Peripheral IVs

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

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) YES NO * Infusate appropriate for peripheral IV: < 500 mOsm/L pH 5-9 Non irritant, non vesicant or vesicant 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.

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

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

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…

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

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

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

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

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

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

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

IV Sites-Feet

IV Sites-Scalp

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

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

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

Clinical Criteria <4kg Clinical Criteria >4kg Grade Clinical Criteria <4kg Clinical Criteria >4kg No symptoms 1 Skin blanched Edema <1CM in any direction Cool to touch With or without pain Edema <2.5 CM in any direction 2 Edema 1-4 CM in any direction Edema 2.5-15 CM in any direction 3 Skin blanched, translucent Gross edema >4 CM in any direction Mild –moderate pain Gross edema >15 CM in any direction Possible numbness 4 Skin tight, leaking or with blistering Skin discolored bruised, swollen Deep pitting tissue edema Circulatory impairment Moderate to severe pain Infiltration of any blood product, irritant, or vesicant.

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

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

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

Grade Clinical Criteria No symptoms 1 Erythema at access site with or without pain 2 Pain at access site with erythema and/or edema 3 Streak formation Palpable venous cord 4 Palpable venous cord >2.5 CM in length Purulent drainage

IV Complications Extravasations Due to administration of vesicant substance

Interventions for Extravasation Extravasated drug Intervention Hyperosomotic solutions (>600 mosm/1) Calcium gluconate/chloride Dextrose> 10% Parenteral Nutrition Potassium> 40meq/1 Radio contrast Media Antidote Hyaluronidase is used to treat extravasations by promoting the drug’s diffusion throughout the tissue bed and increasing its rate of absorption, especially when combine with the use of warm compresses. Apply warm pack to aid drug absorption Nafcillin Penicillin Rifampin Vancomycin Acyclovir Aminophylline Digoxin Valium Mannitol (Antidote:Hyaluronidase) Apply warm pack to aid drug absorption. Sympathomimetics Dopamine Epinephrine Norepinephrine Phenylephrine Vasopressin Antidote: Phentolamine – May cause excessive vasodilation. If Necrosis present Contact Attending physician

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

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

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.”

IV Supplies Equipment 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)

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

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

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

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

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

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

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

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

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

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

IV Key Points Practice

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

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