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Emergency Medicine and Critical Care

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Peripheral Venous Cannulation



In the emergency department, there is a need to deliver: antibiotics for acute infections and sepsis, fluids for patients who are dehydrated, and medications to treat cardiac problems and arrhythmias. And peripheral intravenous access is one of the safest and easiest ways to give patients these treatments.

A majority of IV lines are placed in the superficially located veins of the upper extremities extending from the upper arm to the hand. IV lines may also be placed in the lower extremities. However, caution is advised in patients with a history of diabetes and/or poor peripheral circulation.

The video will begin by outlining the preparation needed for the IV placement procedure. It will then move onto the steps for catheter insertion and conclude by explaining how to effectively flush the IV line.

First, obtain the necessary supplies for the procedure which include: non-sterile gloves, a rubber tourniquet, chlorhexidine or alcohol swabs, combined catheter and needle mechanism, IV set of tubing and bags, adhesive tape, 2x2 or 4x4 inch gauze, normal saline 5 milliliter syringe and 10 milliliter syringes for blood samples.

Next, familiarize yourself with the combined catheter and needle mechanism. Catheters are packaged pre-threaded over needles and many have a safety mechanism in place, which will automatically retract the needle to prevent sharps exposure. When placing the IV, the catheter and needle are inserted together. The catheter is advanced and the needle is withdrawn.

Catheter selection is based on the patient and the reason for IV therapy. Catheter size ranges from 14 gauge to 24 gauge. You may select a 14 to 16 gauge catheter if the patient requires large amounts of fluid or blood. Be sure to have a few different size catheters available, patient vein size is difficult to predict.

Next, wash your hands thoroughly and put on a pair of non-sterile gloves. Then discuss the procedure with the patient.

When the patient is comfortable, position them with the arm extended and straight. Then place a tourniquet on the upper portion of the arm and tie it tightly by crossing the ends over each other and tucking in one of the ends rather than making a knot. This method will ensure that the tourniquet can be easily removed after the vein has been accessed.

Next, choose an insertion site, which may be the most challenging portion of the procedure. Start the palpation in the antecubital fossa, where vessels are largest, and then work your way down the arm. Feel for a vein by palpating for a "squishy" or "springy" area on the patients arm. Look for a vein by inspecting the patient's skin. Veins appear blue or gray. If no vessel is identified in the antecubital fossa, work your way more distally to look for a vessel. You may need to reapply the tourniquet on the forearm for placement of an IV in the hand. Since all patients have different anatomies and varying medical histories, the best vessel for catheter placement will be different.

Once the vein is selected, use a chlorhexidine skin prep or alcohol swab to thoroughly clean a broad area around the vein. This is to reduce the rate of infection. Allow the skin to dry completely.

Now let's review the catheter placement procedure.

Using your non-dominant hand, pull the patient's skin taut from the inferior-distal portion of the insertion site. This is done in order to prevent the vein from "rolling" or moving during the procedure. Next, remove the cannula cover and insert the needle at a 45 degree angle to the skin with the bevel facing up. Insert it slowly to prevent penetrating the vessel. There will be some resistance when poking the needle through the patient's skin.

After, the needle is inserted into the patient's skin, observe the hub of the needle for a "flash" of the patient's blood. Once the "flash" of patient blood is observed, advance the needle a few more millimeters into the patient's vein. Then slightly lower the needle-catheter mechanism and begin to advance the catheter portion. Reducing the angle of insertion is performed to prevent puncturing the posterior wall of the vessel. Next, advance the plastic catheter fully into the vessel while holding the needle still. Remove the tourniquet from the patient. Then place gauze underneath the hub of the catheter to prevent blood spilling from the vein. Apply gentle pressure on the proximal portion of the catheter in the patient's vessel and carefully remove the needle. Immediately place the needle in the sharps container.

Next, place the tubing hookup on the hub of the needle and remove the pressure from the proximal portion of the catheter. Now attach the saline flush syringe to the end of the tubing. Next, draw blood back from the catheter by pulling on the plunger of the flush. Fill the entire tubing hookup with blood. If the patient is experiencing no pain and one is able to draw blood back from the catheter, the catheter is in the correct location. Then flush the saline into the catheter. Lastly, palpate the insertion site for swelling and ask the patient if they experienced any pain associated with the flush. Finally, secure the peripheral IV line to the patient's skin with clear dressing and tape. Adequately securing the line prevents it from becoming dislodged with patient movement. Additional tape or an arm board may be necessary for diaphoretic or pediatric patients.

If the patient is experiencing pain and blood cannot be drawn back from the catheter, the catheter may not be in the correct location within the lumen of the vein. The line should be further examined and assessed. If deemed necessary, remove catheter and begin the process over again at a different insertion site.

Effectively placing an IV in a patient is imperative to treat many common medical problems. Common learner errors include not being prepared with all the supplies prior to starting the procedure and poor vein selection. Anecdotally, being able to "feel" the vein, is more important than visualizing a vein. However, many learners will try and place an IV based on what they can "see". This is truly a procedure that is perfected with practice and patience. Take advantage of opportunities to place IVs in as many patients as possible to master the basics.

You have just watched a JoVE video detailing the steps necessary to place an IV catheter into a patient, which is one of the key procedures in medicine. As always, thanks for watching!

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