144 Section V ■ Vascular Access

5. Apply tourniquet if anatomic site indicates.

a. Place as close to venipuncture site as possible.

b. Tighten until peripheral pulsation stops.

c. Release partially until arterial pulse is fully palpable.

6. Prepare skin area with antiseptic. Allow to dry.

 In the United States, povidone–iodine solution and

isopropyl alcohol are the most commonly used skin disinfectant solutions. Povidone–iodine has been shown to

have greater efficacy than isopropyl alcohol and, in

addition, is less damaging to skin tissue. Povidone–

iodine solution should be applied to the proposed insertion site and allowed to dry for at least 30 seconds. It

should then be removed with sterile saline or sterile

water. The importance of removing the povidone–

iodine solution cannot be overstressed, as there have

been reports of burns, elevated iodine levels, and hypothyroidism in premature infants caused by prolonged

contact and further absorption (10).

7. Select straight segment of vein or confluence of two

tributaries.

8. Grasp catheter between thumb and first finger. For

winged Angiocaths, grasp plastic wings (Fig. 27.2).

9. Anchor vein with index finger of free hand and stretch

skin overlying it. This maneuver may also be used to

produce distention of scalp veins.

10. Hold needle parallel to vessel, in direction of blood flow.

11. Introduce needle through skin a few millimeters distal

to point of entry into vessel (see Chapter 14).

12. Introduce needle gently into vessel until blood appears

in hub of needle or in cannula upon withdrawal of

stylet.

 When using a very small vessel or in an infant with

poor peripheral circulation, blood may not appear

immediately in tubing. Wait. If in doubt, inject a small

amount of saline after releasing tourniquet.

13. Remove stylet. Do not advance needle farther, because

the back wall of the vessel may be pierced.

14. Advance cannula as far as possible.

 Injecting a small amount of blood or flush solution

into the vein prior to advancing the cannula may assist

cannulation (Fig. 27.3) (14).

15. Remove tourniquet.

16. Connect T connecter and syringe, and infuse small

amount of saline gently to confirm intravascular

position.

17. Anchor needle or cannula as shown in Fig. 27.4

18. Attach IV tubing and secure to skin.

19. If an armboard is necessary for securing site, place the

affected extremity in an anatomically correct position

before taping. Consider placing cotton or a 2- × 2-inch

gauze square beneath the hub of T connector to prevent a pressure injury.

E. Complications (15–17)

1. Hematoma: The most common but not usually significant complication. Hematomas can often be managed

with gentle manual pressure.

2. Phlebitis (18,19)

 Phlebitis remains the most common significant

complication associated with the use of peripheral

venous catheters. When phlebitis does occur, the risk of

local catheter-related infection may be increased (19).

The use of heparinized solution to prolong patency of

peripheral IV catheters in neonates is controversial

(20). The catheter material, catheter size, and tonicity

of the infusate also influence the incidence of phlebitis.

Fig. 27.3. Injecting a small amount of flush solution will distend wall of vein and facilitate cannulation. (Redrawn from Filston

HC, Johnson DG. Percutaneous venous cannulation in neonates:

a method for catheter insertion without “cutdown.” Pediatrics.

1971;48:896, with permission of American Academy of Pediatrics.)

Fig. 27.2. Simulated procedure showing IV needle held in

dominant hand, while index finger and thumb of nondominant

hand are used to anchor vein and stretch overlying skin.