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*Vessels have three layers (structures): the tunica externa (or adventicia [outer]); media (middle); and intima (or interna [inner]), made up of a single layer of endothelial cells, very fragile. It is of note to understand that the intima (inner) layer of veins do not contain nerves (the layer where catheters dwell and infusions/infusates are administered). Therefore, when a patient complains of tenderness or pain at, around, or above the area of insertion, something is wrong. Assess for inadvertent arterial puncture; catheter tip malposition; infusion/insusate infiltration or extravasation; chemical, mechanical, and/or bacterial insult. All indicate injury has extended beyond the inner layer of the vessel. Stop the infusion. Assessment findings determine the next steps.
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*Do not compromise the integrity of the catheter by bending. Bending will make it difficult for the plastic sheath to follow the steel needle's new contoured shape without piercing the plastic with advancement. When attempting to remove the steel needle, the plastic cannula may be removed at the same time. Tributaries have a fragile wall, frequently associated with a tortuous, varicose appearance with thin-walled ectatic zones interrupted by thick-walled zones (valves, scars, previous thrombosis); therefore, avoid these areas. Leaving a tourniquet on too long will exhaust the vessel and result in collapse. Have you ever wondered why the vein disappeared? 1) The vein's response to injury 2) the tourniquet time. Do not touch the insertion area after properly disinfecting the skin. Maintain aseptic no-touch technique (ANTT); use sterile gloves if you anticipate having to touch the site after disinfection.
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*Do not insert a catheter distal to a previous attempt. Hand veins are limited to anesthesia and renal failure patients. There is too much flexion in this area of insertion to maintain a proper dwell time of a catheter, unless your patient is a scheduled for an outpatient procedure and the catheter will be promptly removed; OR at the patient's request.
*The degree of catheter insertion depends upon the depth of the vessel, determined by the thickness of the epidermis and dermal layers of the skin. The angle of insertion with infants (and the elderly) should be very low, almost level with the skin. Once blood return is visible in the flash chamber, relax, allow the vessel time to also relax from insult and injury. Advancing the needle too fast after blood return will result in piercing the entire diameter of the vessel (going through the vein wall). Our vascular system typically has a degree of contraction after injury (the vessel's normal response to prevent blood loss). Don't lose the vein. Lower the angle of insertion slightly after blood return, relax, take a breath, then advance the needle the length of the bevel (approximately 1 mm), slide the cannula off the steel needle without touching critical points of the catheter and/or skin. Celebrate success!
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I'll explain this video in class. The student that can tell me why I have created a video focusing primarily on lipids and Propofol (the winner, winner), will get a prize. Not just a chicken dinner.
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