43: Venous Access: Peripheral Intravenous Catheterization

Vascular access in nonemergent and emergent situations for the administration of intravenous (IV) fluids and medications

Administration of parenteral nutrition

Administration of blood and blood products

Blood sampling (only after initial IV placement)

Basic. Armboard, adhesive tape, tourniquet, alcohol swabs, normal saline for flush (0.5% normal saline if hypernatremia is a concern), povidone-iodine solution/swabs, transparent dressing material; appropriate IV fluid and connecting tubing, transillumination equipment (optional). In-line filters are sometimes used.

Intravenous catheter. Safety-engineered (shielded) devices preferred: 23- to 25-gauge scalp vein (“butterfly”) needle or a 22- to 24-gauge catheter-over-needle. Use at least 24-gauge for blood transfusion.

Scalp vein (“butterfly”) needle

1. Select the vein. Neonatal IV sites are shown in Figure 43–1. It is useful to select the “Y” or crotch region of the vein, where 2 veins join together for the insertion. To help identify the vein, use palpation, visualization, and transillumination. The dorsum of the hand is the best choice to preserve the sites for potential central venous catheters (cephalic, brachial, greater saphenous veins) if needed. Avoid areas of flexion.

   1. Scalp. Supratrochlear, superficial temporal, or posterior auricular vein (last resort).

   2. Back of the hand. Preferred site using the dorsal venous network. This includes the dorsal metacarpal veins.

   3. Forearm. At the wrist area is the cephalic and basilic vein. Median antebrachial or accessory cephalic vein are higher up on the forearm.

   4. Foot. Dorsal venous arch.

   5. Antecubital fossa. Basilic or cubital veins.

   6. Ankle. Greater and small saphenous veins.

2. Shave the area if a scalp vein is to be used. Try to place needle behind the hair line in the event of cosmetic scarring.

3. Restrain the extremity on an armboard. Or have an assistant help hold the extremity or the head.

4. Pain management. The American Academy of Pediatrics (AAP) recommends topical anesthetics (eg, eutectic mixture of lidocaine and prilocaine [EMLA]) applied 30 minutes before the procedure. Oral sucrose/glucose, pacifier, swaddling, and other nonpharmacologic methods can be used for pain reduction.

5. Apply a tourniquet proximal to the puncture site. If a scalp vein is to be used, a rubber band can be placed around the head, just above the eyebrows.

6. Clean the area with povidone-iodine solution. Allow to dry and wipe off with sterile water or saline.

7. Fill the tubing with flush and detach the syringe from the needle.

8. Grasp the plastic wings. Using your free index finger, pull the skin taut to help stabilize the vein.

9. Insert the needle through the skin in the direction of the blood flow and advance ∽0.5 cm before entry into the side of the vessel. Alternatively, the vessel can be entered directly after puncture of the skin, but this often results in the vessel being punctured “through and through” (Figure 43–2).

10. Advance the needle when blood appears in the flash chamber or tubing. Gently inject some of the flush to ensure patency and proper positioning of the needle.

11. Connect the IV tubing and fluid, and tape the needle into position.

12. Heparin is not recommended for peripheral IV lines. Cochrane review states that heparin in IV fluid may reduce the IV tube changes but could have serious adverse effects. More studies are needed before recommendations can be made on heparin use in neonates with peripheral IV (PIV) catheters.

Catheter-over-needle assembly

1. Follow steps 1–6 for the scalp vein needle.

2. Fill the needle and the hub with flush via syringe, then remove the syringe.

3. Pull the skin taut to stabilize the vein.

4. Puncture the skin then enter the side of the vein in a separate motion. Alternately, the skin and the vein can be entered in one motion.

5. Carefully advance the needle until a flash of blood appears in the hub.

6. Activate the shield to sheathe the needle and advance the catheter. Injecting a small amount of flush solution into the vein before advancing the catheter may help.

7. Remove the tourniquet and gently inject some normal saline into the catheter to verify patency and position.

8. Connect the IV tubing and fluid and tape securely in place using transparent dressing.

Hematoma (most common complication) at the site can often be managed effectively by gentle pressure.

Phlebitis (inflammation of the vein) risk increases the longer a catheter is left in place, especially if >72–96 hours. Sites are rotated at 72- to 96-hour intervals to decrease phlebitis and infection.

Vasospasm rarely occurs when veins are accessed and usually resolves spontaneously.

Infection risk can be minimized by using sterile technique, including antiseptic preparation. The risk of infection rises after 72 hours. Rarely associated with bloodstream infection.

Embolus (air or clot). Never allow the end of the catheter to be open to the air, and make sure that the IV catheter is flushed free of air bubbles before it is connected. Don't use excessive force when flushing.

Infiltration/extravasation injury results from the leakage of fluid from a vein into the surrounding tissue, usually due to improper catheter placement or damage to the vessel. Infiltration of nonvesicant fluid does not cause necrosis, but a large volume can cause compression of the neurovascular structures, leading to compartment syndrome. Extravasation can cause a mild injury or severe necrosis (blisters, tissue injury, and necrosis) and may result in the need for skin grafting. To limit this, confirm intravascular placement of the catheter with the flush solution before the catheter is connected to the IV tubing. Infiltration often means that the catheter needs to be removed. Avoid hyperosmolar solutions for peripheral infusion, and use caution with dopamine, which can cause constriction. Vialon catheter material was found to reduce the risk of infiltration (35% in infants <1500 g) as compared to Teflon. See Chapter 31 for details on management of infiltration and extravasation.

Calcification of subcutaneous tissue secondary to infusion of a calcium-containing solution.

Fluid overload, electrolyte problems (hypernatremia).