Peripheral Intravenous Line Placement
Ha-young Choi
A. Indication
1. Administration of intravenous (IV) medications, fluids, or parenteral nutrition when utilization of the gastrointestinal tract is not possible.
B. Equipment
Since the late 1960s, the variety of equipment available for peripheral vascular access has grown from metallic needles of limited size range and stiff polyethylene tubes to an array of plastic cannulas, single- and multilumen catheters of different sizes and materials, and totally implantable devices (ports). The safest and more effective vascular access is obtained by carefully matching the neonate’s size, therapeutic needs, and the duration of required treatment with the most appropriate device and technique. Placement of peripheral IV lines is described in this chapter. Placement of central venous lines is described in Chapter 34.
Sterile Equipment (Fig. 29.1)
1. Povidone-iodine or other antiseptic swabs (see Chapter 6)
2. Appropriate needle (minimum 24 gauge for blood transfusion)
a. 21- to 26-gauge IV catheter (preferably shielded for patient and operator safety)
3. Connection for cannula (i.e., T connector)
4. 2- × 2-in gauze squares
5. Isotonic saline in 2- or 3-mL syringe
Nonsterile Clean Equipment
1. Tourniquet
2. Procedure light or transilluminator (3)
3. Materials for restraint (see Chapter 5)
4. Warm compress to warm limb, if necessary (infant heel warmer) (4)
5. Appropriate-sized armboard, if necessary
6. Cotton balls or other soft positioners to support IV catheter, if necessary
7. Scissors
8. Roll of 0.5- to 1-in porous adhesive tape, transparent tape, or semipermeable transparent dressings
a. If using tape, use the minimum amount necessary on fragile premature skin, and consider using a pectin barrier (e.g., DuoDERM, ConvaTec/Bristol-Myers Squibb, Princeton, New Jersey; HolliHesive, Hollister, Libertyville, Illinois).
b. Transparent tape or dressing will facilitate observation of IV site and semipermeable dressings allow
small amounts of fluid, such as sweat, under the dressing to evaporate to keep the area dry (e.g., Tegaderm, 3M Health Care, St. Paul, Minnesota).
small amounts of fluid, such as sweat, under the dressing to evaporate to keep the area dry (e.g., Tegaderm, 3M Health Care, St. Paul, Minnesota).
 FIGURE 29.1 Sterile equipment necessary for peripheral IV line placement. |
c. Precut self-adhesive taping devices are available (e.g., Veni-Gard Jr.—ConMed IV Site Care Products, Utica, New York).
9. Restraints and pain control, as appropriate for clinical situation
b. Consider swaddling the baby, leaving the limb needed for IV placement exposed. In addition to serving to restrain the infant, swaddling is also a comfort measure (see Chapter 5).
c. Oral sucrose is frequently used as a nonpharmacologic intervention for procedural pain relief in neonates (7, 8).
d. Some critically ill infants, such as those with persistent pulmonary hypertension, may require additional pain medication or sedatives, to prevent agitation and desaturation during painful procedures.
e. Topical lidocaine cream preparations must be applied well before the start of the procedure, usually 30 to 60 minutes; follow manufacturer recommendations. Be sure to follow dosing recommendations, as it can be absorbed transcutaneously and cause methemoglobinemia (9).
C. Precautions
1. Avoid areas adjacent to superficial skin loss or infection.
2. Avoid vessels across joints, because immobilization is more difficult.
3. Take care to differentiate veins from arteries.
a. Palpate for arterial pulsation.
b. Note effect of vessel occlusion.
(1) Limb vessel: Arteries collapse, veins fill
(2) Scalp vessel: Arteries fill from below, veins fill from above
c. Note color of blood obtained (arterial blood is bright red; venous blood is darker).
d. Note pulsatility of flow once vessel is catheterized (arterial blood will have copious, pulsatile flow).
e. Look for blanching of skin over vessel when fluid is infused (arterial spasm).
4. If limb requires warming prior to procedure, use an infant heel warmer (e.g., Fisherbrand Infant Heel Warmer, Prism Technologies, San Antonio, Texas; Heel Snuggler Infant Heel Warmer, Philips Children’s Medical Ventures, Monroeville, Pennsylvania). “Homemade” compresses such as a diaper soaked in hot water can cause severe thermal injury or maceration. Heat levels appropriate for adults may cause severe burn injuries in the neonate (10).
5. Cut scalp hair using small scissors or trimmer to allow for stabilization of the IV. Do not shave the area, as this can cause abrasions in the skin (11).
6. Apply tourniquet prudently and correctly for quick release (see Fig. 16.3).
a. Minimize time applied.
b. Avoid use in areas with compromised circulation.
c. Avoid use for scalp vessels.
7. When using scalp veins, avoid sites outside the hairline.
8. Be alert for signs of phlebitis or infiltration.
a. Inspect site hourly.
b. Discontinue IV immediately at any sign of local inflammation or cannula malfunction.
c. Long plastic catheters are not recommended for use in neonates because their relative rigidity increases the risk of damage to the vascular endothelium, thus increasing the possibility of venous thrombosis.
d. Arrange tape dressing at IV site to allow adequate inspection or use transparent sterile dressing over site of skin entry. Generally, no dressing change is required unless the dressing is unstable, soiled, or at time of catheter removal.
9. Consider using protective skin preparation in small premature infants to prevent skin trauma upon removal of tape or dressing. Cavilon No Sting Barrier Film, 3M Health Care, St. Paul, Minnesota is a non-alcohol-containing product that is available commercially; however, it, as well as other commercially available skin protectants, has not been tested on neonates.
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