43: Venous Access: Peripheral Intravenous Catheterization

I. INDICATIONS

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

2. Administration of parenteral nutrition

3. Administration of blood and blood products

4. Blood sampling (only after initial IV placement)

II. EQUIPMENT

1. 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.

2. 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.

III. PROCEDURE

1. 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 ...