1. Peripheral IVs

2. Pediatric Challenges Scared of shots 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)
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.

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

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
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 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.

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

23. 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

24. IV Complications Extravasations
Due to administration of vesicant substance

25. 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

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
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)

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 Abbocath Must utilize safety needles
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

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