Introduction
Peripheral vascular access is an important emergency department (ED) technician (EDT) responsibility that involves cannulation of a peripheral vein for blood sample collection or medication, fluid, or contrast administration. The placement of an indwelling venous catheter allows the clinician to obtain multiple blood samples over time, avoiding the need for repeat sticks. Butterfly needles are most frequently used for single-time blood draws where the likelihood of ongoing sample collection is low. The scope of practice for EDTs varies from hospital to hospital, with some hospitals allowing techs to draw blood only through a butterfly needle. EDT’s should work within their scope of practice for their institution that will follow the regulations for their location.
Common sites to obtain intravenous (IV) access include the antecubital fossa (commonly called the AC), the back of the hand, the wrist, and the forearm. Knowing the anatomy of the arm and where larger vessels are expected to be located is helpful in identifying viable spots for access ( Fig. 15.1 ).
Needle through catheter devices come in different diameters (gauges) and lengths. Most devices in adults are 19 to 45 mm long, with the length increasing as the gauge decreases. Larger gauges permit increased flow but may be hard to place in smaller veins. Catheter diameter decreases as its gauge number increases. In most practice settings, gauges range from 14 gauge (largest) to 24 gauge (smallest).
Various products are available for both indwelling needles and butterfly needles. The EDT should be familiar with their institution’s products, as each product may have unique features, such as an autoretracting needle, a needle guard, or a permanent needle. All of the IV products will have universal color code for needle gauge ( Fig. 15.2 ). Finally, some institutions allow for placement of IVs under ultrasound guidance after completing additional training. Consult Chapter 16 of this manual for details of ultrasound-guided IV access.
Patient Triage and Assessment
Indications
The most common indications in the ED for IV access are the need for medication administration and obtaining blood for lab testin. As a general rule, vascular access should be obtained more urgently in acutely ill patients with lower Emergency Severity Index scores.
When deciding on the size and location of an IV, an EDT should consider what the IV is going to be used for. For example, if a patient needs aggressive IV hydration, an 18-gauge needle or larger is preferred. Whereas if a patient is going to receive slow IV push medications, a 22-gauge IV in the hand will be fine. A patient who needs a massive transfusion of blood would benefit most from a 16- or 14-gauge IV, as these lines are the largest and will allow the fastest flow. For the majority of patients, a 20- or 18-gauge IV in the AC will suffice for blood draws, medication, fluids, and contrast for imaging. Always think about why and how the line is going to be used to ensure the best placement and size for the patient.
Areas in Which IV Placement Should Be Avoided
The most common areas to avoid are areas that have been previously injured, have been operated on, or are near a dialysis fistula ( Fig. 15.3 ). Ask the patient if there are any sites that IV placement should be avoided. Patients with contraindications to IVs will be aware that they should not receive an IV at a particular site or will wear a medical band on the affected side. Additionally, vascular access should be avoided in areas of skin with overlying infection or injury to underlying structures, such as broken or dislocated bones.
Special Considerations
A variety of clinical conditions can complicate vascular access. Patients who have a history of injecting drugs often have significant scaring to the peripheral veins they have repeatedly injected into. These patients may have veins that they have not injected into previously and can direct the EDT to areas where vascular access is more likely to be successful. Patients with sickle cell disease or other chronic medical conditions requiring numerous previous IV placements may also have significant vein scaring making cannulation more difficult. Ultrasound guidance, which may be needed to gain vascular access in this patient population, is discussed in Chapter 16 of this handbook. The ED technician may encounter other IV access challenges, such as the loss of skin elasticity and aging-related venous fragility in elderly patients or decreased venous pressure in dehydrated patients. Vascular access troubleshooting tips are reviewed later in this chapter.
If multiple attempts to obtain vascular access are unsuccessful, the EDT should inform the provider caring for the patient. It is possible that the provider will ask another staff member to attempt to place the IV, or the provider will place alternate forms of vascular access, such as a central line, or request an intraosseous (IO) line.
IV Peripheral Vascular Access
Before initiating any procedure, it is vital that the EDT practice good hand hygiene and follow Universal Precautions, including wearing gloves and disposing of needles in designated sharps containers.
Equipment Needed ( Fig. 15.4 )
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Fig. 15.4
Standard intravenous start kit supplies.
(From Kaplan BL, Liu SW, Zane, RD. Peripheral Intravenous Access. In: Roberts JR, Custalow CB. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Elsevier; 2019:394-404.e2.)
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Chlorhexidine product or alcohol pad
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Tegaderm
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Tape
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Needle
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Extension set
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Vacutainer
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Tubes that correspond to labs ordered
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Gauze
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Saline flush
To start an IV line, begin by applying a tourniquet to the patient’s arm and feel for an appropriate vein ( Fig. 15.5 , picture 1). The tourniquet should be sufficiently proximal on the arm so that the EDT has the whole arm to search for a suitable location, and tight enough to slow venous blood return to engorge the veins making them more easily palpable. The tourniquet should not be so tight that arterial flow to the limb is compromised. A vein that is a good candidate for an IV line will be large, “bouncy”, and straight. These veins are most apparent in the antecubital space, forearm, wrist, or hands. It is important to feel for these veins and rely more on touch than visualization of a vein. A good place to start feeling is in the AC and then working down about an inch. Here the veins are still superficial, but the catheter is less likely to become bent with arm movement after successful placement.
