2019 Oweek - PIVC - WSLHD

20-Mar-19

1

VP/PIVC

Insertion

2019

1

Anthony Marshall

CNC Vascular Access, Westmead

Page 9248

Content Indications

Considerations & Contraindications

Complications

Anatomy & Physiology

Vein Selection

Equipment

Procedure

Trouble Shooting/First Aid

Summary

2

0

1

2

3

4

56 7 8

9

10

11

12

13

14

3.5Human body

cannot sustain life

5.8Cancer cells

begin to form

6.8Disease

symptoms begin

★7.35-7.45

Ideal blood pH

TimentinCephazolin Penicillian

ACID ALKALINE

9.8Human body

cannot sustain life

8.5Disease

symptoms begin

Vancomycin Dilution Challenge

• Attempting to dilute an infusate with an extreme pH is volume prohibitive. The best option is hemodilution

• So how much dilution?X 20

• 1gram of Vancomycin reconstituted in

20mL sterile H20 = pH 3

• How much dilution will it take to

bring this 1gram dose to a peripheral

vein friendly pH of 6?• 20mL + 180mL = pH 4

• 20mL + 1980mL = pH 5

• 20mL + 19880mL = pH 6

20-Mar-19

2

Size Matters- Bigger is Better

Vessel Diameter Flow

Digital/Metacarpal Veins

2-5mm 20ml/min

Forearm Cephalic/Basilic

Veins

6mm 40ml/min

Basilic Upper Arm Vein

10mm 95ml/min

Axillary Vein 16mm 333ml/min

Subclavian Vein 19mm 800ml/min

SVC 20mm 2000ml/min

7

Considerations

• Clinical indications for PIVC• Alternatives have been considered• Benefits outweigh the risks!!!• Check pt:

• ID & allergies• obtain verbal consent• The rate at which fluid will be administered.

(indication/expected duration)• Position of patient during planned procedures• Size and condition of patients veins.• Present or Past medical history. (Renal, lymph node

dissection, mastectomy, CVA, injury or infection)• Non dominant and avoid certain area’s

Complications of IV

Therapy

Systemic complications

COMPLICATIONS

Local complications

Phlebitis

Haematoma

Infiltration

Extravasation

Thrombosis

Septicaemia - SAC 2

Pulmonary Oedema

Speed Shock (rapid infusion)

Anaphylaxis (allergic reaction)

Pulmonary Embolism e.g Thrombosis

8Braun Introcan Safety (2009)

20-Mar-19

3

PIVC Size and IndicationColour Gauge Ext Dia x

length (mm)Flow Rate (mL/min)

Yellow 24 0.7 x 19 23

Blue 22 0.9 x 25 36

Pink 20 1.1 x 32 40

Green 18 1.3 x 45 75

Grey 16 1.7 x 45 150

Orange 14 2.1 x 45 300

Triple Lumen CVC

16 7.5 Fr x 150 50

Site SelectionBest site for cannulation

•Cepahalic vein

(forearm)

Avoid unless necessary

•Anticubital fossa

•Digital

•Check site

•Apply tourniquet

•Vein should be round,

firm, flexible & full

•Ask for assistance if

uncertain if appropriate

site not found

•Release tourniquet

•Determine need for

topical or local

anaesthetic

10

Equipment� Eye protection and PPE

� Protective Blue sheet

� Disposable tourniquet

� Soluprep (chlorhexidine gluconate with alcohol)

� Cannulation pack

� Sterile gloves

� Cannula & Cannula Cap – “bung”

� Extension tubing

� Blunt drawing up needle/Syringe

� N/Saline

� Topical or local anaesthetic if indicated

� Date Label (Green Sticker)

� Sharps and garbage bin nearby

� All on standardised trolley in treatment rooms

12

20-Mar-19

4

13 14

•Cannulation Pack

15

Practice

20-Mar-19

5

17

Blood Safe PIVC

18

Blood Safe PIVC

19

Need Guidance and

Assistance

� Seek assistance if unable to insert after 2 attempts (new attempt should be proximal to original attempt)

� Note: Each attempt requires a new cannula

� Ultrasound machine available in B6c medication room

� All Cannula bacteraemia will be rated SAC 2 (Severity Assessment Code 2)

� Senior Management notification. Detailed investigation required to determine specific cause and improve practice.

20-Mar-19

6

A/H PIVC Team

21

U/S Guided PIVC• Difficult Intravenous Vascular Access

(DIVA) with 1 or more attempts

• Alerts:• Non visible/palpable veins

• Patient says “people always have trouble finding my veins”

• Patients who want a PICC, nobody “wants” a PICC

• Treatment less than 6 days, if longer, insert a midline or PICC

• U/S allows for more appropriate vessel choice

• Decreases risks of vascular depletion and improves outcomes

Completion

� Place insertion label on cannulation site dressing

� Electronic record entry

� Make sure patient is comfortable with buzzer in reach

� If medications or fluids due, advise RN that cannula is

inserted

If you following these practice guidelines

patients in your care will be SAFE

Post-insertion care

� Review of insertion site as part of routine clinical review

� Cannula change to occur as clinically indicated or

should not be left in for more than 72 hrs

Surveillance and re-site vital to prevent

complications or identify complications early

20-Mar-19

7

First Aid� Skin: wash the exposed site

with soap and water

� Eyes: rinse thoroughly while eyes are open with water/normal saline

� Mouth: spit out and rinse with water several times

� Clothing: remove, shower if necessary

Then….� Inform your manager/supervisor

� Complete an incident on IIMS

� Contact the person at your facility responsible for Occupational Exposure management:

During Normal Business Hours (0730-1600hrs)

� Westmead Staff Health Clinics

56777

Level 1, University Clinics

After hours:

� Present to ED

Venepuncture and Specimens� E-ordering for most

pathology tests, but not all.

� Label must have Emp No and Date/Time

� Blood Bank Specimens

� Equipment

� Order of Draw

� Sending test

� A/VBG’s

27

Blood Cultures

28

20-Mar-19

8

29

Policies and Procedures

Resources

•HETI