Vascular AccessMary Corcoran RN, BSN, MICN
Peripheral Access
Peripheral Access is obtained using Aseptic technique
Initial insertion attempts should begin distally and progress up the extremity◦ If the situation and pt vasculature allow
During resuscitation peripheral access is preferred to eliminate interruption in chest compression for central line insertion
Proximal veins may be used when giving medication with extremely short half life, or for rapid fluid or CT contrast infusion ◦ Adenosine
Scalp Veins have no valves and are easily visible on infants- allowing infusion in both directions
Tips and Tricks
Infiltration of fluid or medication (can cause necrosis with certain meds)
Phlebitis Embolism
◦ Of blood, air, or catheter fragments Infection Cellulitis Needle stick and blood exposure for
RN
Potential Complications
In ER- anywhere you can find a vein◦ Arms, legs, Neck, Abdomen,
Hands, Feet, Breasts etc… Most Common are
◦ Hands, A/C (antecubital), Forearms, and EJ’s (external Jugular)
Just make sure to always point toward the heart
**note: check with your facility for specific locations and protocols
Location
Size and Type of cath are determined by urgency of need, patient size and vasculature◦ Larger Diameter (12,14,16,18g)- used for rapid
fluid, drug, or blood infusion◦ Smaller Catheter (20,22,24g)- are used for routine
vascular access, and patients with smaller veins
Catheter Selection
IV Insertion
Central Venus Access
Subclavian Vein- under the clavicle
Internal Jugular- also under the clavicle
Femoral Vein- In the groin
Where are they placed?
Why do we place them?
Short Term Long Term
When all other peripheral access is unavailable
When condition is unstable and requires hemodynamic monitoring (eg CVP)
Prolonged IV Therapy◦ TPN, extended Abx
therapy, or caustic medication administration Vancomycin
Debilitating diseases
◦ AIDS, Cancer
Central Line Insertion
Non tunneled Tunneled Implanted
Example PICC- Peripherally Inserted Central Catheters
Broviac Port-a-Cath, norport, lifeport
Characteristics Single or Multi-Lumen
Single or Multi- Lumen w/ cuff
Implanted in chest wall
Advantages Easy removal and placement
Unlimited use, painless access
Less trauma to body image, minimal infection
Disadvantages Activity Restriction, dislodges easily
Mental and Physical Requirements for self care
High Insertion Costs, more painful
Venus Access Devices
Intraosseous Infusion
Inserted in to the bone marrow, blood can be drawn from the marrow, and fluids, medication, and blood infused through the marrow
Used on adults and pediatric patients
When all else fails…
Anterior Tibia, Medial Malleolus, Sternum, Distal Femur, Humerus, or Iliac Crest
Where do we place them?
You Tube Video for Humeral IO, staring someone familiar…..
Sternal IO insertion- only done in military currently
Fluid and Blood Replacement
Example Uses
Isotonic 0.9% Normal Saline (NS),Lactated Ringers
Expands intravascular volume, used for hydration, and maintenance fluid
Hypotonic NS 0.45%NS 0.2%Dextrose 5% in Water (D5W)
Shifts H2O intracellular, assessing renal patients,and mixing medications
Hypertonic D5% in NSD10% in NS
D10% in WaterD10% in 0.45%NSD20% in Water
Shifts intra cell fluid to extracellular, used in too much hypotonic solution administration
Maintenance to promote diuresis
Maintenance IV Fluid
Whole Blood◦ Unfiltered and carries significant risks of
infection and transmission, is expensive, and not readily available
PRBC’s (Packed Red Blood Cells)◦ Are used most often for blood replacement
FFP (Fresh Frozen Plasma)◦ Contains Clotting Factors
Albumin (5% isoonocoit, 25% isotonic “salt poor”)◦ Used as volume expander when risk of
interstitial edema is great (pulmonary/cardiac disease)
Blood Administration
Blood Compatibility Patient Compatible Transfusion
Type A A or AB Plasma
Type B A or O RBC’s
Type AB AB Plasma; A, B, AB or O RBC’s
Type O A, B, AB or O Plasma; O RBC’s
Rh- Must Receive Rh- Blood
Rh+ Can Receive Rh- Blood or Rh+ Blood
O- Universal Doner for RBC’s
AB+ Universal Doner for Plasma
*caution in pregnant mothers/females
Transfusion Reactions Hemolytic
◦ Cause- Blood Incompatibility◦ Prevention- Type and Crossmatch, infuse first
50cc slowly◦ Assessment- Fever, Chills, Dyspnea, Tachypnea,
fever, olguria, hematuria, chest tightness Collect blood and urine
◦ Intervention- Discontinue Immediately FATALITY may occur after 100cc, start NS or LR, consider diuretics, and monitor BUN, Creatinine
Transfusion Reaction Allergic
◦ Cause- Antibody Reaction to allergens◦ Prevention- Screen donors for allergy; administer
antihistamines (Benadryl) prior to transfusion◦ Assessment- Chills, hives, wheezing, vertigo,
Anaphlaxis, dyspnea, bronchospasm and generlized edema
◦ Intervention- Stop Infusion, give antihistamines, epi, NS or LR
Transfusion Reactions Circulatory overload
◦ Cause-infusion of large amounts of blood, especially to elderly, or cardiac hx
◦ Prevention- Infuse Slowly; check drip rate and frequency
◦ Assessment- Pulmonary Crackles, Cough, dyspnea, pulmonary edema, increased CVP
◦ Intervention- Stop infusion, treat pulmonary edema
Transfusion Reaction Hypocalcaemia
◦ Cause-Precipitate from acid citrate dextrose calcium dilution with massive transfusions
◦ Prevention- use blood immediately
◦ Assess- Numbness, and tingling to extremities
◦ Intervention- Stop infusion, give Calcium
Hyperkalemia◦ Cause- Hemolysis of
red blood cells Release Potassium
◦ Prevention- Use blood immediately
◦ Assess- Nausea, Vomiting, Muscle weakness, bradycardia
◦ Intervention- stop Infusion