The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Intravenous Catheterization

by Josh Ivker

• Allows the sampling of venous blood for diagnosis of electrolyte imbalances, infection, malignancy, other disease states, drug levels, etc.
  
• Allows access to venous circulation for the administration of nutrients, drugs or fluids
  
• Performed as a precaution on all patients in unstable or life threatening conditions.

Contraindications
Locations to avoid IV placement

• Extremities with massive edema, bums, traumatic injury, sclerosis, phlebitis, or thrombosis,, as circulation may be compromised or occluded in these areas
  
• Ipsilateral arm to mastectomy, neck trauma, indwelling fistula
  
• Vein that may be compromised due to trauma located proximally
  
• Areas affected by cellulitis, as penetration into area may seed the central circulation with bacteria

Limitations

• Any solution that is irritating or hypertonic should be administered via a central line
  
• This is also true of prolonged administration of nutrition
  
• In general, solutions that are injected / dripped into an IV should be clear. Notable exception is propofol (Diprivan) a.k.a. "milk of anesthesia".

Equipment

• Iodine swabs
  
• Alcohol swabs
  
• Gauze
  
• Antibiotic ointment or film barrier
  
• Tourniquet, rubber strap or tubing
  
• Blood pressure cuff inflated to 10-15mm of pressure below systolic pressure
  
• Intravenous catheters: Adult 20g, 18g, 16g: Pediatric 24g, 22g
  
• Tape
  
• Latex gloves
  
• Arm board (if immobilization of extremity is necessary)

Preparation

• Explain [what you are going to do, and why you are going to do it, to the patient prior to performing the procedure (if time and circumstances allow)]
  
• Before beginning procedure have all equipment assembled and easily accessible as this procedure is often done by a lone practitioner
  
• Always employ universal precautions when contact with bodily fluids is possible

Procedure

1. Assembly of IV infusion
   
   • Close regulating clamp on tubing; insert spiked end of
     tubing into the receptacle on the bottom of the infusion bag then invert bag
     
   • Squeeze drip chamber in the tubing assembly to fill it halfway with fluid; then open the regulating clamp to flush all air out of the tubing
     
2. For Heparin Lock
   Flush tubing with Heparin or saline solution prior to
   attaching to catheter in vein
   
3. Place tourniquet 3-4 cm above insertion sight; tourniquet should restrict venous return without impairing arterial circulation; to assure arterial patency check for a distal pulse.
   
4. Choose a vein that is straight, large and easily accessible if at all possible. Beware of tortuous areas (how will you thread the catheter?) One tip is to insert just proximal to a branch point; the vein tends to be bigger and rolls less.
   
5. The most distal vein accessible should be selected first if several sites are available; this allows the use of more proximal sites if the initial attempt is unsuccessful and avoids fluid leakage from previous puncture sites
   
6. If the vein is inapparent, have the patient tense, then relax local muscles repeatedly to increase blood flow to the area, apply a warm compress to the area, or tap sharply over the vein to induce reflexive vasodilatation. Use your sense of touch to feel the vein as well as look at it. Sometimes this will be the only landmark you will have.
   
7. Swab insertion site with Iodine swab with a circular motion starting from the center and working outward for 4-5 cm; repeat with alcohol swabs
   
8. With your non-dominant hand, pull skin taut to stabilize the vein. Do not contaminate the needle or catheter by touching it.
   
9. Puncture the skin rapidly with the catheter needle bevel up at a 30' angle directly over the vein; once in the subcutaneous space, level off the angle of insertion approaching a position nearly parallel with skin surface
   
10. Advance needle until blood is seen in the flash chamber of the catheter; a pop may be felt upon entering the vein. Once you feel the pop, advance slightly (1 mm) further to ensure you are completely in the vein.
    
11. Advance the catheter over the needle to the hub of the catheter; apply pressure proximally over the catheter tip and remove the needle
    
12. Blood samples may be taken at this time, or Hep lock or IV tubing assembly can be attached
    
13. Antibiotic ointment can be applied to the insertion site then cover the site with gauze or a clear film dressing
    
14. Tape the hub of the catheter and the IV tubing to the skin to secure placement; often a loop of tubing is made and taped down to avoid dislodging the
    catheter if the tubing is accidentally pulled

Complications

• Valve obstruction; if catheter will not advance after blood enters the flash chamber, a valve may be obstructing catheter advancement; begin flow of saline through the tubing and attempt to advance catheter; if localized swelling occurs, discontinue immediately
  
• Bruising at or near the insertion site or hematoma formation; due to extravasated blood, possibly from the puncture of the veins' posterior wall
  
• Cellulitis, phlebitis, localized tissue necrosis; if extravasated fluid is irritating or hypertonic then tissue damage may occur. Phlebitis may also occur if irritating fluid remains in the vessel
  
• Nerve, tendon, or arterial damage due to direct injury from the needle or from compression by localized hematoma and/or swelling
  
• Localized infection, or sepsis due to introduction of bacteria at the site and into the circulation
  
• Air embolism; the introduction of air into the central circulation; rarely occurs in a peripheral line

Follow Up

• Insertion site should be checked periodically for localize swelling, irritation, or pain; if any of these are present, remove the catheter and start another IV in a different site
  
• Peripheral catheters should be changed at least every three days to reduce the risk of complications (most notably, infection); all intravenous access sites should be dated and timed, or documentation of such placed within the patient's record