • Consider patient’s current and future setting; (i.e. Home Care?) • Select device that is least invasive, with lowest risk of complications, which will last the duration of therapy. • Device selection should consider input from the patient/family, safety, patient activity, comfort, body image and medical history. • Consider anticipated changes in patient’s medical status? • Is vascular access for nutrition only? If so, have enteral feeds been considered? YES NO Choose Peripheral IV and reassess daily* Choose PICC or Non-tunneled CVC Choose PICC *REMINDER: Discuss IV access on a daily basis during Family Centered Care Rounds.

4. Prepare Patient • Infant • Ask parent or someone familiar to assist during procedure if possible • During the procedure, provide patient with pacifier • Use soothing voice • Provide music

5. Prepare Patient • Toddler • Explain procedure in simple terms • Use medical play • Hold their hand • Allow to have their security item (toy, blanket) • Limit explanation to 10 minutes and prepare just before the procedure

6. Prepare Patient • Preschooler • Prepare just before • Show procedure on a doll first to lessen anxiety • Inform patient that it’s okay to cry, just don’t move • Count 1,2, 3…

7. Prepare Patient • School age • Make sure they understand which part of the body will be involved • Provide detailed explanation • Use a doll to show procedure or other medical play interventions • Allow to participate in small tasks during the procedure • Limit explanations to 20 minutes and prepare ahead of time

8. Prepare Patient • Adolescent • Provide detailed explanation • Use visuals during explanation and correct terminology • Allow time for discussion • If possible, allow them to choose when to begin the procedure • Allow them to help during the procedure

9. Preparing the Patient Additional Tips • Always have a helper to hold • Use family to help support/distract child • May need to mummy wrap active toddlers • Tell child to be brave, but that it’s OK to cry

10. Afterwards… • Rewards • Have stickers available after IV insertion. Kids love stickers!! • Cuddle infants after IV insertion • Have parents/siblings tell child how brave they were

11. Infants Hands Feet Scalp Toddlers Hands Feet Scalp only if <18 months School Age Hands Feet Adolescents Hands Arms Avoid feet IV Sites

12. IV Sites Digital Dorsal veins Dorsal Metacarpal veins Dorsal venous network Basilic vein Cephalic vein

13. IV Sites Cephalic vein Median Cubital vein Accessory Cephalic vein Basilic vein Cephalic vein Median antebrachial vein

14. IV Sites-Feet

15. IV Sites-Scalp

16. IV Sites • Tips • Use a tourniquet • Warm extremity • Tap/flick • Palpate with the same finger • Look at all extremities

17. Areas to Avoid • Red sclerotic veins • Blown veins • Areas of swelling or tenderness • Arteries • Infected lesions • Fistulas • AV shunts • Paralyzed extremities

18. IV Complications • Infiltration • Swelling • Pain • Cool to touch • Compare both extremities • IV pump will continue to run

19. Clinical Criteria >4kg Clinical Criteria >4kg

20. Interventions for Infiltration Do not immediately remove IV Stop infusion Elevate effected extremity Determine infusate If infusate is a vesicant, refer to Nursing Policy III-306  Monitoring and Management of Infiltration/Extravastion If infusate is not a vesicant, remove IV Notify physician Restart new IV if continued therapy is necessary Continue assessment of site and surrounding tissue, PRN

21. Check it HOURLY! • “The RN is responsible for observing the IV site for signs of infiltration at least hourly and notifying the physician for orders for all IV infiltrates or other delays related to IV therapy.” • II-101 Safe Administration of Parenteral Therapy, Including Drugs Given Via the Intrathecal Route –Pharmacy and Therapuetics Policy

22. IV Complications • Phlebitis • Pain • Red,tender • Heat, inflamed • Streaks along vein • Chances increase drastically after 3 days

24. IV Complications • Extravasations • Due to administration of vesicant substance

25. Interventions for Extravasation

26. IV Complications • Infection • Very important to use aseptic technique and using equipment right after removal from packaging

27. Other things… • A. Drawing blood from existing venous access may risk losing the IV access. • B.  Blood cultures can not be sent from any established peripheral line • III-203 Saline Well Guidelines/Blood Draw from an Established Venous Access

28. It is the CCHMC Policy… • “If the procedure on a patient is not successful after three (3) attempts, assistance and advice from a more experienced, qualified professional should be requested.”

29. IV Supplies 1. Select appropriate size steel needle or plastic cannula based on patient's size. 2.  Assemble equipment using aseptic technique. -   Steel needle or plastic cannula -   Normal saline flush -   Extension tubing -   Gauze pads -   Padded armboard -   Tape -   Protective cup for IV site -   Tourniquet -   Transparent dressing for cannula use -   Gloves -  Chlorhexadine swabstick (iodine for CHG sensitivity) • Equipment

30. What Size should I use? Sizes • 24g • Used for infants • Used for small short veins • 22g • Used for toddlers and school age • Good for obtaining blood

31. Sizes continued… • 20 g • Used for adolescents • 18 g • Used for large veins, large volumes, or trauma patients • Often placed in the O.R.

32. IV Catheters Types • AngioCaths • Must utilize safety needles • Abbocath • May still see these around • Do not have safety needle features

33. IV Insertion • Procedure • Prepare patient (consider patient’s developmental age when preparing for the procedure) • Prepare IV supplies • Select catheter size • Insert IV into patient • Monitor IV per policy

34. IV Insertion • Insertion directions • Prepare site, alcohol area for 20 seconds • Quick stick through skin • Direct method • Watch for blood return • Advance • Disconnect stylet • Flashback, then advance

35. IV Insertion • Use a 1” piece to secure t-connector • Keep site visible • Restrain board (not arm) • Use IV board (only if needed) • Right size • Small • Medium • Large • Padded

36. IV Insertion • Use minimal amount of tape • Use Securement Device • Sterile dressing • Must keep dry • Keep site visible • Allows you to • Catch injuries early • Gives you the ability to check site every hour and before medications

37. Policies to Check Out… • II-101 Safe Administration of Parenteral Therapy, Including Drugs Given Via the Intrathecal Route (Pharmacy and Therapuetics Policy Book) • III-301 IV Insertion (Nursing Policies, Procedures and Standards Manual) • III-203 Saline Well Guidelines/Blood Draw from an Established Venous Access (Nursing Policies, Procedures and Standards Manual) • III-306 Monitoring and Management of Infiltration/Extravasation

38. Key Points • Find out if patient is right or left handed • Encourage movement of fingers, can hold a pencil, do homework, toy, doll etc • Make sure tape is NOT too tight • Chart site check every hour

39. IV Key Points • Always have a person to hold • Use butterflies for quick in and out blood draws i.e. clinics • Use distal sites first • Tell patient what you are going to do before you do it

40. IV Key Points • Practice • Practice • Practice

41. Other ways to obtain blood… • Heel Stick • Finger Stick • Heel and Finger sticks: blood can be collected in a Capillary tube or the small microtainers • Butterfly Needles • 27, 25, 23, 21

42. SME Contact Information • Mary Hamilton • 6-4334 • mary.hamilton@cchmc.org