Venipuncture DMI 63 Kyle Thornton
Disclaimer • This is intended to be a step by step process • It is completely from memory • If I forgot something, I’ll slip it in on our next meeting
Injecting Contrast? • What do you need to know? • Is there an order? • What are the 5 rights of medication • What is the pt’s renal function? • Does the patient have allergies? • Does the patient take any medications that are incompatible with IV contrast? • What is IV contrast? • What emergency meds do I need? • What gauge needle should I use? • Where is a good injection site? • What else do I need? • What can go wrong?
Is there an order? • Orders will vary • A contrast study is ordered as w/contrast • or • Enhanced • For example: • Abdomen w/contrast • or • Chest enhanced • If order states unenhanced or w/out contrast • No venipuncture necessary • MD will make that determination
What are the 5 rights of medication • The right patient • The right medication • The right route • The right amount • The right time
What is the pt’s. renal function? • How do we find out this information? • We could ask • but • How many pt’s. actually know their renal function • so… • We need lab values: • Should be within at least 72 hours • Most hospitals require: • Creatinine: app. 0.6 – 1.2 mg/dl • Source: http://www.medicinenet.com/creatinine_blood_test/page2.htm • eGfr: UCSF value; > 60 • Textbook mentions BUN, but this generally isn’t requested • Normal BUN value is about 7 – 20mg/dl • Source: http://www.lifeoptions.org/kidneyinfo/labvalues.php
What is creatinine? • Waste product made from protein breakdown • Reasons for elevation: • Muscle breakdown • HIV medications • Impaired renal function
What is eGfr? • More accurate than creatinine • Indicates rate at which kidneys are filtering wastes from blood • Source: • http://www.lifeoptions.org/kidneyinfo/labvalues.php
Is an elevated creatinine and low eGfr a deal breaker? • Not always • Is it known that the pt. has renal disease? • Is the pt. on dialysis? • When is the next scheduled dialysis? • Can the pt. be pre-hydrated prior to the study • Hydration provided by: • Sodium bicarbonate – IV • Mucomyst - Oral
Does the pt. have allergies? • Are allergies a deal breaker? • Depends… • Is there an alternative study? • Can the pt. tolerate pre-medication? • UCSF Pre-medication protocol for contrast allergies: • 12 hours before test: • 50mg. Prednisone or 32 Medrol • 2 hours before test: • 50mg. Prednisone or 32 mg. Medrol • 300mg. Tagamet or 150 mg. Zantac • 50mg. Benadryl
Does the pt. have allergies • Warning! • Pre-medication does not mean there won’t be a reaction • It reduces the likelihood
Does the pt. take any medications that are incompatible with contrast? • Insulin dependent diabetics and oral medication • Glucophage, Glucovance, aka Metformin • Must be suspended for 48 hours after contrast administration
What is IV contrast? • An iodinated medium bound in either an organic or inorganic compound • Organic: Non-ionic • Characteristics: • Low osmolarity = 290 – 884 • About 1.1 to 3X that of blood • Blood is app. 280 – 303 • Iodine content = 320 – 370 • Does not dissociate into component molecules • Remains intact • Side effects less likely • For more information, go to: • http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=17432
What is IV contrast? • Ionic • Characteristics • High osmolar value • 580 – 2100 • Iodine content • 300 – 370 • Dissociates into component molecules • Reactions and side effects more likely • N/V highly likely!
What emergency meds do I need? • An emergency medication box will generally contain: • Steroid – counteract inflammatory response • Antihistamine – counteract histamine release • Vasodilator – increase blood pressure
Don’t forget! • Did you screen for pregnancy? • Did the pt. have a similar exam recently? • Should wait at least 12 hours between contrast injections • Did you screen for allergies? • Did you screen for other medications?
If the patient has an existing IV access port… • You must make sure it is functioning • Wash your hands • Put on gloves • Examine site • Check tubing connections • Clean the port of the connecting tubing w/rubbing alcohol • Draw back on syringe • Check for blood flow into tubing • Flush w/saline by hand • Observe flush • Test power inject with saline at same rate/pressure as planned contrast infusion • If in doubt, don’t infuse contrast • Ask MD or RN to examine site • Restart IV access if necessary
What type of needle do I need? • Butterfly versus Angiocath • Butterfly • Needle is attached to tubing • Good for hand injections • Not suitable for the power injector • Angiocath • Needle is sheathed within a clear plastic catheter • After venipuncture, needle is removed, catheter remains in vein • Requires tubing to be attached • Good for long term IV solution therapy • Suitable for the power injector • Often used with a saline lock
What gauge of needle do I need? • For power injector, the lowest practical gauge should be used • Often injections are delivered at a rate of 3 – 5ml/sec at 300 – 350 PSI • The faster the injection rate, and the greater the pressure, the lower the gauge should be • 16 or 18 • Slower injection rates and lower PSI may use higher gauges • 20 – 22 • Should not be > 20
Where is a good injection site? • Injection site depends upon: • The type of solution to be administered • The duration of the administration • IV contrast is short duration • The antecubital fossa is ideal • Veins are larger and more accessible • Able to withstand greater pressure
Where is a good injection site? • Vein v. artery • If there’s a pulse, don’t go there • CRT’s are limited to upper extremity • Hand veins (dorsal venous arch and superficial dorsal veins) are difficult to stick and hurt • Anterior wrist veins (radial) are difficult to stick and hurt • Antecubital veins are best, but • If you miss, you need to go to the other arm
Where is a good injection site? • Forearm and antecubital veins • Basilic • Courses medial side of arm • Follows ulna and medial humerus • Medial • Medial through the forearm • Joins median cubital at antecubital fossa • Cephalic • Courses lateral side of arm • Follows radius and lateral humerus
What else do I need? • Hand wash • Gloves • Cleansing solution • Tourniquet • Tape or tegaderm • Tubing • Towel • Arm board • Saline
Inserting the venipuncture device • Wash your hands – sing happy birthday to yourself twice • Put on gloves • Apply tourniquet • Cleanse the site – sing happy birthday to yourself twice • Put on new gloves • Perform the venipuncture • Watch for backflow of blood • If it’s bright red and seems to come out with pressure – STOP!
Inserting the venipuncture device • If dark and oozing, continue • Attach tubing and secure • Loosen tourniquet • Inject saline – about 10cc • It’s a good idea to hand inject saline first • then, • Inject saline using the power injector at the same rate and pressure as the contrast injection • If that’s all good, • Inject the contrast as the protocol directs
Before you inject… • Did you check the order? • Did you observe the 5 rights of medication? • Did you check renal function? • Did you screen for allergies? • Did you screen for pregnancy? • Do you have all your supplies? • Is your IV site functioning? • Did you test with saline?
Injecting • Remove tourniquet • Observe infusion • Palpate infusion site to ensure contrast is flowing • If not, stop injection immediately • Assure patient, who is probably feeling hot flashes! • Usually ceases in a couple of minutes
What can go wrong? • Angiocath disconnects from tubing • Contrasts goes everywhere • Infiltration • This is much worse! • In case of infiltration • Stop infusion immediately • Call a physician or nurse • Apply ice (UCSF protocol) • Await further orders
D/C’ing the IV • If the study is complete • No further IV access is needed • DC the IV • You will need: • Gauze • Bandage • Sharps container
D/C’ing the IV • Remove the tape • Have the gauze ready • Remove the venipuncture device in one movement • Press the gauze on the wound • Elevate the extremity • Hold pressure for about a minute • Check the site • Apply a bandage • Check the site again • Check the site one more time before pt. leaves
If you’re not DC’ing the IV • Flush tubing w/saline to remove all contrast, blood, etc. • Clamp tubing off • If you paused an existing infusion: • Flush the tubing w/saline • Reconnect tubing with infusion • Resume pump if applicable