A & P of Peripheral Veins http://emprocedures.com/peripheralIV/introduction.htm

1. A & P of Peripheral Veinshttp://emprocedures.com/peripheralIV/introduction.htm Successful cannulation of a peripheral vein requires proper site selection, as well as knowledge of the gross anatomy of a vein.

2. Anatomy of a Vein • Anatomy of a VeinPotential IV Sites • Anatomy of a Vein Veins are thin walled-structures that lack the thick, circumferential smooth muscular layer that is present in arteries. As such, peripheral veins may collapse and may be difficult to cannulate (or even locate) in patients with hypovolemia, low blood pressure, . Common causes of hypovolemia? • Venous return to the heart is dependent upon contraction of regional skeletal muscle (e.g. the gastrocnemius and soleus in the lower leg.) Additionally, many veins contain valves that prevent retrograde flow of blood. ( Moore, KL) If the intravenous catheter abuts one of these valves, flow of intravenous solution may be occluded. (Similiarly, valves can interfere with phlebotomy.) Client is “valvey”

3. Artery vs. Vein

4. General Concepts • The identification of the optimal site involves both visual and tactile exploration. The vein may be visible as a blue-green subcutaneous structure. It may “pop out” as it engorges with blood or merely be palpable as a springy canal coursing between the soft tissues. Given the wide variation in anatomic location of superificial veins, purely "blind" attempts, without visual or palpable landmarks, are highly unlikely to be successful and should be discouraged except in emergent situations. • Ideally target a good sized vein with a straight segment at least the length of the catheter. For elective placement, site consideration should include: • Ease of access • Use of the non-dominant extremity • Avoiding joint areas • Avoiding use of the lower extremities

5. Contraindications:

6. Upper ExtremityIn most situations, intravenous catheters are inserted in the antecubital fossa, the forearm, the wrist, or the dorsum of the hand. • The three main veins of the antecubital fossa (the cephalic, basilic, and median cubital) are frequently used. These veins are usually large, easy to find, and accomodating of larger IV catheters. Thus, they are ideal sites when large amounts of fluids must be administered. However, their location in a flexor region is a drawback, as bending of the elbow can be uncomfortable to the patient and may occlude the flow of the intravenous solution. Cannulation of the cephalic, basilic, or other unnamed veins of the forearm is preferrable

7. Veins of the forearm

8. Veins of the hand • The veins in the dorsal hand may be utilized if large bore access (18 gauge or larger) is not required. Care must be taken to find a vein that is straight and will accept the entire length of the catheter. • The portion of the cephalic vein in the region of the radial styloid is commonly known as the "student's" or "intern's" vein, as it is often a large, straight vein that is easy to cannulate

9. Veins of the hand

10. Veins of the feet • Cannulation of the veins of the feet is not ideal. ***ADD REFERENCES*** Insertion can be quite painful, and the catheter may cause more discomfort than if it were started in the hand or forearm. Additionally, IV catheters placed in the feet are more likely to become infected, to not flow properly, and are more likely to produce phlebitis. • The great saphenous vein runs anteriorly to the medial malleolus, and may be accessed via a peripheral venous cutdown in emergent situations. The lesser saphenous vein runs along the lateral aspect of the foot. These two veins converge medially to form the dorsal venous arch. There are numerous unnamed vessels that are branches of these veins. (Clemente) Any vein in the foot large enough to accept the IV catheter may be used if necessary.

11. Veins of the feet

12. External Jugular Not to be cannulated by LPN • The external jugular ("EJ") vein can be cannulated if necessary. It orginates near the angle of the mandible, and courses over the sternocleidomastiod muscle. Proximal to the clavicle, the EJ dives into the subcutaneous tissue, eventually emptying into the subclavian vein. (Moore) • The EJ is a large vein that can accomodate a large bore IV catheter (18 gauge or larger), in most patients. It is especially useful in patients with poor access in the arms who require a large volume of fluid. Additionally, the EJ is often engorged in patients with heart failure and provides an alternative in these patients if other venous access sites are not available. Please refer to the Alternatives section for further discussion on utilizing the external jugular vein

13. External Jugular Vein

14. A little bit of info • Peripheral intravenous (IV) catheter placement and phlebotomy are arguably the most commonly performed procedures in medicine, performed on over 25 million patients each year in US hospitals. (Soifer 1998). This skill should be a part of the basic skill set of any health care provider. Phlebotomy is simply drawing blood. IV catheterization allows blood sampling as well as ongoing direct access into the circulating bloodstream. The fundamental techniques are the same. As commonplace as these procedures are, however, they are not entirely without complications, local and systemic.

15. Your patient needs an iv now what • You need a doctor’s order for IV fluids and placement. • Order must contain: date/time, infusate name, route of administration, volume to be infused, rate of infusion, duration of infusion, physical signature. • Never place an IV into the arm of a patient with a AV fistula or graft. • Avoid extremities which are flaccid or contracted • Avoid the arms on the side of recent mastectomy or axillary nodal removal

16. For IV site selection consider the following • Primary medical diagnosis • Chronic diseased that increase complication • Type of solution and duration of treatment being ordered. • Any past history of vasovagal reactions • Fragile/rolling veins • Patients prior iv experience • Condition of vein Avoid areas which are: bruised, red and swollen, veins near infected areas, sites near previous dc’d IV’s

17. Always try to be prepared • In French, and in cooking, this means to lay out all of your expected ingredients and equipment ahead of time, prepared and within reach. It is often beneficial to have a selection of IV catheters available as well as extra blood tubes, tape, etc., should additional supplies be required.

18. Predicting difficult access • Difficult Access • Conditions that may predict difficult access include: • Dehydration/intravascular depletion • Chronic illness with venous scarring from frequent IV access • IV drug use with venous scarring • Obesity • Significant edema • Tortuous, fragile vessels due to advanced age • Thin vessel walls due to age, steroid use, certain disease conditions • When presented with these situations, using the vasodilating techniques below may facilitate cannulation. If you are unsuccessful, Alternative Techniques may be required.

19. Dependent position

20. Preparation of client • Before Anything Else do an Assessment • Determine the following: • The type and amount of solution to be infused • The exact amount (dose) of any medications to be added to a compatible solution • The rate of flow or the time over which the infusion is to be completed • Assess for any allergies (e.g., to tape or povidone-iodine)

21. Make sure you know why they are receiving the IV • Purposes of Intravenous Therapy • To supply fluid when clients are unable to take in an adequate volume of fluids by mouth • To provide salts and other electrolytes needed to maintain electrolyte imbalance • To provide glucose (dextrose), the main fuel for metabolism • To provide water-soluble vitamins and medications • To establish a lifeline for rapidly needed medications.

22. Gather the equipment • Prior to beginning the procedure, gather all the required equipment. Once the cannula has been inserted, it will be attached to a connecting tubing. This can be flushed with saline and secured to the arm without intravenous fluids attached (i.e. a "saline lock".) If IV fluids are going to be infused, the bag of fluid will need to be attached to IV tubing (a "drip set") prior to the procedure

23. Obtain the following • Assess the following: • Vital signs for baseline data • Skin turgor • Allergy to latex, tape or iodine • Bleeding tendencies • Disease or injury to extremities • Status of veins to determine appropriate venipuncture site

24. WIPE • Preparation: • Introduce self and verify the client’s identity. • Explain the procedure to the client. A venipuncture can cause discomfort for a few seconds, but there should be no discomforts while the solution is flowing. • Use a doll to demonstrate for children and explain the procedure to the parents.

25. Prepare the patient • Explain the procedure to the patient. Tell the patient that the procedure may be mildy painful, but is brief. Ask that he / she hold the extemity completely still until the completion of the cannulation. Take time to answer any questions that the patient might have. • The patient should be laying in the bed, with the opposite bed rail up, to prevent injury should the patient faint during the procedure.

26. Site Selection • Select the venipuncture site • a. Use the client’s nondominant arm, unless contraindicated. • b. Identify possible venipuncture sites by looking for veins that are relatively straight, not sclerotic or tortuous, and avoid venous valves. • c. The vein should be palpable, but may not be visible, especially in clients with dark skin. • d. Consider the catheter length; look for a site sufficiently distal to the wrist or elbow that the tip of the catheter will not be at a point of flexion. • e. Check agency protocol about shaving. • f. Place a towel or bed protector under the extremity to protect linens.

28. Site prep and tourniquet • After selecting the site of insertion, a tourniquet should be applied to the extemity. This should be placed tight enough to engorge the vein, but not so tight that it causes the patient undue pain. If the vein fails to engorge, the extremity should be held in a dependent fashion, or warmed, as detailed in the Preparation section. The site should then be cleansed with an alcohol prep or povidone iodine swab. Use a circular motion, working your ways outwards from the site. Is alcohol is used, a moderate amount of friction should be applied, and the area should be rubbed for 60 seconds. A quick swipe is simply not effective. If iodine is to be used, it should be applied and allowed to dry for at least 30 seconds, and then wiped cleaned with an alcohol prep.

29. Patient Positioning for success • As with any procedure, positioning of both the patient and the performer should be optimized. The patient should be seated or in a reclining position for comfort and safety. Immobilize the extremity, particularly for pediatric or uncooperative patients. Keep the extremity in full extension to make the vein taut, and place the intended cannulation site in a dependant position to engorge the vein.

30. Dependent position

31. Lenhardt and associates showed in a randomized trial that actively warming patient's hands with a warming mitt prior to cannulation reduced the time needed to complete the procedure and increased success rates. (Lenhardt, 2002) While these warming mitts will not likely be available at your institution, cheap and conveinent alternatives (such as having the patient hold the hand in a bowl of warm water, or applying a warm towel will likley have the same effect.

32. Air embolism • While it is classically taught that 5 ml / kg of air is needed to produce an "air lock" of the right ventricle and pulmonary artery, circulatory collapse has been reported with as little as 20cc of air. Should signicant air embolization occur, the patient should be placed in a left lateral recumbent position to trap the air in the right atrium. Available interventions include aspiration via a central venous catheter, hyperbaric treatment, and in severe cases, thoractomy. (Feied 2002) • To prevent air embolism, all tubing should be flushed prior to utilization. Additionally, all connections must be tight, and fluid bags should not be allowed to completely empty before replacement. If this occurs, the line should be removed from the catheter and re-flushed.