Category Archives: Infusion Nursing Standards of Practice

What do you think…

Q:  We have a 24/7  vascular access team, yet we find that an ultrasound machine  in a medical floor is used for PIV insertion by untrained nurses and residents. The machine is there for other purposes but is being used for hard IV sticks.

A:  There is increasing evidence to show the use of ultrasound or vein finding technology increase success rates particularly in patients with difficult veins to access. The INS standards recommend the nurse to consider using visualization technologies that aid in vein identification and selection (S33). The use of  ultrasound allow the identification of peripheral vessels and guide the insertion procedure.  There are reports that ultrasound guided peripheral IV cannulation is successful more than 90% of cases. In addition, it improves patient satisfaction and safety with fewer sticks.

I think anyone who reads this post will agree that healthcare providers using these technology must be properly trained and/or competency checked off. Just because there is an ultrasound machine available on a medical unit doesn’t entitle anyone to use it without proper training. The operator should be very familiar with the ultrasound machine, the type of transducers used, how to improve ultrasound gain and how to control its outcome. The operator should be especially knowledgeable of the sonographic artefacts that can mislead him/her.

In addition, your facility/institution/organization should have policies and procedures related to the training. competencies and use of ultrasound technology. Check out what your policy is and hope you have one. In some, the use of utlrasound for PIV insertion is limited to vascular access teams and the ED. In your case, with a 24/7 vascular access team, the medical floor should take advantage of your service and expertise.

Thanks for your question. I wish you the best.

References:

  1. Infusion Nurses Society 2011 Standards of Practice.
  2.  Abu-Zidan Fikri M Point-of-care ultrasound in critically ill patients: Where do we stand?J Emerg Trauma Shock. 2012 Jan-Mar; 5(1): 70–71.
  3. Elia F, Ferrari G, et al Standard-length catheters vs long catheters inultrasound-guided peripheral vein cannulation. American Journal of Emergency Medicine (2012) 30, 712–716

 

 

 

 

 

 

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Large Volume IV Solution Shortages

It just doesn’t seem right that the national crisis with “drug shortages” would include  large volume (1000mL) IV solutions we commonly administer to our patients:

  • 0.9% Sodium Chloride Injection
  • 0.45% Sodium Chloride Injection
  • Lactated Ringer’s Injection
  • 5% Dextrose Injection

 

IV

But the reality is there is a shortage, IV saline solution, in particular is on the list of national drug shortages and the shortage is not expected to resolve until May or June this year. Not having IV Saline solution available  is like not have bread and milk at the grocery stores.

So what can be done?  The American Society of Health-System Pharmacists (ASHP) released a list of conservation strategies that organizations might consider to manage the shortage.  Click here to view details of the document.

 

What can clinicians do to conserve?

  • Use oral hydration whenever possible.
  • Review the suggested clinical approaches and product conservation strategies in collaboration with the organization’s stakeholders and the Pharmacy and Therapeutics (P&T) Committee or other organization-wide medication policy group for applicability to the organization.
  • Implement an organization-specific action plan to conserve IV fluids where possible. Allow flexibility as the shortage status of specific products may change frequently. For example, Lactated Ringer’s
  • Injection may be more available than 0.9% Sodium Chloride Injection and vice-versa depending product availability and allocation schedules.
  • Develop medical staff-approved policies for substitution of IV solutions based on product availability within the organization. Example: an organization might allow substitution of Lactated Ringer’s Injection for 0.9% Sodium Chloride Injection or vice-versa depending on what is in stock. Table 1 provides a comparison of common intravenous fluid components.

 

Please feel free to share what you /your organization are doing to cope with this IV Solution Shortage.

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Vesicants and Extravasation

These two terms defined by the Infusion Nurses Society means:

Vesicant – an agent capable of causing blistering, tissue sloughing or necrosis when it escapes from the intended vascular pathway into surrounding tissue.

Extravasation – the inadvertent infiltration of vesicant solution or medication into surrounding tissue.

There are several chemotherapeutic agents with vesicant properties, and when inadvertently infused into the surrounding tissue from an infiltrated IV, these agents may have the potential to cause blisters, severe tissue injury or necrosis, known as extravasation. The damage to the tissue can occur from direct contact with the vesicant medication, from compression of surrounding tissues by a large volume of fluid or from severe vasoconstriction.

But chemo agents are not the only vesicants that cause extravasation injuries. There are non-chemo medications and solutions that have vesicant properties as well and can cause extravasation. Listed below are a few non-chemo agents:

  • Vancomycin
  • Nafcillin
  • Calcium Chloride
  • Potassium Chloride
  • Sodium Chloride
  • Calcium Gluconate
  • Dobutamine
  • Diazepam
  • Dopamine
  • Norepinephrine (Levophed)
  • Phenytoin (Dilantin)
  • Promethazine (Phernergan)
  • Propofol
  • Vasopressin
  • Radiologic contrast agents

As nurses, it is our responsibility to take preventive measures, monitor, identify signs/symptoms and institute prompt treatment per policy or as ordered. If you administer any of these agents, prevention is key and consider the following:

1. Location, location, location:  When selecting an IV site, avoid areas of flexion  – this includes the wrist, hand, and antecubital fossa.  Be mindful of any punctures to veins above the area you are about to stick. If patient had a recent blood draw from the antecubital fossa, use the opposite arm to find a suitable site.  Oh, btw, extravasation can also happen in patients with central venous access.

2. Bigger is not better: Use the smallest gauge IV catheter to administer the prescribed therapy.  Good flow rates are possible even with a small gauge catheter. Using an IV catheter too large for the vein will obstruct blood flow and might cause thrombosis distal to the IV site.

3. Know your medications: Were you surprised to see a medication listed above as a vesicant?  Medications and solutions with an osmolarity greater than 600 mosmol/L  and pH lower than 5 or higher than 9 should not be infused via a peripheral IV. Know the adverse events, if any for each medication. If in doubt, always ask our friendly pharmacists!!

4. Secure your IV device: Use a stabilization device to anchor and avoid movement of the catheter. When using a dressing, avoid obscuring the IV site to allow you to observe the site.

5. Check  IV patency and assess site: Key to early recognition of complications. Refer to your organization’s policy on frequency of IV site checks.  Infusion pumps will not tell you if an IV site in infiltrating. Always aspirate for positive blood return prior to use, but remember, checking for blood return or back flow of blood is good for patency but not a reliable method for assessing infiltration at IV site. If infusion continues to run when you apply digital pressure 3 inches above peripheral IV site in front of catheter tip – suspect infiltration

6. Policy/procedure for extravasation: Do you know if your organization has one for non-chemo agents? Have you even read it? What are you expected to do when extravasation happens?  Is there a rating scale to document the severity of the problem? Are you expected to complete an “incident report”? Can you photograph the site?

7. Hot or cold: Which do you use? What does your policy state about compress? Do you need an doctor’s order for this?

8. Antidote: Is there one for the medication you administered? Obtain physician’s orders for the appropriate antidote. How is it given?

9. Document, document, document!! I know, you’ve heard this before….if it’s not documented, you didn’t do it! Keep this in mind, you will not remember what happened in the past, so hopefully, your documentation can defend you.

10. Don’t forget the patient/family: Keep them informed and provide information regarding treatment and management.

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SPC Insertion Guide Card Deck

There is a great resource available to nurses and other healthcare providers. It is the SPC insertion guide card deck. The Short Peripheral Catheter (SPC) Insertion Card Deck provides step-by-step instruction for successful venipuncture in children and adults. The deck highlights proper site selection, insertion techniques, as well as care and maintenance methods. It also includes recommendations for identifying common complications such as phlebitis, infiltration, and extravasation. Key information is presented in concise, bulleted points, and is augmented by useful figures.

 12_13_SPC_Cards_LG
The laminated 5” x 8” cards (4 cards, 8 sides) are joined with a plastic ring that allows for use in any practice setting. Readily portable, the cards can be carried in a lab coat pocket or attached to a medication cart for easy reference at the point of care.
These card decks are available for purchase at the INS website – click here.
Disclosures:

1. SPC Insertion Card Deck: Copyright Infusion Nurses Society used with permission from the Infusion Nurses Society

2. I served as the chairperson of the IV Safety Task Force Committee who developed the position paper and the above insertion card deck. This was a volunteer committee and did not involve any compensation.

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Short Peripheral Catheter Checklist

This great resource in available free to download to INS members from the INS website – SPC  Checklist. SPC means short peripheral catheter, which man y of us call “peripheral IV catheter” or “PIV”. This checklist was part of the IV Safety Task Force position paper project on Recommendations for Improving Safety Practices for Short Peripheral Catheters.

SPC Checklist

Modeled after the CDC checklist for Prevention of Central Line Associated Blood Stream Infections, the SPC Checklist covers assessment, monitoring, removal, and safety strategies.  The checklist is designed to help your efforts in implementing evidence based best practices in SPC insertion, care and maintenance as well as promote IV safety practices.

Download you free copy now, go to www.ins1.org

Disclosures:

1. SPC Checklist: Copyright Infusion Nurses Society used with permission from the Infusion Nurses Society

2. I served as the chairperson of the IV Safety Task Force Committee who developed the position paper and the above checklist. This was a volunteer committee and was not compensated for this project.

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Think Safety, Insert Safely

In June of 2013, I was honored to chair a national task force for the Infusion Nurses Society’s (INS) project on Short Peripheral Catheter Safety (SPC).  Along with five other colleagues, we embarked on a task  to identify the safety and practice issues and  look at ways to promote safety in the insertion and management of short peripheral catheters for all patient populations as well as for the clinician.

Yes, we are concerned with short peripheral catheters or as many clinicians call it “PIV” insertion and maintenance. That simple and common procedure routinely performed by nurses and other clinicians often accompanied by the prevailing thought that simple and routine = complication free.  Unfortunately, many nurses/clinicians underestimate the risks involved in PIV insertion, care, and maintenance until they are faced with infusion-therapy related complications and litigation.

Back in June 2013, I posted an blog entry looking for RNs inserting peripheral IV’s to take a short survey.  I was so thrilled that many  of my blog readers and nursing colleagues have taken the survey. Thank you for taking the time to complete the survey. The survey results were used in the development of  the position paper. This position paper entitled “Recommendations for Improving Safety Practices with Short Peripheral Catheters” is now available on the INS website. (Click here)

On Feb. 4, 2014 on behalf of  INS, I will be presenting a live webinar “Recommendations for Improving Safety Practices With Short Peripheral Catheters” that will discuss the findings of the task force and the statement of INS’ position.  Due to unprecedented demand, the webinar is sold out. But thanks to the support by an educational grant from BD Medical, INS members will be able to view the archived presentation free of charge in the INS Knowledge Center later next week.

When it comes to short peripheral catheters, we encourage nurses/clinicians to…Think safety, Insert safely!

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Q&A: IO and Blood Transfusion

Q:  A twitter colleague posted:  Can you give blood through an IO?

A:  IO as in intraosseous access. An old concept that is now getting more attention as an alternate access for infusion therapy in emergent and non-emergent situations. IO access uses the intraosseous space that contains thousands of non-collapsible intertwined blood vessels that absorbs any fluids. In situations where the peripheral vascular system shuts down, the IO space acts like a non-collapsible vein providing speed and bioavailability of the vascular route.

The answer is yes.  Many of the IO device manufacturers have stated blood transfusion can be given via IO. Blood transfusion through the IO route was first described in the 1940s and reported to be safe  and effective. 1,2

Preclinical studies conducted in the 1990s addressed IO blood transfusion. One study in piglets found significant improvement in hemodynamic variables after IO infusion of hyper-osmotic saline and IO transfusion of whole blood in an animal model of hemorrhagic shock and concluded that IO infusion is easy to establish and holds utility for treatment of shock victims.3

A second study examined hematologic parameters (hemoglobin, schistocytes, free hemoglobin in plasma, bilirubin, lactate dehydrogenase, platelets, fibrinogen, and alveolar-arteriolar O2 gradient) in IO and IV autologous blood transfusions and found that all hematologic parameters remained within normal limits in both IO and IV groups.4 The researchers concluded that IO blood transfusions are hematologically safe—without risk of appreciable hemolysis, disseminated intravascular coagulation, or fat embolism syndrome.

A 2009 article describes a case study in which a 79-year-old woman presented in hemorrhagic shock, and for whom peripheral access was impossible. An EZ-IO catheter was placed and used to administer crystalloid and colloid fluids, blood products and drugs, stabilizing the patient during a central access procedure. 5

Traditional therapies given by IV route may be given by the IO route and studies have shown both routes have the same pharmacologic effects.6

For more information and for Position Papers and Standard of Practice, go to this link. 7

References:

1. Gimson JD. Bone-marrow transfusion in infants and children-Introducing a specially designed needle. British
Medical Journal 1944;208:748-9.

2. Henning N. Intrasternal and intraosseous injections and transfusions. JAMA 1945;128:240.

3. Ronning G, Busund R, Revhaug A. Resuscitation of pigs with haemorrhagic shock by an intraosseous
hyperosmotic solution and transfusion of autologous whole blood. Eur J Surg 1993; 159:133-9.

4. Plewa MC, King RW, Fenn-Buderer N, Gretzinger K, Renuart D, Cruz R. Hematologic safety of intraosseous
blood transfusion in a swine model of pediatric hemorrhagic hypovolemia. Acad Emerg Med 1995;2(9):799-809.

5. Burgert JM. Intraosseous infusion of blood products and epinephrine in an adult patient in hemorrhagic shock. AANA Journal 2009;77(5):359-63.

6.Von Hoff DD, Kuhn JG, Burris HA, Miller LJ. Does intraosseous equal intravenous? A pharmacokinetic study. American Journal of Emergency Medicine 2008;26:31-8.

7. Vidacare IO website - http://www.vidacare.com/EZ-IO/Evidence-Based-Medicine-Intraosseous-Standards-of-Practice.aspx

You Tube video by Vidacare – makers of EZ-IO.

 

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Q&A: Tips to improve IV insertion skills

Q: Do you have any tips on how to improve my IV insertion skills?

A: This is one of the FAQ and often comes from new blog readers. I have blogged about this many times before but I thought I’d post it again. To some of my long time readers, this may not be new but it’s always a good refresher.

Here are some tips I find helpful when peripheral veins are hard to find.

Palpation: Apply the tourniquet. Use your index finger to palpate the veins. Press directly on the vein with your index finger, assessing for vein softness and volume. Then release the pressure slowly without lifting your finger and feel the vein bounce back to your index finger. Repeat as often to ensure you found a suitable vein. Don’t stick without palpating the vein!

Tapping: Apply the tourniquet. Lightly tapping the skin or area where you see veins will help distend the vessel. Avoid “beating” the skin as it might cause venospasms.

Dry heat: Use dry heat to the proposed site. Application of dry heat increases blood flow allowing for good venous dilatation, thus improved vein visualization.  A study showed dry heat is 2.7 times more likely than moist heat to result in successful IV insertion on the first attempt, have significantly lower insertion times, and more comfortable.

Stroking: Stroking the vein toward the hand allow for venous refill.

Open/Close fist: Open and close fist during vein assessment but keep arm relaxed during venipuncture.Keep arm/hand in low (dangling) position.

Skin Anchoring: An important step to the success of venipuncture. Prevent the movement of veins during venipuncture.(especially for “rolling veins”). Pull skin downward below the point of insertion with the thumb of the non-dominant hand or pull skin above the point of insertion with forefingers or pull skin from underneath the extremity.

Insertion: Select the smallest gauge and shortest length catheter. Position catheter tip bevel up. Approach angle to skin at 10 –15 degree. Deeper veins need greater angle. Superficial require lesser angle. If parallel to the skin surface, will drag the skin as you puncture it. Lower angle once blood return is observed and advance the catheter.

Vein Viewer and Ultrasound: There are devices that can help you find veins. The equipment ranges from transillumination to ultrasound. These are expensive equipment and would require training prior to use. There is increasing evidence that the use of ultrasound for venous access is safe and successful.

Take a deep breath: Both you and the patient! Let the patient know when you are ready to stick and tell them to take a deep breath and blow it out slowly. This will distract them from the stick and help the tension in their arm.

Patience: Take the time to do a vein assessment and vein palpation prior to each attempt, don’t stick only because you can see a blue line. Some veins are located deep in the superficial fascia and the extra “fatty deposits” doesn’t help. Veins won’t change position just because you are in a hurry.

Oh, and do document your unsuccessful attempts at PIV insertion – many nurses don’t.

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Q&A: Insulin and PICCs

Q: What kind of IV solutions can be given through a PICC line? Is it safe to give Humolog insulin or should I start another IV line?

A:  PICC is short for peripherally inserted central catheter. It is a central vascular access device (CVAD) inserted into an extremity and advanced in the venous system until the distal tip is positioned in the vena cava. CVAD can be used to administer short-or-long term continuous or intermittent infusion solutions such as antineoplastic medications, vesicants or known irritants, peripheral nutrition, a variety of antibiotics, and any medications with a pH of less than 5 or greater than 9 and osmolarity of greater than 5 or greater than 9 and osmolarity of greater than 600mOsm/L.

Humalog insulin can be administered intravenously through a PICC.  Consideration should be given to what other solution/medication  is infusing through the  line. It is always best to consult your pharmacist for proper concentration, infusion method, admixture, stability and clinical monitoring protocol when administering intravenous insulin.

6007_Figure_1

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Q&A: PIV insertion

Q: I know I’m in the vein but get no blood return and when I flush with saline to check it blows. Can it be pt is dehydrated.

A: The presence of a blood return during the insertion of a peripheral IV catheter is an indication that the tip of the catheter has entered the vein. If you do not get a blood return at all, the tip of the catheter may have not entered the vein or punctured through the vein. Dehydrated patients are always a challenge when assessing for a suitable vein for venipuncture. As a general rule, it is best to select veins that feel soft , resilient and bouncy as you palpate over and across the vein. After applying the tourniquet, give the veins time to fill (venous distention) which will help in assessing for veins to puncture. After you have punctured the vein, wait for the blood return before advancing the rest of catheter. In dehydrated patients, blood return may be slow and advancing the catheter too quickly before you see the blood return might end up puncturing through the vessel.

iv_catheter_patient1

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