EXPLAIN THE PROCEDURE

Explain the procedure to the patient. Tell the patient that the procedure may be
mildy painful, but is brief. Ask that he / she hold the extemity completely still until
the completion of the cannulation. Take time to answer any questions that the
patient might have.
The patient should be laying in the bed, with the opposite bed rail up, to prevent
injury should the patient faint during the procedure.
GATHER YOUR EQUIPMENT
Prior to beginning the procedure, gather all the required equipment. Once the
cannula has been inserted, it will be attached to a connecting tubing. This can be
flushed with saline and secured to the arm without intravenous fluids attached (i.e. a
"saline lock".) If IV fluids are going to be infused, the bag of fluid will need to be
attached to IV tubing (a "drip set") prior to the procedure.

To "spike" the IV bag, first remove the plug from the bottom of the bag. Next,
remove the protective cap from the end of the IV tubing, and firmly insert the sharp
spike into the bag. Squeeze the drip chamber with your fingers until it is halfway full
of fluid. Finally, open all clamps and allow the solution to course the tubing, flushing
all air out of the line. Once this is done, tighten the regulating clamp again.

PREPARE THE PATIENT

After selecting the site of insertion, a tourniquet should be applied to the extemity.
This should be placed tight enough to engorge the vein, but not so tight that it
causes the patient undue pain. If the vein fails to engorge, the extremity should be
held in a dependent fashion, or warmed, as detailed in the Preparation section.
The site should then be cleansed with an alcohol prep or povidone iodine swab. Use a
circular motion, working your ways outwards from the site.
Is alcohol is used, a moderate amount of friction should be applied, and the area
should be rubbed for 60 seconds. A quick swipe is simply not effective. If iodine is to
be used, it should be applied and allowed to dry for at least 30 seconds, and then
wiped cleaned with an alcohol prep. (Weinstein 2001)
INSERT AND ADVANCE CATHETER
1. Apply distal traction to the vein by using your non-dominant thumb. This is an imporant
point that is often overlooked. Traction stabilizes the vein and prevents it from "rolling"
during the insertion sequence.
2. The angiocatheter is gripped between the thumb and middle finger of the dominant
hand.
3. The needle is inserted bevel-up. The initial angle of entry should be approximately 15-
30 degrees.
4. Successful entry into the vessel is indicated by return of blood into the flash chamber.
5. LOWER THE ANGLE OF THE ANGIOCATHETER, SO THAT THE CATHETER CAN BE
ADVANCED IN A PLANE AS CLOSE TO PARALLEL TO THE VEIN AS POSSIBLE. THIS
PREVENTS THE CATHETER FROM PENETRATING THE POSTERIOR WALL OF THE VEIN
AND INFILTRATION OF THE IV.

6. HOLDING THE HUB OF THE PLASTIC CATHETER WITH YOUR INDEX FINGER, THE
NEEDLE IS WITHDRAWN SEVERAL MILLIMETERS. THIS COVERS THE TIP OF THE NEEDLE
WITH THE PLASTIC CATHETER, WHICH ALSO GUARDS AGAINST PUNCTURING THE
POSTERIOR WALL OF THE VEIN.

7. THE CATHETER IS PUSHED OVER THE NEEDLE WITH THE INDEX FINGER, UNTIL THE
HUB OF THE CATHETER ABUTS THE SKIN.

TWO POINTS DESERVE SPECIAL CONSIDERATION. FIRST, IT IS THE PLASTIC CATHETER,

NOT THE NEEDLE, THAT SHOULD BE ADVANCED INTO THE VEIN. IF THE SHARP TIP OF
THE NEEDLE IS THE LEADING POINT, VESSEL INJURY AND RESULTANT INFILTRATION IS
LIKELY. SECONDLY, THE CATHETER SHOULD NEVER BE FORCED INTO THE VEIN. IF
RESISTANCE IS MET, DO NOT ADVANCE THE CATHETER, AND CONSIDER ONE OF THE
TROUBLESHOOTING MEASURES LISTED BELOW.
ATTACH TUBING / PHLEBOTOMY / FLUSH
1. Once the catheter is fully advanced, the traction can be released. Then, use the thumb
and index finger of your non-dominant hand to hold the hub of the catheter. The other
fingers are used to tamponade the vein, just beyond the tip of the catheter, to prevent
blood from leaking out.

2. Remove the needle, and retract the needle (if it is so equipped.)

3. Attach the connecting tubing and apply a dressing (e.g. Tegaderm; tape may also be
used.)
4. Blood may drawn at this point by attaching a vacutainer to the connecting tubing.
(Please refer to the Phlebotomy chapter for further details.) Remember, if you are
planning on drawing blood, the connector tubing should NOT be pre-flushed with saline to
prevent dilution of the sample.

5. Remove the tourniquet.

5. Flush the line with normal saline. If the line does not flush easily, it may not be patent
or may have infiltrated. See the troubleshooting section below for measures that may be
tried.

FINAL STEPS
1. Tape the connecting tubing to the skin. A loop ("U" shape) should be incorporated to
prevent any tension placed on the line from pulling out the catheter.

2. IV fluids may be attached to the connecting tubing, if desired.

3. Carefully throw all sharps away in an approved sharps bucket or box.

TROUBLESHOOTING
Confirmation of Placement
Proper IV placement is confirmed by a smooth saline flush without evidence of
extravasation into the subcutaneous tissues. The ability to draw blood provides further
confimation but is not a requirement since blood flow may be obstructed by a valve or
from vein collapse due to suction.

Infiltration
Infiltration occurs when the vein is damaged during insertion and the infused fluid flows
into the subcutaneous tissues instead of the vein. Infiltration has occured if a
subcutaneous mass occurs during flushing or infusion of fluids; also, the line will be hard
to flush and / or fluid from an IV bag will not flow. If infiltration occurs, the catheter must
be removed and another attempt should be pursued. Refer to the Complications section
for more information on cofirmation of placement and infiltration.
Inability to advance catheter
Occasionally it will be difficult to advance the catheter into the vein, despite a good
flashback of blood during initial venepuncture. This can occur due to a venous valve, or to
a tortuous vein. The catheter should never be forced into the vein, and this is likely to
damage the vessel and cause infiltration. Several tricks are available in this situation:
 Vary the amount of traction placed on the vein. First, try to pull the vein a bit
tauter and advance the catheter. If unsuccessful, traction can be reduced (or even
 released) and further attempts at advancement can be pursued.
 "Float" the catheter in. If the catheter can be partially advanced but meets
resistance before insertion is completed, infusing saline through the line (via a flush or
IV fluids) during advancement may facilitate passage. (The fluids act to distend the
vessel and opens valves.) Excessive pressure should not be used in order to prevent
infiltration.
 Secure the catheter while it is partially inserted. If a long cather is used (1" or
longer) it may be possible to have a patent line with only part of the catheter in the
vein. This is not ideal and should not be relied upon unless other access is not
available. If this method is chosen, free flow of fluids and absence of infiltation must be
assured, and extra care should be taken in securing the line.

Infiltration and Extravasation

Infiltration of the IV occurs when the tip becomes dislodged from the vessel lumen. This
complication should be suspected when the intravenous fluid flows poorly, if the line is
difficult to flush, if the automated pump sounds an alarm, or if the patient complains of
pain. (Liu 2004, Weinstein 2001)

Infiltration can become a serious situation if toxic fluids are being administered through
the line. These include hypertonic agents, cytotoxic agents, and vasopressors.
Vasopressors, such as norepinephrine or dopamine extravasate into local tissues from an
infiltrative line, severe tissue necrosis may result. This can be treated by injecting five cc
phentolamine mixed with five cc of saline into the subcutaneous tissues with a small
gauge needle. (Liu 2004)

It can be difficult at times to confirm that an intravenous catheter is actually within the
lumen. Backflow of blood into the intravenous tubing upon the application of negative
pressure (e.g. withdrawing on a syringe attached to the catheter) is not a reliable
indicator, as the tip of the catheter may be partially in and partially out of the vessel
lumen. Conversely, the absence of backflow does not necessarily indicate catheter
malposition, as the tip of the needle may intraluminal but adjacent to a valve or vessel
wall. The most reliable method to confirm intraluminal placement, and to exclude
infiltration, is to apply tourniquet proximal to the catheter site tight enough to restrict
venous flow. A catheter in the appropriate position will cease to flow in this situation,
whereas an infiltrated line may continue to flow. (Weinstein 2001)

Arterial Placement
Peripheral catheters may accidentally be inserted into arteries instead of veins. This
would occur most commonly in the antecubital fossa, with the catheter entering the
brachial artery instead of the median cubital or basilic vein. Arterial cannulation is
distinguished by arterial flow (pumping) of blood, which will also be a bright scarlet red if
patient is not hypoxic. In this situation phlebotomy may still be performed but the
catheter should subsequently be removed. Pressure should be placed over the site for one
full minute, longer if patient is coagulopathic.
Air embolism
Air embolism is more commonly seen with central venous catheters,
however may also occur with peripheral catheters. If air is introduced
into the vascular system, it may accumulate and cause complications
such as blockage of the right side of the vascular system (i.e. venous)
leading to outflow obstruction of the right ventricle and pulmonary
arteries. Possible symtpoms include impaired gas exchange,
hypotension, and circulatory collapse. (Breen 2000, Feied 2002) Left-
sided (arterial) obstruction may also occur, if an atrial or ventricular
septal defect is present. Obstruction of the coronary or cerebral arteries
by air can lead to myocardial infarction and acute stroke, respectively.
(Breen 2000, Shockley 2002)
While it is classically taught that 5 ml / kg of air is needed to produce an "air lock" of the
right ventricle and pulmonary artery, circulatory collapse has been reported with as little
as 20cc of air. Should signicant air embolization occur, the patient should be placed in a
left lateral recumbent position to trap the air in the right atrium. Available interventions
include aspiration via a central venous catheter, hyperbaric treatment, and in severe
cases, thoractomy. (Feied 2002)
To prevent air embolism, all tubing should be flushed prior to utilization. Additionally, all
connections must be tight, and fluid bags should not be allowed to completely empty
before replacement. If this occurs, the line should be removed from the catheter and re-
flushed. (Weinstein 2001)

Catheter fracture and embolism

Catheter embolism is a rare complication of peripheral intravenous catheters. If the tip of
the synthetic catheter is sheared off, it may potentially embolize and travel proximally in
the circulation. This sequence of events occurs when the needle is withdrawn from the
catheter and then reinserted. Therefore, once the needle is removed it should never be
reinserted. (Weinstein 2001) Catheter embolism carries a high complication rate (up to
49%), and fluoroscopic catheterization and retrieval of the foreign body is usually
recommended. (Roye 1996)

LATE COMPLICATIONS
Infection | Thrombophlebitis | Phlebitis

Infection
Infection is a common complication of intravenous therapy.
Intravenous catheters can lead to local infection as well as
bacteremia from several mechanisms. The most common source of
infection is skin flora, which migrates distally down the intravenous
catheter. Coagulase negative staph and staphylococcus aureus, as
well as yeasts (e.g. candida), are frequent isolates responsible for
infection. (Garrison 1994) Other sources of infection include hematogenous spread from
distant infections, as well as infected solutions or other equipment. Gram negative bacilli
are often associated in these situations. (Sitges 1999) It should be noted that patients at
the extremes of age (less than one year or greater than 60 years), those with infections
at remote sites, and those with underlying immunodeficiency disorders are at greater risk
for iatrogenic catheter related infections. (Garrison 1994)
The diagnosis of infection related to peripheral venous catheters is relatively
straightforward. In most cases, localized inflammation, induration, and erythema will be
present. Cultures of the catheter tip, which are often useful in regards to central venous
catheter-related infections, are not routinely required for peripheral lines. More severe
sequelae from line infections (such as septic shock, sustained bacteremia, metastatic
infection, and endocarditis) are usually associated with the use of central venous
catheters. (Garrison 1994, Sitges 1999)
The peripheral venous catheter should be removed at once if infection is suspected. the
decision to begin antibiotics must be made on an individual basis. Antibiotics with activity
against gram positive organisms (such as first-generation cephalosporins, penicillin, or
vancomycin) should be initiated if there is evidence of systemic infection or spreading
local infection.
Catheter related infections are best controlled by meticulous attention to sterility and
preparation during insertion. Alcohol preps are adequate only if done appropriately (i.e.
applied with a moderate amount of friction for one minute.) A quick swipe with an alcohol
prep simply not effective. Iodine-based solutions are more effective than alcohol, and
should be used if the patient is not allergic to iodine. These preps are most effective if
allowed to dry on the skin for at least 30 seconds. (Weinstein 2001)
Thrombophlebitis
Peripheral venous thrombophlebitis, an extremely common
complication, is heralded by pain, erythema, swelling, and a
palpable cord along the course of the cannulated vein.
Thrombophlebitis is caused by local damage to the venous wall,
and resultant inflammation and thrombus formation. (Tagalakis
2002)

There are multiple risk factors for the development of

thrombophlebitis. The length of duration of cannulation is
proportional to the risk of thrombophlebitis. Catheters placed in
the veins that overlay joints are more likely to cause
thrombophlebitis, as motion of the joint can cause frictional
trauma between the endothelium and the catheter. Stagnant
blood flow in the lower extremities makes veins in this location more likely to develop
thrombophlebitis. Numerous intravenous fluid solutions, such as potassium chloride,
barbiturates, phenytoin, and chemotherapeutic agents, are known to cause endothelial
damage and inflammation. Finally, poor technique and multiple attempts lead to vascular
damage and thrombophlebitis. (Tagalakis 2002, Weinstein 2001)

Should thrombophlebitis developed, the intravenous catheter should be removed

immediately. The most circumstances, no treatment is needed other than elevation of the
extremity and the application of warm compresses. Antibiotics may be required if there is
evidence of surrounding infection. (Weinstein 2001)

Thrombophlebitis can be prevented by following these recommendations (Tagalakis

2002):

 Utilizing a septic technique  Inspecting for thrombophlebitis

daily
 Using of alcohol or iodine prior to
insertion  Replacing catheters every 72
hours
 Securing catheter appropriately
 Avoiding unnecessary tubing
 Avoiding lower extremity changing
insertion sites
 Replacing dressings as needed.

SAFETY CATHETERS
As mentioned in the Equipment section, there has been a proliferation in recent years of
devices designed to prevent accidental needlestick injuries. Over 1000 patents have been
issued in the United States since 1984 for such devices (Russo 1999); thus, it would be
impossible to cover all such equipment in this forum. It is the clinician's responsibility to
1) be knowledgable of the equipment used in his/her environment, and 2) use that
equipment in the appropriate manner.

The angiocathers used at our institution feature retracting needles and flash chambers
that are activated with a touch a button.

Other safety devices that are commonly used include folding

covers that securely snap onto needles after use. This devices
should be activated immediatly after use to avoid risk of
needlestick. Recapping of needles is strongly discouraged, and is
in fact a violation of OSHA regulations. (NIOSH 1999).

All needles, including those that have safety devices that have
been deployed, must be disposed of in approved, puncture
resistant containers.

It should be noted that the highest risk needlestick is that which involves a hollow needle
that has been in an artery or vein. The great majority of healthcare workers who have
contracted HIV from occupational exposures occurred in this fashion. (Cardo 1997)

"NEEDLE-LESS" SYSTEMS
In addition to safety catheters, many systems have been developed that obviate the need
to use the sharp needles at all. Historically, it was standard practice for intravenous
medicines to be administered into intravenous tubing via a sharp needle attached to a
syringe. This practice should be discouraged, and a needleless system should be used if
available. The use of such systems has been shown to decrease the incidence of
needlestick injuries. However, their efficacy in reducing the transmission of blood-borne
infectious diseases is unproven, mainly because the risk of disease transmission from
needles that has not been exposed to blood is extremely low. (Russo 1999)

UNIVERSAL PRECAUTIONS
Appropriate Universal Precautions should always be maintained to protect the patient, the
person performing the procedure, and other individuals involved in all aspects of care (i.e.
housekeeping staff who clean the room). This includes handwashing, the use of gloves and
other protective barriers, proper sharps disposal and the correct usage of safety features. Please
see the Universal Precautions section of the General Principles chapter for further discussion.