“Peripheral Intravenous Line Placement” by Brienne Leary for OPENPediatrics
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“Peripheral Intravenous Line Placement” by Brienne Leary for OPENPediatrics

October 10, 2019

Peripheral Intravenous Line Placement by Brienne
Leary. Healthcare workers in all healthcare settings
should always adhere to the latest World Health Organization guidelines on hand hygiene and
barrier precautions before and after contact with a patient, bodily fluids, or patient’s
surroundings. For more information, please watch our video
entitled Hand Hygiene. Hi. My name is Brienne Leary and I’m a nurse in
the pediatric medical surgical ICU here at Boston Children’s Hospital. Today, we’re going to talk about the indications
for peripheral intravenous catheter, also known as a peripheral IV. I will demonstrate the procedure to place
a peripheral IV. In closing, we’ll discuss issues and troubleshooting. And how you can manage and care for your peripheral
IV. Indications and Contraindications. Peripheral intravenous access may be necessary
when a patient requires fluid, medications, blood products, or nourishment intravenously. Contraindications to consider. Avoid extremities with a broken bone or that
have experienced trauma, an area with compartment syndrome, any area with significant swelling
or edema, a site of a previous infiltrate in the same extremity. However, it’s important to note that you may
access the same vein above the infiltration site. You should also avoid any areas with open
wounds or broken skin. Equipment and Procedure. So, it is essential to gather the necessary
equipment before you start. The equipment you should plan to prepare is
the appropriate sized IV catheter, a two by two gauze, an alcohol or chloraprep solution,
clear adhesive dressing, clean gloves, tourniquet, a positive pressure cap if available, a T-connector
or extension tubing, saline flush, stabilization board, tape, and an alcohol-based hand sanitizer
or soap and water to perform hand hygiene. Now we’re ready for the procedure. You will have the most success if you prepare
adequately prior to beginning the procedure. First, choose the most appropriate sized IV
catheter for your patient. This should be chosen based on your patient’s
age, size, condition, and the primary use for the IV. Standard pediatric sizes are usually 24 to
20 gauge IV. Next, you’ll want to open the gauze and your
alcohol or chlorhexidine cleaning solution. If it is a presoaked pad, grasp the pad at
the corner and place it in the center of the two by two gauze. Open the T-connector and then prepare your
saline flush. If available, open the positive pressure cap. You’ll want to attach the normal saline flush
to the cap and prime the cap through with normal saline. This cap provides a safety feature that will
prevent back flow of blood from the vein or air entry into the vein when the extension
tubing or T-connector is not clamped. You’ll flush through the cap and the T-connector
to prime the tubing. Ensure that all air is removed. This is a note– if you plan to draw labs
upon placement of the peripheral IV, do not flush the saline through the connector. Instead, attach an empty syringe to the T-connector
extension tubing so that you can withdraw blood upon placement of the catheter into
the patient’s vein. Now, you can open the transparent film dressing. Next, you want to prepare your tape to have
it ready to secure your IV once in place. There are many variations of taping. Here, tape is prepared by tearing a few half
inch pieces along with a few short, one-inch pieces. Their application will be demonstrated shortly. It’s now time to wash your hands with an alcohol-based
hand sanitizer or soap and water. Next, you’ll prepare to put on your clean
gloves. It is not necessary to use sterile gloves
for this procedure. You’ll want to recruit other people to help
hold the child, if necessary. If possible, have parents present when doing
an IV to help soothe and calm the child. For infants, it can often help to swaddle
them in a blanket. Next, we’ll talk about how to best choose
a site for your patient’s peripheral IV placement. Sites most distal on any extremity are always
preferred. This allows you to use the same vein, but
at a location further up the extremity in the future. This may be needed as a result of an infiltration
or other issue that occurs at the original site. The dorsum of the hand is one of the most
common areas used in the pediatric population. Specifically, there is a large vein called
the cephalic vein that runs along the thumb down the wrist. The basilic vein is also present in the hand
and forearm. There are also a number of smaller vessels
which you might be able to access as well. The saphenous vein is located in the ankle. It is located right in front of the medial
malleolus, or the ankle bone, and runs up the inner part of the leg. Again, you will see other small vessels across
the dorsal surface of the foot and along the lateral edge. Any of these can be used if they appear large
enough. For infants or babies, scalp veins can also
be a great resource, particularly in those who are difficult to locate other veins. These veins run along the forehead and behind
the ear. A point of caution here– the temporal artery
can often look like a large vein and runs in front of the ear. Be sure to palpate to make sure that you don’t
feel a pulse before you attempt to cannulate for a peripheral IV. The direction of a scalp vein in terms of
valves always runs away from the top of the head. Here are some guiding principles. No matter where you choose to place your patient’s
peripheral IV, the direction of the IV catheter should always follow the direction of venous
blood flow. In the head, the catheter is placed to point
down to the feet. For the rest of the body, the catheter is
always inserted aiming up toward the head. Tourniquets are usually used to help find
veins. Elastic bands can be used on small babies
instead of traditional tourniquets, and especially for scalp IVs. If a traditional tourniquet is not available,
get creative. You can use any object that is able to temporarily
apply pressure in its place, such as a glove or even an assistant’s hand. Now we’re going to talk about the procedure
to place the IV. First, you will need to find the vein. You should visualize for the vein or you can
palpate and feel a bouncy tube. Sometimes, you will need to place the tourniquet
as your first step to help find the veins and fill them with blood to make it easier
to visualize. Next, you’re going to apply the tourniquet. You’ll loop the tourniquet under the patient’s
extremity and then pull both tabs upwards, cross the ends over each other, and then pull
one tab behind and under the other one. Pull it partially through to create a small
loop, but do not pull it all the way through. This will leave a tail for easy removal. Next, you’ll want to prep the skin using your
cleansing prep pad and gauze. Let the area dry for approximately 30 seconds. Remove the plastic covering from the IV catheter
exposing the needle and cannula. Loosen the catheter from the needle. Prepare approach the vein with the IV catheter. Make sure you hold the IV catheter with the
bevel of the needle facing up. Next, you’ll want to puncture the skin using
a 25 to 30 degree angle initially to access the vein. Insert the IV slowly to avoid going through
the vessel. Look for a flashback of blood in the catheter
as an indication that the IV is in the vessel. Once flashback is visualized, advance the
catheter slightly and then decrease the angle of the catheter to be more parallel with the
skin. Carefully advance the catheter off the introducing
needle by simultaneously stabilizing the needle and sliding the catheter completely under
the skin. If advancement stops, the catheter may be
hitting up against a valve. You can remove the tourniquet, attach a saline
flush directly to the catheter, and then try to advance while flushing in saline. After advancing the catheter, remove the tourniquet. If possible, apply pressure above the insertion
site and remove the needle. There should still be blood flowing back,
indicating that the catheter is in the vein. Secure your sharps, attach the T-connector,
and flush the catheter, looking for infiltration. Infiltration is caused when the catheter is
no longer in the vein and fluid is now infusing into the patient’s soft tissue. It can also occur when there is a hole in
the vein that has gotten large enough to allow for extra fluid to leak out around the insertion
site and into the tissue. Next, we’ll talk about securing the IV. If the T-connector has a metal or thick end,
place a piece of gauze under the end before putting the dressing on to protect the skin
from breakdown. You’ll want to dress the site with a transparent
occlusive dressing. Make effort not to cover the insertion site
with anything opaque. This is important so that the site can be
monitored for signs and symptoms of infiltration or phlebitis. Assess, again, for the patency by flushing
and clamp the T-connector. Secure the catheter with tape using the chevron
technique. This is shown here by taking a half-inch piece
of tape, adhesive side up, sliding it under the hub of the catheter and cross the tabs
over one another, adhering them to the patient on opposite sides. When necessary, use a second piece of tape
and secure the attachment device. When an IV is placed over a joint, use a supporting
device, such as an arm board, to keep the child from bending the extremity. A protective device can also be placed over
the IV to avoid accidental removal, such as with a sock or a wrap. The protective device should be removable
to allow for hourly assessment of the site for signs and symptoms of infiltration or
phlebitis. Next, you’ll want to put the date, time, and
size of the catheter on a piece of tape across the dressing. Troubleshooting. Now, we’ll talk about some troubleshooting
tips. In younger children, it may be difficult to
feel the veins. Instead, you’ll want to look for the telltale
bluish color. In older children, it can often be hard to
see the veins. In this case, you’ll want to use palpation
to find the veins. Again, it should feel like a bouncy tube. For patients who have limited veins, here
are some things you could try. In infants, remember to always check the scalp. You can always look in the patient’s upper
arm area to assess for veins. The small veins on the inside of the wrist
or fingers can also be useful. Just be cautious of the nerve supply that
runs through here. Finally, you can always check on the sides
or the back of the patient’s knees. For patients that are edematous, hypotensive,
in shock, or have signs or symptoms of poor perfusion, here are some things to try. Lower the extremity. If available, use a transilluminator or flashlight. This will work best if you dim the room light
and place the light behind the patient’s skin. You can also try to use a steeper angle when
accessing the vein and probe a bit deeper to get through the edematous tissue. Finally, you can take the plug out of the
end of the catheter, flush the catheter before you start to use it, and this will help the
blood show you a flashback a little bit quicker. Assessment and Monitoring. Before using the IV, make sure that it is
patent, for either continuous or intermittent use. If the infusion is continuous, monitor the
IV site frequently, at least every hour. Assess the site at the end of IV therapy. Once the IV is placed and deemed patent, place
an occlusive dressing that allows for visualization of the site. Manually flush the IV catheter to check for
patency, leaking, redness, blanching, and swelling. You should check the patient’s IV site frequently
for patency or signs and symptoms of complications. These complications can often include infiltration,
phlebitis, dislodgement, leaking, or loss of patency. Signs and symptoms of infiltration include
swelling and cooler temperature to touch around the IV site, blanching or white areas around
the IV site, difficulty flushing, cessation of blood return with aspiration. However, is important to note that this finding
alone does not indicate that an IV no longer works. Again, you should always flush the IV to assess
for patency and if it flushes easily without signs of leaking or blanching it may still
be usable and safe. Phlebitis is a little bit different. It is caused by medications or fluids that
have been delivered to the patient intravenously that have caused inflammation to the vein. Indications that phlebitis has occurred include
redness at the IV site, a red streak up the extremity along the vein, a hot feeling of
the skin, or the vein may now feel like a hard cord underneath the patient’s skin. Last, we’ll review documentation. You should always put the date and time of
the procedure in the patient’s chart. Note the size of the IV catheter used. You will also want to note the number of attempts
that were needed to place the peripheral IV successfully. Note the vital signs before, during, and after
the procedure. Chart the patient’s comfort with the procedure
and any interventions you took to provide care and comfort. Note any adverse outcomes. And finally, you will need to document routine
peripheral IV checks, again, monitoring for signs and symptoms of complications. Thank you for watching this video on how to
place a peripheral IV in a pediatric patient. Please help us improve the content by providing
us with some feedback.

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