Venipuncture

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Venipuncture

• DMI 63
• Kyle Thornton

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Disclaimer

• This is intended to be a step by step process
• It is completely from memory
• If I forgot something, Ill slip it in on our
  next meeting

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Injecting Contrast?

• What do you need to know?
• Is there an order?
• What are the 5 rights of medication
• What is the pts 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?

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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

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What are the 5 rights of medication

• The right patient
• The right medication
• The right route
• The right amount
• The right time

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What is the pts. renal function?

• How do we find out this information?
• We could ask
• but
• How many pts. 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_bloo
  d_test/page2.htm
• eGfr UCSF value gt 60
• Textbook mentions BUN, but this generally isnt
  requested
• Normal BUN value is about 7 20mg/dl
• Source http//www.lifeoptions.org/kidneyinfo/labv
  alues.php

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What is creatinine?

• Waste product made from protein breakdown
• Reasons for elevation
• Muscle breakdown
• HIV medications
• Impaired renal function

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What is eGfr?

• More accurate than creatinine
• Indicates rate at which kidneys are filtering
  wastes from blood
• Source
• http//www.lifeoptions.org/kidneyinfo/labvalues.ph
  p

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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

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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

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Does the pt. have allergies

• Warning!
• Pre-medication does not mean there wont be a
  reaction
• It reduces the likelihood

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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

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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?
  id17432

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Omnipaque a commonly used brand of contrast
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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!

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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

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Dont 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?

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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, dont infuse contrast
• Ask MD or RN to examine site
• Restart IV access if necessary

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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

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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 gt 20

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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

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Where is a good injection site?

• Vein v. artery
• If theres a pulse, dont go there
• CRTs 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

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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

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What else do I need?

• Hand wash
• Gloves
• Cleansing solution
• Tourniquet
• Tape or tegaderm
• Tubing
• Towel
• Arm board
• Saline

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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 its bright red and seems to come out with
  pressure STOP!

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Inserting the venipuncture device

• If dark and oozing, continue
• Attach tubing and secure
• Loosen tourniquet
• Inject saline about 10cc
• Its 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 thats all good,
• Inject the contrast as the protocol directs

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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?

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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

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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

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D/Cing the IV

• If the study is complete
• No further IV access is needed
• DC the IV
• You will need
• Gauze
• Bandage
• Sharps container

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D/Cing 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

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If youre not DCing 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