VENEPUNCTURE & PERIPHERAL VENOUS LINE

VENEPUNCTURE & PERIPHERAL VENOUS LINE

Preparation :

• Alcohol swab
• Topical anaesthetic (TA)
• Catheter or needle; sizes 25, 23, 21 G
• Tourniquet
• Heparinised saline, T-connector, rubber bung for setting an IV line

Indications :

1. Blood sampling
2. Intravenous fluid, medications and blood components

Complications :

1. Haematoma or bleeding
2. Thrombophlebitis
3. Extravasation of fluid or medications – this might lead to skin necrosis and gangrene. Neonates especially – digital ischaemia and even partial limb loss, nerve damage, contractures of skin and across joints

Procedure :

1. Identify the vein for venepuncture. Secure the identified limb and apply tourniquet or equivalent.
2. TA may be applied half an hour earlier.
3. Clean the skin with alcohol swab.
4. Puncture the skin and advance the needle or catheter in the same direction as the vein at 15-30 degrees angle.
5. In venepuncture, blood is collected once blood flows out from the needle. The needle is then removed and pressure applied once sufficient blood is obtained.
6. In setting an intravenous line, the catheter is advanced a few millimetres further. Once blood appears at the hub, then withdraw the needle while advancing the catheter.
7. Remove the tourniquet and flush the catheter with heparinised saline.
8. Secure the catheter and connect it to either rubber bung or IV drip.
9. Immobilise the joint above and below the site of catheter insertion with restraining board and tape.

Precaution - Extravasation

1. Signs include:

• pain, tenderness at insertion site especially during infusion or giving slow bolus drugs.
• redness
• swelling
• reduced movement of affected site.

(Note – the inflammatory response can be reduced in neonates especially preterm babies)

2. Observation

The insertion site should be observed for signs of extravasation:
• at least every 4 hours for ill patients.
• sick preterm in NICU – observation should be done more often, that is, every hour.
• each time before, during and after slow bolus or infusion.
(Consider re-siting the intravenous catheter every 48 to 72 hours)

3. If severe extravasation occurs, especially in the following situation:

• preterm babies
• delay in detection of extravasation
• hyperosmolal solutions or irritant drugs used (glucose concentration >10%, sodium bicarbonate, calcium solution, dopamine)

Refer to plastic surgeon / orthopaedics surgeon. Consider performing ‘subcutaneous saline irrigation’ especially for neonates. The drug hyaluronidase is not readily available. Therefore please use normal saline to flush out as much of the irritant drugs as possible

4. Reminder

• If the patient is in shock, the venous flow back and the arterial flow (in case of accidental cannulation of an artery) is sluggish.
• BEWARE! An artery can be accidentally cannulated, e.g. the brachial artery at the cubital fossa and the temporal artery at the side of the head of a neonate.
• Ensure the drug prescribed is given by the proper mode of administration. Some drugs can only be given by slow infusion (e.g. fusidic acid) instead of slow bolus in order to reduce tissue damage from extravasation.