ANATOMY OF IV SITES Successful cannulation: proper site selection of IV access sites knowledge of the gross anatomy of a vein .

General Concepts The identification of the optimal site involves both visual and tactile exploration The vein may be visible as a blue-green subcutaneous structure It may pop out as it engorges with blood or merely be palpable as a springy canal coursing between the soft tissues ANATOMY OF THE VEIN Veins are thin walled-structures that lack the thick, circumferential smooth muscular layer that is present in arteries Peripheral veins may collapse and may be difficult to cannulate (or even locate) in patients with hypovolemia, low blood pressure, etc. Venous return to the heart is dependent upon contraction of regional skeletal muscle (e.g. the gastrocnemius and soleus in the lower leg) Additionally, many veins contain valves that prevent retrograde flow of blood ( Moore, KL) If the intravenous catheter abuts one of these valves, flow of intravenous solution may be occluded. (Similiarly, valves can interfere with phlebotomy Upper Extremity In most situations, intravenous catheters are inserted in the: Antecubital fossa Forearm Wrist Dorsum of the hand. The three main veins of the antecubital fossa that are frequently used: Cephalic Basilic Median cubital These veins are usually large, easy to find, and accomodating of larger IV catheters.

The three main veins of the antecubital fossa that are frequently used: Cephalic Basilic Median cubital These veins are usually large, easy to find, and accomodating of larger IV catheters Veins of the upper extremity, showing the dorsal venous network of the hand as well as the palmar venous network , including the basilic and cephalic veins of the forearm Veins of the arm: the basilic and cephalic veins. Cannulation of the cephalic, basilic, or other unnamed veins of the forearm is preferrable They are ideal sites when large amounts of fluids must be administered Their location in a flexor region is a drawback, as bending of the elbow can be uncomfortable to the patient and may occlude the flow of the intravenous solution. The veins in the dorsal hand may be utilized if large bore access (18 gauge or larger) is not required Care must be taken to find a vein that is straight and will accept the entire length of the catheter. Lower Extremity Cannulation of the veins of the feet is not ideal !!! Insertion can be quite painful, and the catheter may cause more discomfort than if it were started in the hand or forearm Additionally, IV catheters placed in the feet are more likely to become infected, to not flow properly, and are more likely to produce phlebitis. Veins of the Foot: Great saphenous vein runs anteriorly to the medial malleolus, and may be accessed via a peripheral venous cutdown in emergent

situations Lesser saphenous vein runs along the lateral aspect of the foot These two veins converge medially to form the dorsal venous arch . There are numerous unnamed vessels that are branches of these veins (Clemente) Any vein in the foot large enough to accept the IV catheter may be used if necessary. . External Jugular The external jugular ("EJ") vein can be cannulated if necessary It originates near the angle of the mandible, and courses over the sternocleidomastiod muscle Proximal to the clavicle, the EJ dives into the subcutaneous tissue, eventually emptying into the subclavian vein (Moore) The EJ is a large vein that can accomodate a large bore IV catheter (18 gauge or larger), in most patients It is especially useful in patients with poor access in the arms who require a large volume of fluid Additionally, the EJ is often engorged in patients with heart failure and provides an alternative in these patients if other venous access sites are not available Scalp Veins Veins of the scalp as well as the vasculature, facial nerve, and lymphatics of the face From Drake L, Vogl AW, Mitchell AWM, Tibbitts RM, Richardson PE: Grays Atlas of Anatomy. Philadelphia, Churchill Livingstone Elsevier, 2008 Indications: IV access is usually needed for anesthesia care, laboring patients, trauma patients, hospital inpatients, and patient care requiring any of the following: Emergency administration of medications Fluid

resuscitation Administration of blood products Elective administration of intravenous antibiotics, chemotherapeutic agents, or other treatments Administration of diagnostic substances, such as methylene blue, indocyanine green, indigo carmine, or intravenous contrast agents Patients donating blood products Contraindications: Absolute Contraindications None Relative Contraindications Avoid extremities that have massive edema, burns, or injury; in these cases other IV sites need to be accessed. Avoid going through an area of cellulitis; the area of infection should not be punctured with a needle because of the risk of inoculating deeper tissue or the bloodstream with bacteria. Avoid extremities with an indwelling fistula; it is preferable to place the IV in another extremity because of changes in vascular flow secondary to the fistula. Relative Contraindications An upper extremity on the same side of a mastectomy should be avoided, particularly if an axillary node dissection was carried out, because of concerns of previous lymphatic system damage and adequate lymphatic flow. Very short procedures performed on pediatric patients, like placement of ear tubes Bleeding diathesis Medication administration that will take longer than 6 days (preference is then for a peripherally inserted central catheter) Type of fluid to be administered through peripheral IV is too caustic; hypertonic solutions and some

therapeutic agents should not be infused in a peripheral IV. Complications: Common Complications Inability to identify a vein for catheter placement Failing to get a flash once the catheter is inserted A flash appears, but there is no further blood flow. Failing to thread the catheter into a vein after the needle is retracted Infiltration; remove the catheter and apply pressure Kinking of the catheter; usually the catheter must be removed Infrequent Complications Difficult IV access Minor bleeding Infection Localized site infection Cellulitis Superficial thrombophlebitis Serious and/or Rare Complications Infiltration of a caustic material, such as a chemotherapeutic agents or Pentothal , which can lead to severe pain, tissue irritation, vasospasm, necrosis, and sloughing of tissues Abscess formation Catheter-related bacteremia Bacterial endocarditis Scope of Practiced. Determine solution & medication incompatibilities.e. Change IV site, tubings, dressings, according to IVT Standards.f. Establish flow rates of solutions, medications, blood and blood components as prescribed. technical ability in the use, care, maintenance and evaluation of IV equipment.h. Nursing management of patients receiving IV therapy and peripheral/central/parenteral nutrition in various set ups . Adherence to established infection control practices.j. Observation & assessment of all adverse reactions.k. Appropriate documentation relevant to

the preparation, administration, termination of all forms of IVT. Indications of IV Therapya.Maintain hydration and / or correct dehydration in patients unable to tolerate sufficient volumes of oral fluids / medications.b.Parenteral Nutritionc.Administration of drugsd.Transfusion of blood or blood components Contraindications Administration of irritant fluids or drugs through peripheral access. 10 golden rules for administering drugs safely Type of FluidMedication additives & flow rateElectronic infusion deviceDuration of therapy & nurses signature Location & condition of insertion siteComplications, patients response & nursing interventionsPatient teaching & evidence of patient understanding instructions or perform a return demonstrationSignature of nurseOther observations Measures to reduce patients risks Objectives(I) prevent hospital acquired infection; (2) environmental protection; (3) protection of hospital personnel and visitors, garbage collectors, scavengers and the community at large. The ordinance classifies hospital waste and prescribes the use of a color coding of waste bags to identify the types of wastes.It provides for the standard storage procedures and the alternative disposal system such as incinerator system, enclosed burning pit, ground pits and the sewage disposal system for hospital waste