Technique For Peripheral Venous Access

Care must be taken to minimize the risk of local infectious complications, which occur in up to one-third of patients undergoing venous catheterization and may rarely result in septicemia. Insertion of peripheral venous catheters should be preceded by a surgical prep and followed routinely by placement of a sterile dressing. Consideration of the indications for venous access and what constitutes appropriate and adequate access in individual patients will minimize risk and facilitate management of emergencies when they occur. If peripheral veins are small, size and visibility can be enhanced by application of hot, moist compresses for 5 min, by tapping gently on the vein before attempting puncture, or by application of nitroglycerin ointment (0.4% for children less than 1 year old; 2% for others) over an area 1 in. in diameter for 2 min and then wiping off. Once access has been obtained, gentle circumferential occlusive taping may be necessary if stability of the site is tenuous, with the IV line looped and secondarily secured to prevent traction at the point at which the line penetrates the skin. The size of the catheter can usually be determined by the color of the hub; otherwise, it should be written on the tape dressing. When venous access is required primarily for drug administration, consideration should be given to placing a saline or heparin lock. By comparison with adults, obtaining IV access in children is often a challenge. Children tend to be more anxious and thus uncooperative. Generous subcutaneous fat may prevent vessel palpation and direct visualization. Finally, a child's vessels are smaller, and children readily lose body heat, which promotes vasoconstriction.


Complications from placement of peripheral IV lines include hematoma formation, phlebitis, and cellulitis. Phlebitis may occur in up to 75% of hospitalized patients. There is general agreement that catheters should not be left in place for longer than 3 days before replacement. Nerve and tendon damage, deep venous thrombosis, suppurative thrombophlebitis, and septicemia are rare. The unusual event of extravasation of irritative, vasoconstricting, or tissue-toxic substances such as 50% dextrose, epinephrine, phenytoin, and some drugs used for chemotherapy of malignancies may cause problems ranging from minor pain and inflammation to full-thickness sloughing of skin, necessitating skin grafting. In rare situations, reactive arterial vasospasm has led to ischemia and ultimately tissue necrosis in extremities with very distally placed IV lines that may have infiltrated. Catheter-over-needle assemblies are now in common use and provide more stable, reliable access than the steel needles they replaced. Microparticulate matter in IV solutions is removed by in-line micropore filters.

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