Quite often the management of patients in the ED requires the establishment of intravenous access for acute resuscitation, hydration, pain control, patient monitoring, blood transfusion and blood sample collection. Although there are various techniques for achieving these objectives, the inclusion of a peripheral venous catheter is the first choice, being a simple, fast and with minimal complications for the patient when performed by staff with a good level of training and skill . This guide explains broadly the use of peripheral venous catheter and briefly describes other techniques para el acceso venoso.
Catéteres venosos centrales: es un procedimiento programado, que requiere estabilidad del paciente, tiempo y condiciones más exigentes en la técnica aséptica, por lo tanto, su inserción en urgencias no resulta práctica.
Sin embargo, la enfermera debe conocer su manejo, puesto que cuando el paciente llega a urgencias con el catéter instaurado está indicado su uso y no la inserción de un catéter venoso periférico.
Infusión intraósea: se utiliza para la administración de líquidos y medicamentos en niños menores de ocho años cuando los intentos por obtener un acceso venoso no han tenido éxito and in front of a revival.
is a temporary measure and should be replaced by venous access as soon as possible. The puncture is performed with spinal needle with stylet or Ga 16-18 gauge hypodermic needle attached to a syringe in the anteromedial aspect of proximal tibia. This procedure is contraindicated in patients over eight years, split, bone disorders and use of toxic drugs for the bone marrow. This procedure must be performed by a physician.
Venodiseción: is addressing a vein through the incision of the skin, subcutaneous tissue and direct insertion of a catheter into the vein. Is indicated in situations in which it was impossible for percutaneous puncture. Its use is increasingly restricted, as reports indicate an increased incidence of infections due to tissue manipulation, requires trained personnel, equipment and longer dissection surgery. It is performed most often in children.
In patients with multiple trauma site of choice is a saphenous vein at ankle level, making the front and cut 2 cm above the medial malleolus and tibial. Followed by the median basilic vein in the antecubital region, 2.5 cm lateral to the medial epicondyle of humerus in flexion crease elbow. In urgent cases we recommend dissection of the vein more easily identified, however, certain factors may influence this election, an example is the external jugular vein, easily accessible by very superficial, but the result is unsightly.
peripheral venous catheter: the use of peripheral intravenous catheters in patients with ED is a high frequency.
Like any invasive procedure has risks and complications, including phlebitis and thrombosis, in some cases altering the patient's progress and prolong hospital stay with a corresponding increase in the cost of care.
The progress in the last twenty years has been marked by introducing materials that cause less local reaction, reduce bacterial colonization and marked reduction in the caliber of the peripheral cannula. Despite the progress made has not been able to establish a protocol for management of peripheral venous catheters to provide security in reducing complications when placing a peripheral catheter, the only thing that is certain is that strict application of aseptic technique performing the procedure reduces complications. Other measures, such as placement of gauze versus transparent dressings, catheter periodic change and cure 24 hours after insertion, not ensure the absence of phlebitis and reactions at the insertion site. It all depends on the duration of intravenous therapy, the patient's activity level, skin conditions and the number of insertions already performed. INDICATIONS
• Fluid and electrolytes.
• Administration of intravenous medications.
• Transfusion of blood and its derivatives.
• Collection of blood samples.
• Maintain intravenous permeble emergency.
• Performing diagnostic studies.
PROCEDURE
Catéteres venosos centrales: es un procedimiento programado, que requiere estabilidad del paciente, tiempo y condiciones más exigentes en la técnica aséptica, por lo tanto, su inserción en urgencias no resulta práctica.
Sin embargo, la enfermera debe conocer su manejo, puesto que cuando el paciente llega a urgencias con el catéter instaurado está indicado su uso y no la inserción de un catéter venoso periférico.
Infusión intraósea: se utiliza para la administración de líquidos y medicamentos en niños menores de ocho años cuando los intentos por obtener un acceso venoso no han tenido éxito and in front of a revival.
is a temporary measure and should be replaced by venous access as soon as possible. The puncture is performed with spinal needle with stylet or Ga 16-18 gauge hypodermic needle attached to a syringe in the anteromedial aspect of proximal tibia. This procedure is contraindicated in patients over eight years, split, bone disorders and use of toxic drugs for the bone marrow. This procedure must be performed by a physician.
Venodiseción: is addressing a vein through the incision of the skin, subcutaneous tissue and direct insertion of a catheter into the vein. Is indicated in situations in which it was impossible for percutaneous puncture. Its use is increasingly restricted, as reports indicate an increased incidence of infections due to tissue manipulation, requires trained personnel, equipment and longer dissection surgery. It is performed most often in children.
In patients with multiple trauma site of choice is a saphenous vein at ankle level, making the front and cut 2 cm above the medial malleolus and tibial. Followed by the median basilic vein in the antecubital region, 2.5 cm lateral to the medial epicondyle of humerus in flexion crease elbow. In urgent cases we recommend dissection of the vein more easily identified, however, certain factors may influence this election, an example is the external jugular vein, easily accessible by very superficial, but the result is unsightly.
peripheral venous catheter: the use of peripheral intravenous catheters in patients with ED is a high frequency.
Like any invasive procedure has risks and complications, including phlebitis and thrombosis, in some cases altering the patient's progress and prolong hospital stay with a corresponding increase in the cost of care.
The progress in the last twenty years has been marked by introducing materials that cause less local reaction, reduce bacterial colonization and marked reduction in the caliber of the peripheral cannula. Despite the progress made has not been able to establish a protocol for management of peripheral venous catheters to provide security in reducing complications when placing a peripheral catheter, the only thing that is certain is that strict application of aseptic technique performing the procedure reduces complications. Other measures, such as placement of gauze versus transparent dressings, catheter periodic change and cure 24 hours after insertion, not ensure the absence of phlebitis and reactions at the insertion site. It all depends on the duration of intravenous therapy, the patient's activity level, skin conditions and the number of insertions already performed. INDICATIONS
• Fluid and electrolytes.
• Administration of intravenous medications.
• Transfusion of blood and its derivatives.
• Collection of blood samples.
• Maintain intravenous permeble emergency.
• Performing diagnostic studies.
PROCEDURE
1. Explain to the patient the procedure.
2. Patient's location so that the tip remains in a firm, flat surface.
3. Hand washing and placement of clean gloves.
4. Puncture site selection: assessing size, condition of the vein, the presence of twists and bruises, an indication of the catheter.
5. Tourniquet application: to feel and see the veins. Do not stress too much, since blood flow is obstructed, it can be seen to feel the pulse.
6. If an elder or a child to apply the tourniquet too soft, or use your fingers like this otherwise you may damage the vein at the time of needle insertion.
7. Palpation of the vein, use the index and middle fingers of the nondominant hand to feel the vein, they have greater sensitivity than the dominant hand, a healthy vein is palpable soft, supple, durable and without a pulse. Palpation is the technique of greater value if you can see, locate and define the path of the vein catheter insertion will be successful. If not feel or see the vein attempt the following operations: placing a warm compress along arm or insertion site 10 minutes before tourniquet application, perform massage in the direction of blood flow and indicate the patient to open and close the hand.
8. Skin preparation with antiseptic solution may be alcohol 70% to 10% povidone iodine or 2%. Rub the insertion site of the center to the periphery for a period of 60 seconds and let the solution sit for two minutes, after which the excess is removed. Do not use alcohol after applying iodine solution because it prevents the residual antiseptic activity of iodine.
9. Fixing the vein, without contact with the area ready for puncture, using the index finger and thumb of the nondominant hand stretching the skin.
10. puncture technique: direct the needle at an angle of 10-30 ° with the bevel up to penetrate the skin, then reduce the angle to avoid crossing the posterior wall of the vein. To obtain blood return to the chamber of the needle, the tourniquet is removed and the catheter is advanced and simultaneously withdrawn the guide wire, is occluded for a moment the flow pressure with the thumb on the vein at the site of locates the catheter tip, and discarded once the needle into a provided for this purpose.
11. Connect the equipment with the solution to be infused or adapter (plug heparinized) and adjust the infusion rate at an appropriate pace.
12. For the introduction of a catheter with the catheter cap is washed with 1 mL of saline haparinizada (100 IU / mL).
13. Check that the liquid flows freely, cover with dressing and secure the catheter.
14. Venipuncture mark the date, time and size of the catheter. Mark infusion to date.
15. Register in history the procedure, complications and patient response.
16. Assessed at least once per shift the site of venipuncture and the solutions are infused.
17. Make healing insertion site every 48 hours, or sooner if the dressing gets wet or in poor condition.
18. Change venipuncture every 72 hours, or sooner if there is pain, cold, pale skin, redness or swelling at the puncture site.
19. Explain to the patient's signs and symptoms of phlebitis and extravasation to timely report his presence.
RECOMMENDATIONS SET
RECOMMENDATIONS SET
- The health professional must have extensive knowledge of the procedure and its aim to select the type of catheter and vein to be used.
- Use the catheter shorter and smaller gauge that fits the prescribed treatment and select the vein that matches the size and length of the catheter.
- Use small-bore catheters and length for the administration of antibiotics and fluid maintenance.
- For blood, a catheter 18 gauge or higher Ga.
- If a patient receives Irritating drugs using 24-22 gauge catheter Ga and place in a large vein to facilitate the hemodilution and reduce irritation of the vein.
- A venipuncture in the hand is suitable for small-caliber catheters such as Ga 22 and 24, larger-caliber catheters are indicated in the forearm and arm.
- The cephalic vein, intermediate cephalic or basilica are ideal.
- Avoid if possible place the catheter in the dominant arm.
- Avoiding the following sites flexion (bending the wrist or elbow) to reduce risk of extravasation. If necessary, apply a restraint.
- Do not try to puncture a vein more than twice because of lack of experience, state of the patient or vein. Seek help from another person.
- Do not use a peripheral to the infusion of irritants or hyperosmolar (osmolality greater than 500 mOs / mL) and parenteral nutrition and 50% dextrose.
- Avoid using veins that have submitted phlebitis.
- Avoid puncturing the veins of the arm on the side of a mastectomy or lymph node.
- A general principle is to start from the distal to proximal.
- Do not shave the puncture site; microabrasion occur that increase the risk of infection if it is necessary to cut hair.
- Do not palpate the insertion site after cleaning the skin with antiseptic solution.
- Do not choose a sclerotic vein, which seems to feel it a string and moves with ease.
- Avoid a vein painful, swollen or near areas of extravasation or phlebitis.
- No choice veins in areas of sensitivity disorders, since the patient did not show alterations early.
- No members paretic perform venipuncture.
- Do not use lower-limb veins for the high risk of thrombophlebitis.
- Avoid puncturing the veins of the anterior aspect of the wrist, because the risk of nerve and tendon injury during the procedure or infused fluid extravasation.
not puncture the skin sites where there is injury (fungi, abrasions, etc.).. COMPLICATIONS
• Phlebitis: involves inflammation of a vein due to an alteration endothelium. Platelets migrate to the injured area and around the tip of the catheter begins the formation of a thrombus. Platelet aggregation causes histamine release, increasing blood flow by vasodilation in the area. The signosy characteristic symptoms are: mild pain, redness of the area or the venous route, local heat, to feel the vein has the appearance of lace, fever may occur. Its incidence is 30-35%. Phlebitis are presented for three types of causes: bacterial, chemical and mechanical.
Phlebitis is presented bacterial microorganisms in the solution, equipment contamination during insertion, technical deficiency Aseptic (hand washing and skin preparation) and absence or poor placement of the dressing. Chemical phlebitis caused by irritation of the vein by acids, alkalines or hypertonic. Mechanical phlebitis associated with slow infusion, inadequate fixation of the catheter insertion site (flex zones, tortuosity of the vein) catheter size larger than the size of the vein and the vein punctured injury.
The following drugs or groups have been identified as causative agents of phlebitis: antibiotics (63% of cases), antivirals, anticonvulsants (phenytoin, phenobarbital), benzodiazepines (diazepam and midazolam), adrenergic (dobutamine, dopamine, norepinephrine), local anesthetics (lidocaine), antiarrhythmics (amiodarone), calcium antagonists (nimodipine), antiulcer (omeprazole) and electrolyte solutions (potassium).
Prevention of phlebitis: identification and control of risk factors are the basis for prevention. There should be a guide to peripheral venous catheter insertion and monitoring program of the catheters to verify compliance with defined estánderes and early identification of complications.
chemical phlebitis is prevented by the use of veins with good venous flow to facilitate hemodilution, diluting the drug in 30-60 mL of solution and infused into a time of 30-60 minutes.
• Extravasation: is the infusion of fluid outside the blood vessel in the tissue surrounding the vein. Signs and symptoms include pain, local erythema, burning sensation and absence of venous return. Then formed a blister that turns into ulcer damage to cells caused by drug extravasation.
is important to prevent this complication, for irreversible tissue damage, which depends on the characteristics of the liquid: hyperosmolar solutions (calcium, potassium and glucose), diagnostic agents, adrenergic (adrenaline, dopamine, dobutamine and noradrenaline) irritant solutions at basic pH (phenytoin, sodium bicarbonate, acetazolamide, acyclovir, and thiopental) and others (amphotericin, diazepam, diazoxide , doxapram, phenobarbital, gamciclovir, methocarbamol, sodium nitroprusside, pentamidine, promethazine, rifampin, tetracycline and vancomycin).
knowledge of drugs capable of irritant or vesicant allows accurate selection of venipuncture site (ideally in the forearm and to prevent lower limb veins of the wrist and back of the hand, small vessel diameter, enlarged or sclerotic).
Management General measures consist of extravasation stop infusion, aspirate 5 mL of blood, administer 5-10 ml of solvent, remove the catheter, mark the edges of the affected area, elevate the limb and monitor progress.
Specific measures include physical means (heat to promote drainage of the drug or cold when an antidote is injected locally) pharmacological measures by the administration of antidotes for topical or systemic and surgical treatment.
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