Peripheral Venous Access

Indications

Peripheral IVs are used to:

• administer medications, IV fluids, blood, or parenteral nutrition
• maintain access for the above in a potentially unstable patient
• sample venous blood (when necessary)

Contraindications

The following contraindications all relate to the site chosen rather than the procedure itself.

• existing skin infection in intended IV site
• venous thrombosis proximal to intended site
• arterial-venous shunt (i.e. for hemodialysis) in extremity
• lymphatic obstruction (i.e. following axillary node dissection) in extremity

Choosing Catheter Size

Teflon/Plastic catheters are the most common type of catheter used. They range in size from 14 - 25g.

• 22-25g - pediatric applications or occasionally in adults with very small veins
• 20g - standard, multipurpose adult IV
• 18g - suitable for higher flow rates in adults and for routine administration of blood products
• 14 - 16g - large (painful) catheters reserved for situations where volume resuscitation is needed or anticipated. i.e. hypovolemic shock, GI bleeding, Some preoperative surgical cases

Butterfly Catheters are generally used only in pediatrics and for very short-term venous access, as they tend to perforate veins easily and are more prone to infection. Sizes 20 - 25g.

Safety IV catheter systems are increasingly used to reduce needle stick injuries by encasing the entire needle within a guard.

Choosing the Site

Upper extremities are generally preferred to lower as they are more convenient for staff and patient and pose lesser risk of infection, phlebitis and deep vein thrombosis.

Preferred sites are dorsal hand and volar forearm, in the non-dominant arm if possible. Try to pick a long straight section of vein or a bifurcation. Start as far distal on the arm as possible - if you miss you can try more proximally without getting leaks from previous sites.

If the IV is being placed to resuscitate a patient, veins within the antecubital fossa (the inside of the elbow) should be considered, given their relatively bigger size.

Sites to Avoid

• joints - more difficult to stop the IV from kinking or infiltrating when the joint is flexed
• infected skin/cellulitis - for obvious reasons.
• extremities with arteriovenous fistulas (ie hemodialysis patients)
• traumatized extremities - veins may be interrupted or occluded proximally
• extremities with venous insufficiency i.e. post mastectomy
• paretic limbs i.e. stroke, spinal cord injury

Materials Required

• povidone - Iodine Swabs
• alcohol Swabs
• tourniquet - Velcro, Elastic or BP Cuff
• IV Catheter (Hopefully just one)
• normal saline Lock
• 10 cc syringe with normal saline for flushing
• tape
• transparent Dressing (i.e. Tegaderm, Opsite)
• gloves
• IV infusion setup
• local Anaesthetic i.e. 1 - 2 % Plain Xylocaine in Tuberculin Syringe
• incontinence Pad - for under the patient’s arm so the area nurse won’t curse you
• incontinence Pad - for yourself if first try with an IV (Optional)

Accessing the Vein

Explain the procedure to the patient and why it is necessary- obtain verbal consent.

Get everything ready - open packages, tear your pieces of tape etc.

minimal standard (Universal) precautions for IV starts is gloves.

Ensure the patient is comfortable - lying or sitting.

Prepare normal saline lock by cleaning the port with an alcohol swab and priming it with sterile normal saline flush solution. Leave the saline flush syringe attached.

Apply the tourniquet 5 - 10 cm proximal to the chosen site. If using a BP cuff inflate it to ~ 15 mm Hg below arterial systolic pressure.

Prep the skin with Povidone - Iodine starting over the site and circling outwards. Follow this with an alcohol swab in the same fashion. If you choose to use local anaesthesia, raise a small intradermal weal of Xylocaine over the site.

Using your non-dominant hand, hold the patient’s extremity and gently pull the skin taught over the vein. Using the safety IV catheter insert the needle bevel upwards, parallel to the skin surface.

Push the needle into the vein until you feel a pop and blood appears in the flash chamber of the IV Cannula. While holding the needle stationary, advance the cannula into the vein by placing the forefinger of your dominate hand, or the thumb of your non dominate hand, against the push-off tab. Pull the needle back into the needle guard until it clicks.

The needle is now encased in the needle guard to help prevent needle stick injuries.

Remove the tourniquet from the patient's arm.

Attach the primed Normal Saline lock and flush it with 1-3 mls of Normal saline flush solution using the positive pressure technique (the saline injected via a syringe at the same time as the syringe is being removed).

Cover the site with a sterile transparent dressing.

Swab the top of the Normal saline lock again and connect the primed IV tubing. Observe for fluid flow and continue to watch for swelling.

Tape the tubing in place. Properly dispose of sharps, gloves etc