Peripheral Venous Catheter Insertion
Dot Point Summary
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ideally, the insertion of peripheral venous catheters should only be performed by a medical officer or registered nurse who has been accredited to do so
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a new (sterile) cannula should be used for each insertion attempt
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refer insertion to another member of staff after three (3) unsuccessful insertion attempts, if possible
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ideally cannulas should be replaced every 48-72 hours
Indications
Venous access for the administration of fluid (including glucose and parenteral nutrition), medications, blood or blood products.
Definition of terms
Asepsis is the prevention of microbial contamination of living tissues or sterile materials by removal, exclusion or destruction of micro-organisms.
No touch technique implies the use of sterile equipment, decontaminated hands and avoidance of surfaces or hands contacting exposed sterile equipment or sites. (This refers to the surfaces of sterile equipment that will come into contact with surfaces or sites that must remain uncontaminated to maintain asepsis). These procedures require
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gloves if contact with blood or body fluids is likely
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sterile equipment
Equipment
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clean trolley
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sterile gloves (use standard precautions for all procedures where contact with blood possible)
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basic dressing pack
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24g Optiva or Insyte Neonatal catheter
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blunt end drawing up needle
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10 ml ampoule of 0.9% Sodium Chloride
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2 x 2ml syringes containing 0.9% Sodium Chloride, one to flush cannula and one to prime extension set
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3-way stopcock (tap) if for continuous infusion
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skin antiseptic solution
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2% aqueous chlorhexidene for all peripheral IV's in infants < 1000 grams up to 14 days of age
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Persist-Plus (1%chlorhexidine in 70%ethanol) for all other IV's
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extension tubing
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tapes
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splint
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sterile occlusive dressing to cover the insertion point eg Tegaderm or IV3000
Technique
Compared with IV cannulation in adults, the veins in babies are smaller and, perhaps most importantly, poorly supported by surrounding soft tissue. Veins may suffer heavily during a prolonged stay in intensive care or special care and often veins that have been used previously need to be re-cannulated.
The first essential is to be methodical and to look. Get the baby where you can see and have access to all limbs while ensuring that he/she is warm and well oxygenated. Ensure that you have a good light. The standard light built into the radiant heaters is too flat and it is better to switch this off and to use an angled procedure light. Take time and look in all of the usual site s until you find the best available vein. This may take up to 2-5 minutes. The first acceptable vein is not usually the best. This process of taking a good long look should be repeated after every two attempts.
Look for a vein which
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runs straight
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fills and empties
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stands up a little
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is easy to splint
In sick or smaller babies, try to avoid, if possible, veins which are used for insertion of percutaneous central venous catheters
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saphenous at knee
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cubital fossa
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superficial temporal
Preferred Sites
1. Hand
Dorsal arch veins
Are best seen on the back of the hand but are usually larger and easier to enter just over the back of the wrist. Skin entry should be more distally. These veins can often be palpated in a larger infant rather better than they can be seen. IV's inserted here are easily splinted and any infiltration easily spotted, so are the preferred site.
Cephalic Vein, in anatomical snuffbox
This is often quite large, especially if the dorsal arch is well used. This vein can often be felt rather better than it can be seen and is one of the veins to try if one must do it "blind" in a large baby. The feeder veins over the dorsum of the hand in the first interspace need to be treated with respect, as it is possible to cannulate an artery here, risking loss of a thumb, or part thereof. (princeps pollicis artery). This is present in about 10% of infants. If present is usually the sole supply to thumb.
The cephalic vein is large and tends to last quite well. It is a good secondary site. It can also be used for insertion of percutaneous central venous catheters.
2. Wrist
Volar aspect
Veins are easily seen on the volar side of the wrist. They are usually quite small and fragile and, while easily cannulated, do not last well.
They are useful secondary sites, but must be carefully watched when noxious substances (eg Dopamine, Vancomycin) are infused, as they are prone to "burn".
3. Cubital Fossa
Median antecubital, Cephalic and Basilic veins
Are easy to hit and tend to last quite well if splinted properly. Median nerve and brachial artery are both vulnerable. These veins are the preferred sites for insertion of percutaneous central venous catheters. These should be avoided unless absolutely necessary in any infant likely to need long term IV therapy.
4. Foot
Dorsal arch
Are small, but easily cannulated and last surprisingly well. Vein on lateral aspect, running below malleolus, is easy of access but must be splinted carefully and watched for infiltration.
Veins leading up to short saphenous are often good value.
Saphenous vein, ankle
Runs reliably just anterior to medical malleolus and is large and straight. Easy to access and lasts well although not always readily visualised.
5. Leg
Saphenous vein. Knee
Runs just behind medial aspect of knee. Often visible both behind knee and as it curves around top of tibia. Access is easy and lasts well if properly splinted. However, this vein is a good site for the insertion of percutaneous central venous catheters and should be avoided if possible in any infant likely to need long term IV therapy.
6. Scalp
Superficial temporal
Runs anterior to ear and is accessible over a distance of 5-8 cm. in most babies. Is accessable and lasts well. However, this vein is a good site for the insertion of percutaneous central venous catheters and should be avoided if possible in any infant likely to need long term IV therapy.
One hazard is the proximity of the temporal artery, which runs beside it. In small infants it can be almost impossible to tell the difference, even when the catheter has been inserted. It is important to try to identify the vessels separately, by careful palpation and by observation in a good light (in the smaller infants one can see the artery pulsate). If the catheter is in an artery, it must be removed.
Posterior auricular
A moderate sized vein runs behind the ear and over the temporal bone. This vein and its branches are accessable and last quite well. There is a moderate risk of cannulating an artery in this area as well, so care must be taken.
Supratrochlear vein
This vein runs down from scalp over forehead and bridge of nose. It usually needs a shave of the hair to be accessible. Is quite easy to access and easily secured and lasts well.
The major drawback is that that the vein has anastomoses via the orbital plexus with the cavernous sinus. Thrombophlebitis of the vein has therefore a direct communication intracranially.
A further disadvantage is that any 'burn' caused by infiltration will be in the middle of the forehead. Because of these factors, it should only be used as a vein of last resort.
Scalp veins should only be used once other alternatives are exhausted. Most involve at least partial shaving of the head. Infants will take 6-12 months to grow hair back properly. This distresses parents and makes the baby look 'funny' for the first year or so.
Procedure
Ideally, the insertion of peripheral venous catheters should only be performed by a medical officer or registered nurse who has been accredited to do so.
Consider provision of pain relief consistent with the condition of the infant and the urgency of the procedure
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application of 0.5 -1g EMLA to proposed site 60-90 minutes prior to insertion
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oral sucrose
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non-pharmacological settling techniques
1. Set up IV trolley. Carefully wipe surface of trolley with solution provided (either isopropyl wipes or 1% chlorhexidene in 70% alcohol).
2. Place basic dressing pack onto clean IV trolley and open so that contents remain sterile (plastic covering can be flattened out to create sterile surface on trolley). Place additional sterile items onto this sterile surface.
3. Choose suitable vein.
4. Wash and dry hands thoroughly. Put on gloves.
5. Assemble equipment that has been opened onto the basic dressing pack.
6. Draw up 0.9% Sodium Chloride solution into 2 x 2ml syringes using drawing up needle.
7. Prime cannula and assembled equipment with 0.9% Sodium Chloride solution.
8. Swab skin with appropriate antiseptic solution swab. Allow skin to dry.
9. Ensure good light.
10. Tourniquet
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use a piece of gauze while your assistant immoblises the infant
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use your assistant's hand The usual mistake is to squeeze too hard, blocking off all circulation.
11. Pull skin taut. Identify vein and enter skin at an angle and away from the vein.
12. Once through skin, stop and reorient your needle tip and the vein. It is much easier if one advances directly over the vein, rather than from the side.
13. Aim to enter vein on a straight stretch.
14. Advance in a stop-start fashion once near vein.
(The flashback is often rather slow; it is easy to go straight through before knowing that one has hit anything). In very small infants or very bad veins one may not see blood return; only being aware of a slight change in resistance as the needle is advanced. If one waits a few seconds, blood sometimes appears, but do not rely on it. It may be necessary to try to advance the catheter without this confirmation.
15. When blood appears, stop. Check that needle is advancing on the line of the vein. Make any necessary correction.
16. Lift tip of needle slightly. Advance another 1-2mm. Check if bleeding into chamber continues. If so, needle tip is still in vein. Hold base of needle steady, push catheter off needle, either with other hand or index finger of right hand. Advance up vein as far as it will easily go.
If bleeding has stopped after initial small advance of catheter/needle unit, it is likely that the needle tip is out of the other side of the vein. There is a reasonable chance that the catheter tip is still within the vein. If needle is pulled back into the catheter there is a good chance that you will see blood coming up the catheter. If so, attempt to advance the catheter up the vein, leaving the needle in the catheter, but pulled back a little, to stiffen it. You have about a 50% chance of successfully feeding it up.
17. Release tourniquet. Syringe with 0.9% Normal Saline to check patency. If catheter has not been able to be advanced fully, syringing may also help to advance it further up the vein.
18. Remove any blood spills near insertion site before strapping.
19. Without touching the insertion site, apply a piece of Tegaderm over the hub of the catheter and its insertion site. Use 2 Vee tapes around the end of the hub of catheter (sterilised micropore tape is contained in the IV starter pack) over the Tegaderm.
20. Attach extension tubing and 3-way tap, securing luerlocks.
21. Splint. Shape splint to limb and immobilise joint above insertion (use smallest possible and avoid pressure areas). Tape loosely at top and over fingers. A little more firmly over the hub of the catheter. If necessary place a piece of gauze/telfar between the hub and the skin so as to avoid a pressure area. Fingers/toes must be visible, as must the area around the catheter tip.
22. For every additional attempt begin from step 1. Avoid the temptation to use partly clean equipment. It is best for the infant that with every attempt strict precautions are taken to reduce the risk of infection.
N.B. A new cannula is required for each insertion attempt
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if contamination occurs during the procedure, discard the contaminated equipment and don another pair of gloves
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refer insertion to another member of staff after 3 unsuccessful insertion attempts
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discard dressing pack and contaminated equipment if it becomes heavily contaminated due to multiple insertion attempts. Transfer uncontaminated tubing to new dressing pack.
Potential complications
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phlebitis
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cellulitis
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sepsis
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tissue necrosis
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air embolus (incorrect priming)
The likelihood of phlebitis and sepsis secondary to IV cannulas can be reduced by electively resiting the cannula every 48-72 hours. This will depend to some extent on the availability of other sites. If this approach is adopted, it is important to ensure that the new (replacement) IV cannula is in situ and functioning before the old one is removed (especially if the baby is nil orally and/or dependent on IV glucose to maintain glucose homeostasis).
References
Royal Women's Hospital (Melbourne, Victoria) Policy and Procedure Manual - Policy number 9W-04-2-049
Mercy Hospital for Women (Melbourne, Victoria) Procedure Manual, 3rd Edition
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