LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
MEDICAL ACADEMYFACULTY OF NURSING
DEPARTMENT OF NURSING AND CARE
ALEX JAYADEVADAS KALABANERJI
VENOUS ACCESS IN CHILDREN UNDERGOING ANESTHESIA
The graduate thesis of the Master‘s degree study programme “Advanced Nursing Practice” (state code 6211GX008)
Tutor of the graduate thesis PhD, MD Laura Lukošienė
CONTENTS
1.ABSTRACT...3
2.ACKNOWLEDGMENT….………...4
3.ABBREVIATION………...………...…...5 4.INTRODUCTION ………...………...6 5.REVIEW OF LITERATURE ………...……75.1Aspects of peripheral cannulation …….…...…...7
5.2Technical Consideration………...…...12
5.3Insertion Of Intravenous Catheter………...…....…14
5.4Removal Of Intravenous Catheter…………...…16
5.5Reducing Pain and Stress during Peripheral Venous Cannulation ...17
5.6Difficult Peripheral Venous Access………...…. 19
6.ORGANISATION AND METHODOLOGY OF RESEARCH …...22
7..RESULTS ………...24
8..DISCUSSION OF RESULTS ………...…...……...26
9.RECOMMENDATIONS TO HEALTH CARE PROFESSIONALS…...30
10.CONCLUSION………...37
11.PRACTICAL RECOMMENDATIONS ………...…...37
12.LIST OF LITERATURE RESOURCES ………...…...…...39
13.ANNEXES………...42
Declaration of The Authors Contributions and Academic Honesty...42
1.ABSTRACT
2.ACKNOWLEDGEMENT
I would like to express my special thanks of gratitude to my Supervisor Dr. Laura Lukošienė as well as our Mentor Lina Spirgiene who gave me the golden opportunity to do this wonderful project on the topic Venous Access in Children Undergoing Anesthesia , which also helped me in doing a lot of Research and i came to know about so many new things I am really thankful to them. Secondly I would also like to thank my parents and friends who helped me a lot in finalizing this project within the limited time frame.
3.ABBREVIATIONS
VA - Venous Access
DIVA -Difficult Intra Venous Access DVA -Difficult Venous Access US -Ultra Sonography IV -Intra Venous
CVC -Central Venous Catheter
PICC -Peripherally Inserted Central Catheter CVA -Cooling Vibration Analgesia
PCV -Percutaneous Central Vein GTN -Nitroglycerine
4. INTRODUCTION
5.REVIEW OF LITERATURE
DEFINITION
Venous access is any kind of way to access the bloodstream through the veins, either to administer intravenous therapy (medication, fluid), parenteral nutrition, to obtain blood for analysis, or of blood-based treatments such as dialysis or apheresis. Central venous catheters (CVCs) may also be used to measure the central venous pressure. [8,9,10]The most common form of venous access is a peripheral venous cannula which is generally inserted in the hands or forearms. CVCs are required in some situations (e.g. particular drugs), and other devices are needed for dialysis and apheresis. A venous access port is a central venous access device that allows doctors to easily access your veins to give treatments and to take blood. It is made of a non-irritant material and is designed to be inserted under your skin and remain in place for weeks or months. It is also known as a subcutaneous infusion port, and includes a catheter (a thin hollow tube), which is inserted through the skin and is then connected to a port in a pocket under the skin.[9,10].Peripheral venous access is indicated for the administration of fluids, drugs, or if nutrients when other routes are unavailable. Central venous access is indicated if peripheral access is unsuccessful or if hypertonic, irritant, or vasoconstrictor solutions are used. Because of anatomical variations, different peripheral cannulation sites are more appropriate in different age groups. The preferred sites for long-term central venous access in infants and children are the external jugular, facial, internal jugular, saphenous veins at the groin, and subclavian veins. The practical aspects of peripheral and central venous access and the complications are discussed.[21,27]
INDICATIONS
Reasons for pediatric IV cannulation include the following: - Repeated blood sampling
- IV fluid administration - IV medication administration - IV chemotherapy administration - IV nutritional support
- IV blood or blood products administration
- IV administration of radiologic contrast agents (example for computed tomography [CT], magnetic resonance imaging [MRI], or nuclear imaging)[15,16]
ASPECTS OF PERIPHERAL CANNULATION Skin preparation
absorption of chlorhexidine. ChloraPrep (chlorhexidine gluconate 2% in isopropyl alcohol 70%) is not licensed for use in children <2 months of age, and therefore, it is our practice to use 70% isopropyl alcohol wipes for cannulation in children <2 months, with chlorhexidine acetate 0.5% solution used for central access.[19,20,23]
Visualizing Veins
Several approaches utilized in adults to enhance the visibility and palpability of peripheral veins (tourniquet use, gentle tapping of the overlying skin, local warming) are useful in children. Specific devices to aid visualization of veins include the use of transillumination and near-infrared light devices . The latter detect the presence of haemoglobin by a process of differential absorption and project an image of the veins back onto the patient's skin. [2,3,4] The use of red LED-based translumination to highlight veins in a toddler's hands.[33,34]
Sites for Peripheral Cannulation in Children
These commonly include the hands, wrists, feet, antecubital fossae, and the scalp in babies, although the latter can present problems with stabilization of cannulae and increased risk of extravasation. In children, the recognized complication of inadvertent arterial cannulation while accessing the veins in the antecubital fossa is increased.[7,9,11]The long saphenous vein is usually palpable as it courses anterior to the medial malleolus.Less usual sites of peripheral cannulation include the external jugular, abdominal, and axillary veins.[18]
Peripherally inserted central catheter
Peripherally inserted central catheters (PICCs) are available in single-, double-, and triple-lumen configurations and in sizes ranging from 28 G catheters for use in premature neonates to 7 Fr triple-lumen catheters. By convention, single-lumen catheters are described by gauge, while multi-lumen catheters by French (Fr) size . The size of the PICC to be used is determined by the size of the access vein and the therapy required and not simply by the age of the patient. In general, smaller catheters with the least number of lumens are associated with the fewest complications; however, very small catheters are more likely to become blocked. If blood sampling via the PICC is required, then at least a size 3 Fr will be needed.6 Any i.v. infusate can be given by a PICC, but their time in situ (dwell time) is typically <2 months and rarely >6 months. PICCs labelled as ‘power-injectable’ are able to withstand high pressures, allowing i.v. contrast administration during CT scanning.[18,26,34]
Umbilical vein catheter
vein catheterization should not be attempted in the neonate with an abdominal wall defect, peritonitis, or necrotizing enterocolitis.[2]
Central Venous Line
A central venous line (CVL) catheter is placed into a centrally located vein—typically in your child’s neck, chest or groin—so doctors can give her fluids, nutrients or medication over a long period of time. The Division of Interventional Radiology uses ultrasound and a special type of x-ray technology, called fluoroscopy, to guide the placement of the catheter.Central venous lines are essential in anaesthesia for major surgical procedures, for treatment in the ICU as well as for nutrition and drug administration in patients with enteral malnutrition or malignancy.The most common insertion sites are the access via the femoral vein , the internal jugular vein and the subclavian vein. In addition in neonates, there are possibilities for peripheral access with long line silastic catheter via the cubital or the saphenous vein. In situations with extremely difficult venous status – very often after multiple previous central venous punctures and subsequent thrombosis – further possibilities include the transhepatic approach and direct right atrial catheter insertion during surgery.[36]
Central venous catheters: subclavian access
Subclavian central venous catheters in adults are known to have the lowest infection rate.6,7 This however is not proven in children.1,4 In experienced hands the subclavian access is still frequently used despite potentially having the highest rate of serious complications (pneumothorax and hematothorax). Unfortunately subclavian vein catheterisation under ultrasound guidance is very difficult and has yet not come into routine clinical practice. Scrupulous attention to technique and detail are therefore mandatory.[36]
Catheter equipment
The most common catheterisation technique is the Seldinger technique. Different products are available. In very small infants the very often used J-shaped guidewires are disadvantageous, and straight guidewires with a soft tip may be used.5 The size of the catheter inserted should be minimized as far as possible, because thrombosis increases with size.
Catheter position
The catheter position should be in the right atrium or in the superior vena cava. Some case reports of atrial perforation have led to the recommendation for position in the superior vena cava. The catheter length should be estimated in advance and the final position confirmed by X-ray. During insertion an atrial ECG recording connected to the central venous line or the guidewire may be used, but are not standard practice.
Appropriate positioning is extremely important. The key points are:A shoulder roll should expose the chest thereby keeping the shoulders down. An outward rotation of the arms further improves this position. The baby can easily be fixed in this position with a towel . An alternative is a longitudinal towel between the shoulders. The chest is now elevated, but good venous filling requires either liver compression for increasing the central venous pressure – sometimes combined with an elevated PEEP on the ventilator - or the classical Trendelenburg positioning.
Puncture technique
The skin needs cleaning and disinfection. A sterile drape should allow visibility and palpation of the sternal notch and the clavicle. A very helpful technique is palpation of the sternal notch with one finger and palpation of the clavicle with another. Then the puncture can be done under close guidance of the finger tip which helps to push the needle below the clavicle. While advancing the needle attached to a syringe slight aspiration should be performed. In many cases blood can be aspirated only when pulling the needling slowly backwards (during advancement the vein may be compressed or already perforated and transfixed). If there is now positive intra-thoracic pressure (in ventilated children) the puncture can also be done without syringe and aspiration. The author prefers to do this procedure without saline in the syringe. This allows better discrimination between venous and arterial blood. As soon as blood can easily be aspirated the guidewire can be threaded through. Even if it would be possible to dilate the skin without incision it is preferable to incise to avoid damage of the catheter tip. A smooth and undamaged catheter is an important factor to prevent the adhesion of thrombocytes and consequent infection.[36]
Complications
The overall complication rate is reported to be around 4%.1 Serious problems are the pneumothorax and hematothorax. Malpositioning is the most common problem with migration of the catheter to the contralateral subclavian vein or – more frequently – to one of the internal jugular veins. This problem appears to be more common when the catheter is inserted from the right side.[36]
Conclusion
The advantage of the subclavian access for central venous catheters is its good fixation, ease of access and use, and minor infection rate at least in older children. As the rate of serious complications and malpositioning is higher compared to the internal jugular and femoral approach this access should be performed by experienced staff.[36]
Peripheral Venous Access
parenteral nutrition, peripheral venous catheters are also inserted prophylactically before procedures and in unstable patients for emergency use [2].Despite its frequent use, intravenous cannulation is not without risks. It is a leading source of procedure-related pain in the hospital [3, 4].Complications such as clotting, occlusion, leakage, infiltration, extravasation, phlebitis and infection can also occur [5]. In neonatal intensive care units, local complications occur in up to 97%of PVCs [6, 7, 8, 9], and the catheters have a median lifespan of 23–40 h [6,10]. Studies in pediatric departments have reported a lower incidence of complications in approximately a quarter of PVC cases [11,12,13], with catheters having a median lifespan ranging from 29 to 60 h [13,14,15,16].Various risk factors of local PVC complications have been identified in these studies, which may be related to patient characteristics (a younger age [15, 16], underlying conditions such as diabetes or cancer [12], the nature of drugs or fluids used (antibiotics, corticosteroids, hypertonic solution, etc) [6,17], the site of insertion (the antecubital fossa [11,18],wrist [15] and ankle [16]), the characteristics of the catheter(a smaller gauge [15], drug and medication administration methods (infusion pumps [12], and the means of maintaining and securing the PVC (the use of flushes and splints improves PVC patency [15,19].In recent years, significant technological innovations have been developed to promote the insertion use and means of securing peripheral intravenous catheters (PIVC). Cannula insertion can be facilitated with vein visualization devices or ultrasound guidance [20,21,22]. Medical-grade tissue adhesives (cyanoacrylates) and antimicrobial-impregnated dressings have shown promise in reducing local and infectious complications associated with intravenous therapy [23,24,25]. According to recent data, clinical practice and international best practice recommendations for the use, care and maintenance of PVCs have considerably changed [26].In hospitals , as in many other developing countries, new technologies are not available because of their high cost. Even basic products such as chlorhexidine or transparent film dressings are not routinely used in pediatric units. Therefore, the available data on PVC complications in children, their risk factors and recommendations for best practice are not systematically generalizable to our circumstances.
Choice of venous access device
haemodialysis in the future should have particular efforts made to preserve their upper extremity and subclavian veins. In these children, central venous access should be via the internal jugular or femoral veins only.
Contraindications
No absolute contraindications exist for pediatric IV cannulation.Peripheral venous access in an injured, infected, or burned extremity should be avoided if possible.Vesicant solutions can cause blistering and tissue necrosis if they leak into the tissue. Irritant solutions (pH <5, pH >9, or osmolarity >600 mOsm/L, including sclerosing solutions, some chemotherapeutic agents, and vasopressors) also are more safely infused into a central vein. Therefore, these solutions should only be given through a peripheral vein in emergency situations or when central venous access is not readily available.[7,15]
Technical Considerations
In an emergency situation or when patients are expected to require large volumes infused over a short period of time, the largest-gauge and shortest catheter that is likely to fit the chosen vein should be used. The catheter chosen should always be slightly smaller than the vein.Veins have a three-layered wall composed of an internal endothelium surrounded by a thin layer of muscle fibers, which is surrounded by a layer of connective tissue. Venous valves encourage unidirectional flow of blood, prevent pooling of blood in the dependent portions of the extremities, and can impede the passage of a catheter through and into a vein. Venous valves are more numerous just distal to the points where tributaries join larger veins and in the lower extremities. [2]Veins with high internal pressure become engorged and are easier to access. The use of venous tourniquets, dependent positioning, pumping via muscle contraction, and the local application of heat or nitroglycerin ointment can contribute to venous engorgement. The superficial veins of the upper extremities are preferred to those of the lower extremities for peripheral venous access because they interfere less with patient mobility and pose a lower risk for phlebitis. [3] It is easier to insert a venous catheter where two tributaries merge and form a Y shape. It also is recommended to choose a straight portion of a vein to minimize the chance of hitting valves. The scalp veins are easily accessed in infants. They can be engorged by placing a rubber band around the patient’s head at the forehead level.
Patient Education and Consent
Explain the procedure to the patient and/or the patient’s representative, and obtain verbal consent. Equipment
selected for the prescribed therapy, with the aims of preventing damage to the vessel intima and ensuring adequate blood flow around the catheter so as to reduce the risk of phlebitis. [4]
Necessary equipment includes the following Nonsterile gloves
Tourniquet
Antiseptic solution (2% chlorhexidine in 70% isopropyl alcohol) Local anesthetic solution
1-mL syringe with a 30-gauge needle 2 × 2 gauze
Venous access device
Vacuum collection tubes and adaptor Saline or heparin lock
Saline or heparin solution Transparent dressing Paper tape
Padded arm board
1/2-in. gauze bandage roll
The patient’s skin should be washed with soap and water if it is visibly dirty.Because infants and young children are unlikely to cooperate, it is recommended that an assistant aid in stabilizing the extremity during the procedure.
Patient Preparation Anesthesia
Both intradermal injection of a topical anesthetic agent just prior to IV insertion and topical application of a local anesthetic cream about 30 minutes prior to IV insertion have been shown to significantly reduce the pain associated with IV catheterization. One or the other should be used unless the situation is an emergency. [5,6,7]
Positioning
Make sure that there is adequate light and that the room is warm enough to encourage vasodilation. Adjust the height or position of the bed or chair to make sure that you are comfortable and to prevent unnecessary bending. Make sure that the patient is in a comfortable position, and place a pillow or a rolled towel under the patient’s extended arm.[7]
Tip position of centrally placed catheters
Ported catheters that are likely to be used for many years are also sometimes deliberately placed with an initial right atrial tip position to allow for the change in tip position as the child grows.
Approach Considerations
Use properly fitted nonsterile gloves and eye protection device to prevent exposure via accidental blood splashes.
Insertion of Intravenous Catheter
Place a venous tourniquet over the patient’s nondominant arm, and select a site for IV catheter insertion. The veins of choice include the cephalic or basilic veins, followed by the dorsal hand venous network. For prolonged courses of therapy, it is recommended, though not always practical, to start distally and move proximally as distal catheters are replaced. In infants, the dorsal hand and dorsal foot veins are usually easier to access than the antecubital vein. If difficulty is encountered in finding an appropriate vein, one of the following techniques may be used:
-Inspection of the opposite extremity -Opening and closing the fist
-Gravity (holding the arm down) -Gentle tapping or stroking of the site -Application of heat (warm towel/pack)
into the skin will vary according to the device used and the depth of the vein. Small superficial veins are best accessed via a small catheter (22-24 gauge) placed at a 10-25º angle. Deeper veins should be accessed via a larger catheter placed at a 30-45º angle. Upon entry into the vein, the practitioner might feel a “giving way” sensation, and blood should appear in the chamber of the venous access device (ie, flashback). The angle of the venous access device should be reduced to prevent puncture of the posterior wall of the vein. It should be advanced gently and smoothly an additional 2-3 mm into the vein. If no blood is observed in the flashback chamber, the device should be withdrawn to just beneath the skin level, and another attempt to recatheterize the vein should take place. Flashback may stop if the device punctured the posterior wall of the vein or if the patient is extremely hypotensive. If swelling develops, withdraw the device, release the tourniquet, and apply direct pressure for 5 minutes, as a hematoma developed.If venous catheterization is unsuccessful, the needle should never be reintroduced into the catheter. This could result in catheter fragmentation and embolism. While maintaining skin traction with your nondominant hand after the hub of the venous access device was dropped to the skin, hold the needle grip portion of the venous access device in place between your dominant thumb and middle finger, while using your dominant index finger to slide the hub of the catheter over the needle and into the vein. While maintaining skin traction with your nondominant hand after the hub of the venous access device was dropped to the skin, hold the needle grip portion of the venous access device in place between your dominant thumb and middle finger, while using your dominant index finger to slide the hub of the catheter over the needle and into the vein. While using your nondominant middle finger to apply pressure over the catheter to prevent blood spill and holding the hub in place with your nondominant index and thumb fingers, use your dominant hand to withdraw the needle and secure it in its safety cover, a dedicated biohazard sharps container, or both. If blood sampling is needed, use a syringe attached to the saline lock, and obtain the required samples. A Vacutainer adaptor or a syringe can also be directly attached to the venous access device. Release the tourniquet once the blood sample has been obtained. While applying pressure to the catheter to prevent blood spillage and while continuously stabilizing the hub and wings to the skin as described before, disconnect the blood sampling adaptor or syringe, and securely attach the preflushed saline or heparin lock to the hub of the venous access device.[17,19]
catheter is still inside the vein, then immediately flush the tubing with the remainder of the solution. Slide the plastic tubing lock, and continue to lock the tubing, if such a lock is available. Finish securing the tubing to the skin using tape. Place a label indicating date, time, and other facility-required information over the transparent dressing. Keeping an IV line from being pulled out by a pediatric patient can be challenging. The images below show some of the methods for securing such lines[20].
Removal of Intravenous Catheter
Stop the infusion solution and disconnect the tubing, leaving just the saline/heparin lock tubing connected to the venous access device. Release the adhesive tape and transparent dressing from the skin. Withdraw the catheter outside of the vein, and apply direct pressure with gauze for at least 5 minutes.Inspect the catheter for fragmentation, and document in the patient’s chart the date, time, and reason for catheter removal and the integrity of the catheter as inspected.Place a 2 × 2 gauze pad or a cotton ball with a paper tape over the IV insertion site, and instruct the patient to continue manual pressure for 10 more minutes in order to minimize hematoma formation.[15]
Complications
Periprocedural and postprocedural complications may include the following: -Pain
-Failure to access the vein
-Blood stops flowing into the flashback chamber
-Difficulty advancing the catheter over the needle and into the vein -Difficulty flushing after the catheter was placed in a vein
-Arterial puncture -Thrombophlebitis -Peripheral nerve palsy -Compartment syndrome -Skin and soft-tissue necrosis
release venospasm. Finally, attempt to withdraw the needle a few millimeters to move it away from a valve. If it proves difficult to advance the catheter over the needle and into the vein, the cause might be failure to release the catheter from the needle before insertion, encountering a venous valve, removing the needle too far with the catheter being too soft to advance into the vein, poor skin traction, or venous collapse. Release the tourniquet, then reapply it to help engorge the vein. Connect a syringe with normal saline (0.9%) solution to the hub, then attempt to "float" the device in place by simultaneously flushing the catheter and advancing it.If flushing is difficult after the catheter was placed in a vein, the cause might be catheter tip position against a venous wall or a valve, a blood clot, or piercing of the venous wall. Observation of a hematoma necessitates removal of the catheter. Withdraw the catheter slightly to release it from a wall/valve, and attempt to flush it back in. Palpate the vein carefully before attempting to insert a venous access device to ensure that there is no palpable pulse in the vessel. If an accidental arterial puncture did occur, as evidenced by arterial pulsation of blood out of the catheter, remove the catheter and apply direct pressure using gauze for at least 10 minutes. Thrombophlebitis can be caused by thrombus formation with subsequent inflammation, infection, or both. Pain to the IV site along the path of the catheter, skin erythema or induration, swelling, drainage from the skin puncture site, and the presence of a palpable venous cord are the signs of thrombophlebitis. Remove the catheter, and treat with appropriate antibiotics if you suspect an infectious etiology.
REDUCING PAIN AND STRESS DURING PERIPHERAL VENOUS CANNULATION Pharmacological methods
Topical local anesthetics
Topical local anesthetics prevent the transmission of pain by blocking sodium channels in the nerves. Although parental reports indicate that topical local anesthetics have no effect on procedure-related fear on heel lance pain in neonates tetracaine 4% gel and lidocaine 2.5% plus prilocaine 2.5% cream have been shown to be effective in managing pain associated with venepuncture or cannulation in children aged between three months and 15 years – the former providing better pain relief than the latter . Lidocaine 4% cream is as effective as lidocaine 2.5% plus prilocaine 2.5% cream for cannulation in children aged 8-17 years and for venepuncture in those aged 5-17 years.
Vapocoolant sprays
A self-administered, inhaled gas mixture of 50% nitrous oxide and 50% oxygen (Entonox) may be used to reduce pain during minor procedures lasting less than 15 minutes . Entonox has a rapid onset and offset (1-5 minutes) but the patient must be.Able to independently use a hand-held device and inhale the gas.Must be closely monitored for side-effects by a trained health professional. Non-pharmacological methods
Cooling vibration analgesia Cooling vibration analgesia (CVA) combines cold and high-intensity vibrations as counter stimuli to the pain of needle-related procedures . A commonly described device for administering CVA to children is Buzzy, a reusable, battery-powered vibration-producing device to which an ice pack is attached . CVA activates cold and vibration receptors, which, in turn, activate inhibitory interneurons in the spinal cord, thereby reducing pain signals transmitted via peripheral nociceptive pathways.
Hypnosis
Hypnosis aims to change patients’ thoughts, behaviour or perceptions by focusing their attention on instructions and suggestions of relaxation, calmness and wellbeing from a health professional with hypnotherapy training . Changes in cerebral blood flow are higher during a hypnotic state, and it is thought that hypnosis may modulate areas of the brain activated by painful stimuli. Hypnosis has the potential to significantly reduce self-reported pain and distress during needle related procedures
Distraction
Neurocognitive pathways that are directed towards pain perception can be disrupted when attention is drawn towards an engaging task . Common distraction techniques employed to this effect include:
*Watching cartoons; *Playing with a toy; *Listening to music
Distraction techniques significantly reduce children’s self-report of pain and distress during needle-related procedures and routine immunization’s.
Interactive electronic programmes
non-pharmacological strategies. A number of methods are available to health professionals, all with some level of evidence supporting their use in the clinical setting.[12]
DIFFICULT PERIPHERAL VENOUS ACCESS
The placement of peripheral intravenous lines forms a significant part of the workload of junior medical and, increasingly, nursing staff in a hospital environment. However, peripheral venous line placement can be difficult, especially at the extremes of age or if the patient is obese, dark skinned, an intravenous drug abuser, is hypotensive or has multiple injuries limiting the number of limbs available for use. Central venous line placement is not to be undertaken lightly as a substitute for difficult peripheral venous access. The procedures involved usually require a high level of operator skill, as well as conferring a risk of morbidity and mortality.Central venous lines can, in any case, be inserted via peripheral veins if required. Proper selection of site and optimal technique will minimise the need for repeated attempts at venous access.
compress (pads soaked in lukewarm water) for at least 2–3 minutes will improve venous visibility. This is achieved by increased local blood flow which increases venous distension. Immersing the limb in warm water may achieve the same effect. The use of betadine swabs is reportedly helpful in dark skinned patients. Gently wiping the skin with an alcohol swab may help visualisation of the vein as the reflection of the light off the skin changes. Transillumination may help at this stage. The lights in the treatment room need to be turned off and a torch can be placed under the limb to visualise the veins. Venous visualisation may also be possible, even with haematoma formation and with previously punctured veins. The Landry light is a portable battery-operated device which uses a halogen light source delivered through dual fibre-optic arms which rotate 360°. Veins can be identified between the fibre-optic arms as dark lines in the pinker subcutaneous tissue. Surface veins appear darker and more defined than the diffuse lines of deep veins. It does, however, require experience in interpreting visual cues, which is not difficult to acquire.Topical venodilatation may be achieved by the application of 4% nitroglycerin ointment, smeared onto the skin and left for 2–3 minutes.[16,22,24]
Infusion of small veins beyond a proximal tourniquet with a bolus of warm crystalloid may help in improving visualisation of larger veins, when large bore access is required. Ultrasound-guided venepuncture has been described for placement of central venous lines via peripheral veins. This is operator dependent, with a long learning curve, but with increasing availability of ultrasound facilities in accident and emergency departments and perhaps on general wards and in clinics, may become an option for the near future. The use of a transversely oriented 7.5 MHz linear transducer is helpful to locate superficial veins which can be identified even in the presence of oedema. In one study, a hand-held Doppler was felt to accurately identify forearm veins larger than 2 mm in diameter in patients with invisible and impalpable veins, in the presence of a venous tourniquet. [31,18,21]
Children where intravenous cannulation may be predicted to be difficult 1 Patient groups
• The chubby infant and young child (aged 6–18 months) • The obese child
• Children who have undergone multiple previous peripheral cannulations: – ex-premature child (neonatal intensive care unit graduate)
– former paediatric intensive care unit patient 2 Poorly compliant children
• The anxious child • The needle-phobic child • The combative child
• Down syndrome • Mucopolysacharridoses • Certain skin conditions (epidermolysis bullosa, eczema) • Diseases causing limb contractures (arthrogryposis multiplex, dystonic/spastic cerebral palsy) • The oedematous child (nephrotic syndrome, long-standing illness on paediatric intensive care unit)
4 Acute clinical situations • Large burns or scalds • The shocked child
• The child in cardiac arrest
5 Patients where available sites are limited by surgical considerations • Children having operations on multiple limbs simultaneously • Children with multiple limb fractures [13,15]
COMPLICATIONS CENTRAL VENOUS ACCESS Acute complications
Pneumothorax is the most common acute complication with central venous access, with reported rates as high as 4%. For this reason, an upright chest radiograph (or lateral decubitus image if the patient cannot sit upright) should be obtained after central venous access is attempted. The physician should personally view the image after the procedure and obtain radiologic interpretation if necessary.[11,12].Small (<10%), uncomplicated pneumothoraces usually do not require immediate evacuation unless evidence of compromised ventilation is present. Small pneumothoraces should be monitored to ensure that they resolve satisfactorily; they usually resolve spontaneously at a rate of approximately 1% per day. Failure of a small pneumothorax to resolve, an enlarging pneumothorax, or ventilatory compromise is an indication for evacuation (eg, with a thoracostomy tube). Of note, central venous lines that surgeons placed in the operating room rarely result in pneumothorax or bleeding complications.[12,14].Apart from the strategies described above, other measures to reduce complications include proper patient positioning, adequate assistance (eg, for restraint), holding positive-pressure ventilation during needle insertion, and radiologic (eg, fluoroscopic) guidance.[6,7,8]
Thrombosis and occlusion-Venous thrombosis is another frequent complication of long-term
venous access. Several etiologic factors are implicated in thrombosis of vascular-access devices, including the type, size, and location of the catheter, as well as the patient's underlying condition. Large catheters with multiple lumina likely disturb the surrounding blood flow, leading to thrombosis.[19]Procedures in coagulopathic patients
In the presence of a coagulopathy, a more experienced operator should insert the CVC, ideally at an insertion site that allows easy compression of vessels. Femoral access may have a lower risk in this situation. Routine reversal of coagulopathic abnormality is only necessary if platelet count < 50 × 109.l−1, activated partial thromboplastin time > 1.3 times normal and/or international normalised ratio > 1.8, as the risk of hemorrhage is not increased 23. In selected patients, different thresholds for correction may be acceptable. Bleeding risks of insertion and removal vary with the site, size of device, and operator experience. The risks of correction (e.g. infection, lung injury, thrombosis) may exceed that of local bleeding, and it may be preferable to give blood products if problems occur, rather than prophylactically. Vascular access is the most common invasive procedure undergone by patients in secondary care. It is often poorly undertaken and is the source of considerable patient discomfort and inconvenience, as well as morbidity and mortality. Vascular access is essentially a single, often repetitive, task but providing a quality service requires more; this includes all aspects of human factors as well as education, training, audit and technical proficiency
6.ORGANISATION AND METHODOLOGY OF A RESEARCH
A search was conducted in the medicine literature, regarding this topic and using PubMed and Google. The keywords and terms for searching were used: vascular access, venous access, children pediatric, complication, adjunct techniques.
as compared to other veins in critically ill patients [7]. However, in children, the carotid artery is located close to the IJV. The risk of inadvertent carotid puncture during IJV access can be as high as 25% [8]. Moreover, 18% of children exhibit variations in IJV anatomy. For example, in 34% of children, the IJV is located lateral to the carotid artery [9]. In 4% of children, the IJV is smaller than anticipated (< 3 mm for neonates and < 5 mm for older children) and more proximal to the carotid than in adults, leading to a greater risk of artery puncture [10].Traditionally, venous access has been performed on the basis of surface landmarks. However, some pediatric series have reported cannulation failure rates as high as 60% with traditional venous access procedures [11]. Ultrasound (US) guidance for central venous access could allow direct identification of arteries, veins, and adjacent structures, improving the safety of the procedure. The importance of US-guided venous access has increased in recent years [12]. Since 2002, the National Institute for Clinical Excellence (NICE) has recommended US guidance as the method of choice for access to the jugular vein in adults and children [13]. Nevertheless, this procedure has not been universally adopted in children [11]. Materials and methods -This prospective, randomized study was performed at a university hospital.. The legal guardians of all children were required to provide written informed consent for participation, and patients over 6 years old were also asked to provide assent.
The inclusion criteria were children (age 0–18 years) admitted to the study hospital, between September 2013 and July 2014, who required central venous access (at the discretion of the attending physician). Children with disorders of coagulation were excluded, as were tracheotomised patients (because of the proximity of respiratory secretions and the higher likelihood of catheter-related bloodstream infection).[11]The patients were randomized into two groups: US-guided IJV cannulation (intervention group) and IJV cannulation by the traditional, landmark-based method (control group). Randomization was performed case by case, at the time of the procedure, using a simple coin toss.
Recorded variables included the weight and age of the patient, the puncture site (right or left IJV), the unit of the hospital where the procedure was performed (theater or PICU/NICU), time needed to locate the vessel, time needed for successful puncture, number of puncture attempts, time needed to cannulate the vein, and number of complications (Appendix A). The number of puncture attempts was limited to five in one session, after which the procedure was considered a failure.[12]
Statistical analysis
Continuous variables were asymmetrically distributed and thus described as the median and interquartile range (IQR). Categorical variables were described as absolute and relative frequencies. The Mann–Whitney U test was used to compare medians between groups, and the Pearson's chi-squared or Fisher's exact test to compare proportions. All analyses were performed in SPSS version 21.0. Differences with a P-value ≤ 0.05 were considered statistically significant.[12]
7.RESULTS
Fifty-seven patients (age range: 3 days to 18 years) were included in the study. Six patients were excluded because of missing data. Of the remaining patients, 23 had been assigned to the US-guided group and 28 to the control group. There were no between-group differences in age (3.8 [1.8– 8] y and 3.2 [0.9–9] y, respectively; P = 0.373), sex, weight, hospital setting where the procedure was performed, or puncture site.[11,12]
Findings
punctures, and dehydrated patients without peripheral access who have been referred from other wards within the hospital.[14]
In the pediatric population, obtaining venous access in high-risk neonates, severely ill children with cardiac anomalies or very young children (<10 kg) can be very challenging. In the literature to date, the greater saphenous vein has not been primarily used by interventional radiologists as an entry site for venous access in children. To demonstrate the utility and effectiveness of using the greater saphenous vein as a venous access site for the placement of peripherally inserted central catheters in children.[15]
All of the children were transferred to the interventional angiography suite and catheter placement performed by attending pediatric interventional radiologists using general anesthesia. The 3 attending pediatric interventional radiologists participating in the study had 32,19 and 14 years of experience, respectively. Greater saphenous venous access was obtained at the level of the medial malleolus in the ankle using anatomical landmarks via the interventional radiology nurses and at the level of the thigh using US-guidance puncture performed by the interventional radiologists. Deciding between the two puncture sites was determined by ease and availability of candidate veins. The pediatric interventional nurse or anesthesiologist initially attempted venous access into the greater saphenous vein at the level of the medial malleolus. If unsuccessful, ultrasonography of the thigh was performed to assess for accessibility in the greater saphenous at this level. The utilization of US guidance in vascular access has been discussed extensively in prior publications. [17]
Successful PICC placement via the greater saphenous vein was achieved in 67 of 86 children (78%). The mean weight of the 67 children who underwent successful placement was 9.98 kg (range: 2.2– 59 kg); with 51 (76%) weighing <10 kg. Eighty-one percent of these children were younger than 2 years of age. Within the failure subgroup, failure to access the saphenous vein was the most common reason for failed placement. In a subgroup of 6 children with access established at the ankle, there was failure to pass the guidewire or catheter above the level of the knee. Contrast injection in two of these cases confirmed the presence of venospasm within the greater saphenous vein at the level of the knee[18]
decreased potential for future compromise to central venous access. In addition, sparing larger venous vessels, such as the femoral vein, may be advantageous in preservation for future interventions and therapies [10]. Successful utilization of the greater saphenous vein has been described in the oncology literature [11].
In children, the greater saphenous vein provides a safe, suitable alternative for venous access, particularly in very young children (<10 kg) and in a select group of older children who are not mobile. In the lower extremities, greater saphenous venous puncture and access may be a preferred initial access site in small children to preserve future venous access.
7.DISCUSSION OF RESULTS
Obtaining peripheral vascular access in pediatric patients is a complex, time-consuming procedure that is particularly difficult in small children.Young children, including infants and toddlers, have more subcutaneous tissue than older children and adults. In addition, their veins are a smaller caliber and are difficult to visualize and palpate, which contribute to a low rate of insertion success on the first attempt.2,3 Studies conducted with children have shown failure rates for the procedure that range from 9% to 36%, result in several attempts, and in some cases, contribute to related complications, such as hematoma and stress.[1,4].Pediatric nurses, who are responsible for achieving better results during peripheral catheter insertion in children, strive to improve practice. One potential innovation for increasing successful venipuncture could be the use of vascular ultrasound, which has already proved efficacious for central vascular access.Only a few studies have examined the use of ultrasonography for peripheral vascular access in children, and the results differ with regard to success rates[4,12]Two randomized trials were performed in children with a history of difficult access or of previous unsuccessful attempts at insertion using the traditional standard landmark method. The first study was unable to demonstrate a clinically important benefit in a static, ultrasound-aided catheter insertion technique,[12] ]but the second study concluded that ultrasonography-guided catheter insertion improved overall success rates by 16% compared with the standard landmark method. However, no significant difference in success rates was observed in children with difficult access.Two nonrandomized studies concluded that ultrasonography-guided peripheral venipuncture in children could be a significant benefit, reducing the number of insertions and potentially reducing insertion-related pain and the risk of infection.[13,14] This study analyzed whether the use of ultrasound during the routine insertion of peripheral catheters and site identification would increase the insertion success rate and reduce the incidence of infiltration and phlebitis compared with the standard landmark method for catheter insertion.
and increase the visibility and palpability of the veins. To increase the success rate of venipuncture in children, the following other techniques have been used.[19]
Local warming
Local warming dilates the arterioles and decreases α2-adrenergic vasoconstriction. The hand or lower arm can be warmed by wrapping it in towels moistened with warm/hot water or immersing it in warm water. Only one randomized controlled trial assessed the effect of this procedure in facilitating insertion of venous cannulae. In adult patients, Lenhard and co-workers’ [2] showed that local warming facilitates the insertion of venous cannulae, and reduces the time and number of attempts required.
Transillumination techniques
Finding an accessible vein in infants is frequently difficult when the skin is coloured, the infant is dehydrated, obese or shocked, or when the commonly accessible veins are exhausted. Transillumination techniques have been used for many years to facilitate arterial puncture [3] and venous access [4]. Various devices for transillumination have been described but have not gained popularity. Commonly used are cold-light fibreoptic techniques; complications (burns) are rare but possible [5,6]. A 40% efficacy of palm transillumination using a common otoscope in an emergency department setting was recently reported [7], and venous access could be established in 39 out of 40 patients with just one venipuncture
Epidermal Nitroglycerine
infiltration in 37.5%, and phlebitis in 27.5%. In the CV group, arterial puncture occurred during insertion in 2 (3%) patients with no adverse sequelae, catheter slippage occurred in 4 (5%), and poor flow in 2 (3%). A large majority (79.2%) of CV lines functioned successfully until no longer needed, as compared with 15% of PVC catheters. The latter were removed before completion of treatment because of poor flow (40%), phlebitis (20%), or catheter problems (10%). Catheter sepsis was documented in only one CV line. Two cutdowns had major local infections. The average catheter longevity was 10.2 days for CV lines, 4.1 days for PVC.[29].Peripheral venous access is usually required for administration of fluids or medications in hospitalized children. Even for experts, peripheral venipuncture in infants and adolescents is difficult because of small and deeply-located veins. Several devices adjunct to vein identification and catheter insertion have been devised in the attempt to optimize peripheral catheterization . The VeinViewer the latest of such devices and was designed to facilitate vascular access by using near-infrared light (NIR) [1, 4, 9]. NIR emitted from the device is absorbed or scattered in the forward direction by blood, whereas it is scattered in all directions in skin and subcutaneous fat. The light reflected from the vein is detected with a video camera. The resulting image is processed by a computer and then projected back onto the skin, showing veins as black lines against a green background[29]Nurses who had at least 3 years of experience working in pediatric wards or neonatal pediatric intensive care units were enrolled in this study. Because none had previous experience using the device, participating nurses were given two weeks of hands-on experience to become accustomed to the VeinViewer.All procedures were performed in a treatment room under natural light. Before starting each procedure, the difficult intravenous access (DIVA) score of the patient was evaluated [12]. DIVA score is a clinical prediction rule comprising four proportionally weighted variables (vein palpability, vein visibility, patient age, and history of prematurity) which is used to identify patients at high risk of first-attempt intravenous access failure. A DIVA score greater than 3 was reported to estimate a more than 50% failure rate at the first attempt [12]. The nurses also judged the level of intravenous access difficulty subjectively as one of the following three categories: easy, intermediate, and difficult.Each patient was randomized to either the VeinViewer® or control group according to a computer-generated random number. The group assignment card for each patient was sealed in an opaque envelope until the assessment for the difficulty of intravenous access was completed. In the VeinViewer® group, venipuncture was conducted aided by VeinViewer® for the first attempt. If the first attempt failed, the decision about whether to use the VeinViewer® in subsequent attempts was left to the nurse's discretion regardless of the patient’s allocated group.
the procedural time, which was subdivided by preparation time (from tourniquet application to skin puncture), manipulation time (from skin puncture to vein puncture), and confirmation time (from vein puncture to confirmation). The procedural time was analyzed in patients who were catheterized successfully on the first attempt.[30]
Patient characteristics
Among the 128 patients screened for enrollment, 15 declined to participate and 2 were exempted because of schedule cancelations. Finally, 111 patients were randomized into one of the two groups, with 54 in the VeinViewer® group and 57 in the control group. In all patients, the first attempt was performed according to the allocated group. Overall, patient demographics and
characteristics were similar between the two groups[14] Findings
Visible-light transillumination is the longest visualization technique before ultrasonography and near-infrared modalities [5,7]. Both transillumination and ultrasonography require that a probe be held near the puncture site; ultrasonography in particular requires sterile technique because of the risk of infection related to contact. In comparison, the VeinViewer® is a standing-type device that illuminates near-infrared light from 30 cm above the skin, so there is no concern for infection, and nurses can devote both hands to the access procedure. The latest version of the VeinViewer Vision® is smaller than the previous one and has improved portability and diminished discomfort caused by the space it occupies during the procedure. However, there were several weaknesses of the VeinViewer® as reported by the participating nurses; the magnification of the vein image made veins appear larger than their actual width, the vein image became sluggish when the patient moved his or her extremities, and the two-dimensional nature of the image makes it difficult to guess the depth of the vein. For these reasons, the VeinViewer can be a hindrance rather than a help, especially in patients who normally would be easy to access. In the post-study survey, most participating nurses answered that they would like to use the VeinViewer® only in patients for whom they expect first-attempt failure.[12]
available to identify children with difficult intravenous access. Recently, DIVA score was validated with an area under the receiver operating characteristic curve of 0.72. The VeinViewer was helpful in pediatric patients who were predicted to have difficult venous access, enhancing first-attempt success rate.[19].Safe vascular access is integral to anesthetic and critical care practice, but procedures are a frequent source of patient adverse events. Ensuring safe and effective approaches to vascular catheter insertion should be a priority for all practitioners. New technology such as ultrasound and other imaging has increased the number of tools available. This guidance was created using review of current practice and literature, as well as expert opinion. The result is a consensus document which provides practical advice on the safe insertion and removal of vascular access devices.[25]
Multidisciplinary paediatric vascular access teams
Many children's hospitals have introduced specialized vascular access teams resulting in improvements in central line-associated blood stream infections, a reduced need for sedation and anaesthesia, and improved patient experience.16 The teams may utilize the skills of specialist nurses, surgeons, interventional radiologists and play specialists, and also anaesthetist’s’. The exact structure and scope of the team will be dictated by local needs and the available skill mix. Safe vascular access is integral to anesthetic and critical care practice, but procedures are a frequent source of patient adverse events. Ensuring safe and effective approaches to vascular catheter insertion should be a priority for all practitioners. New technology such as ultrasound and other imaging has increased the number of tools available.
8.RECOMMENDATIONS TO HEALTH CARE PROFFESSIONALS
Continuous infusion of IV fluids
Assessment and documentation of findings are to be completed hourly to determine effective delivery of prescribed medications and fluid.
-Each bag of fluid is independently double checked and a signed patient label is put on the bag.
-Check the solution is the prescribed one, the rate of infusion, and the amount infused is noted.
-Document the infused volume: Hourly on fluid balance flowsheet (it is advised to clear the infusion pump hourly)
-Review the cumulative volume infused and fluid output as required based on patient’s clinical condition.
-Pump pressures for each IV line should be documented hourly or when adjusted on the flow sheet.[22,24]
Infusion Pump Pressure
Pressure limit defaults for intravascular infusion pumps are programmed by Biomedical Engineering, based on the manufacturer’s recommendations.
Upper limit infusion pump pressure can be manually increased with clinical discretion to accommodate:
*Increased viscosity of the fluid being administered *High rate of the fluid being administered
*Reduced diameter of the intravascular catheter *Increased length of the intravascular catheter *Increased level of patient activity
*If pump pressure exceeds the recommended limits, check the patency of the PIVC.
Administration of bolus/loading doses:
Administering drugs:
Drugs administered via PIVC may be *diluted into a bag of IV fluids
*added to the burette of an infusion set
*prepared for administration via a volumetric infusion pump *in a syringe for use in a syringe driver
administered directly as a bolus or push
*The most appropriate method should be selected depending on volume of diluent required, patient condition, fluid balance and intended rate of delivery. [22,24]
Drugs administered via:
Burette of an infusion set: to dilute the drug in a smaller volume via burette giving system, hang the bag of infusion fluid and gradually open the roller camp to allow appropriate amount of diluent into the burette. Inject the prescribed drug into the burette via the additive port.
Infusion bag: Clean the access port with disinfectant swab before injecting prepared drug into infusion fluid bag via the additive port. Without contaminating the key part (spike) insert the spike on the administration set into the septum of the infusion bag.
Attach a completed drug label detailing the drug, dose, diluent, volume of diluent, date, time and signature of the nurse and the staff who double checked.
Access PIVC only after cleaning the access port and scrub the hub.
For intermittent infusions, IV lines which are disconnected are to be discarded between infusions. Ensure the cannula is flushed with normal saline once the giving set is disconnected from the cannula. For Opioid infusion bolus refer to the specific guidelines: Children’s Pain Management Service (CPMS)(opioid infusion guideline)
Administering blood products:
>Check patient and blood product identification as per the Blood Product Transfusion Procedure.
>Administer blood product transfusions via a volumetric infusion pump or syringe driver to ensure accurate delivery. Use gravity sets only when rapid administration is required with diligent monitoring of volume.
>Use a Neonatal transfusion set (includes a 170 to 200 micron filter required for blood products) and syringe driver for delivering small volumes of blood products.
>Using aseptic non touch technique, spike the blood product septum with the Neonatal transfusion set and attach an appropriate sized syringe for the transfusion to the 3 way tap. >Draw the required volume into the syringe and prime the rest of the neonatal transfusion set. Label the syringe with both patient and blood product identification details including expiry date and time of blood product.
>If rapid transfusion of small volumes is required, draw the required volume into a syringe through a 170 to 200 micron filter.
>Burettes should not be used for transfusion of blood products.[ 22,25]
Flushing of PIVC’s
>If the cannula is accessed intermittently for the administration of medications or fluids, the cannula should be flushed prior to infusion or at least once a shift.
>Sterile 0.9% sodium chloride for injection should be used to flush a catheter. This must be prescribed as a medication.
>Use 10ml syringe for flushing to avoid excessive pressure and catheter rupture. >Syringes with an internal diameter smaller than that of a 10mL syringe can produce higher pressure in the lumen and rupture the catheter. If resistance is felt during flushing and force is applied this may result in extravasation
>Use aseptic non touch techniques including cleaning the access port (scrub the hub) with a dual disinfectant agent (e.g. chlorhexidine and alcohol) vigorously for at least 15 seconds and allowing to dry prior to accessing the system.
>Flush in a pulsatile (push-pause) motion. Flush catheters: [22,24]
* Immediately after placement
*Prior to and after fluid infusion (as an empty fluid container lacks infusion pressure and will allow blood reflux into the catheter lumen from normal venous pressure) or injection . *Prior to and after blood drawing
Change of PIVC dressing and securement of cannula:
>Dressings to PIVC sites are the first line of defence against infection and dislodgements. The dressing must be kept secure, clean dry and intact.
>Indications for dressing change: when it becomes insecure or if there is blood or fluid leakage under the dressing.
>Determine the need for an assistant considering patient age, developmental level and family participation prior to the procedure.
>If patient is allergic to transparent film dressings, use sterile film dressing to be used and changed daily.
>Carefully remove the old dressing, holding the cannula in place at all times
>Take the opportunity to thoroughly inspect the site of entry of the cannula for any sign of infection.
>Skin preparation using alcohol in 2% chlorhexidine is the preferred solution for dressings.
>Cleanse the area around the catheter insertion site including under the hub using a pattern which will ensure entire area is covered.
>Allow skin preparation to air dry prior to applying any dressing, this allows the disinfectant to work.
>Consider placing a small piece of sterile cotton wool ball or gauze underneath the hub of the cannula to reduce pressure.
>Cover the cannula insertion site with sterile transparent semipermeable, occlusive dressing (e.g. Tegadermtm, IV 3000tm) placed using an aseptic non touch technique over the catheter. This will allow continuous observation of the site and to help stabilise and secure the catheter.
>IV board / splints are recommended to secure PIVC placed in or adjacent to areas of flexion. This will adequately immobilize the joint and minimise the risk of venous damage resulting from flexion. [15,19,21]
>When using Splints, ensure these are positioned and strapped with the limb and digits in a neutral position to prevent injury from restricting blood or nerve supply and to prevent pressure sores
Inspect the splint at least daily and change if soiled by blood or fluid leakage.
>Cover with non-compression tubular bandage. Ensure there is a clear window where the cannula enters the skin- insertion site, so the site can be regularly viewed.
>In Summary, when dressing a peripheral IV cannula ensure: it is secure
*the site is visible
*the child can't injure themselves, or be injured by the connections *the child can't remove or dislodge the cannula
*tapes are not too tight or restrictive.
>Documentation shall contain information on the insertion site, gauge of the needle and date and time of insertion
Change of Extension sets
>Extension sets are to be changed when the access device is changed or immediately upon suspected contamination or when any break in integrity.
>Extension sets are to be primed and attached to the cannula at the time of IV insertion using an aseptic non touch technique
>When exiting the flushing of extension set you must use a positive pressure clamping technique.
>When not in use, extension sets must be clamped [23,24,28]
IV Fluid Considerations via Peripheral IV line
Which Fluids and how much fluids to use
>Refer to the Intravenous Fluids Clinical Practice Guideline: Intravenous Fluids
>Label the fluid bag/syringe with date, time, patient name and signature of two checking staff.
>Label IV line if multiple lines are running: label close to the fluid bag or syringe or below the drip chamber.
>If additives are added to infusion, please label the bag or syringe driver with additives added.
Approved label can be generated by the EMR.[3,9] Fluid bag and infusion changes:
>Fluid bags and syringes with nil additives are changed at least every 7 days. >Fluid bags and infusions with additives are changed every 24 hours.
>Fresh blood products and lipid containing solutions; both the bag, syringe, giving set and lines should be removed or changed at conclusion of infusion or at least every 24 hours. Line changes
>Infusion lines are replaced at least every 7 days using standard aseptic technique.
>Administration sets that have been disconnected (either accidentally or planned) are no longer sterile and to be discarded and replaced.
>If using fresh blood or fresh blood products replace line(s) at the end of the infusion. >If lipid emulsion is being infused change the lipid syringe/bag and line every 24 hours. Removal of PIVCs:
There is no evidence for routine replacement of PIVC unless clinically indicated. PIVC’s should be maintained with regular assessment and documentation of complications. The possible reasons for removal of PIVC’s include a number of complications which range from infiltration, extravasation, phlebitis, occlusion, dislodgement and migration. Once the child’s treatment is over, the PIVC should be removed to avoid any additional complications. • Perform hand hygiene
• Prepare patient and caregiver
• Perform hand hygiene and apply non-sterile gloves, carefully remove the adhesive dressing, holding the cannula in place at all times
• Hold a piece of sterile gauze or cotton wool over the exit site but do not apply pressure • Slowly withdraw the cannula, maintaining a neutral angle with the child’s skin • Cover site with dressing e.g. pressure dot, cotton wool and tape or Band-Aidtm • Advise the child and family that the cotton wool and tape or Band-Aid should remain
in situ for up to 24 hours
• Dispose of waste according to clinical practice, perform hand hygiene
• Document date and reason for removal. Ensure the device is also removed from the LDA in EMR.
Management of complications
There are a range of complications that could occur with the presence of a PIVC in insitu. Some of these complications can be prevented by the correct use of aseptic technique for insertion and maintenance as well as assessing the device as indicated.
• Infection:
*Skin-based bacteria may enter through insertion site *Local cellulitis or systemic bacteraemia are possible.
*Phlebitis: Vein irritation >Due to the presence of the catheter/fluids or medication >Chronically ill patients requiring multiple and recurrent IV access.
>Infiltration/Extravasation: delivery of fluids or medications into surrounding tissue
>If Infiltration/extravasation occurs... (Link to neonatal extravasation guideline). >Immediately stop the infusion and disconnect the tubing as close to the catheter hub as possible.
>Remove the catheter without placing pressure on the site. >Elevate the affected limb.
>Apply either ice packs or warm compresses to the affected area, depending on the drug that extravasated.
>Continue to assess and document the appearance of the site and associated signs and symptoms. Some signs, such as erythema and ulceration, may be delayed for 48 hours or more after the extravasation.
>For neonatal extravasation refer to RCH guideline Neonatal Extravasation Plastics team to review the patient
>Document the date and time of the infusion when extravasation was noted, the type and size of catheter, the drug administered, the estimated amount of extravasated solution, and the administration technique used.>Document the patient's signs and symptoms, treatment, and response to treatment. >Include the time you notified the patient's primary care provider and the primary care provider's name.[27]
