IV Restarts-Are they plaguing your Staff?

3.8 million central venous catheters (CVCs)....

2 million peripherally inserted central catheters (PICCs).....

and 310 million peripheral intravenous devices sold yearly in the US......

 

"Based on average salary and benefits for an RN, the average time of 36 minutes for a nurse to trouble shoot and restart a PIV translates to a labor cost of an estimated $22.79 per incident (Rosenthal, 2005)."

 

Vascular access and Infusion Therapy is clearly a high priority and nurses take a lot of time performing these procedures for our patients. Getting the right vascular access device placed early in the hospital stay can speed treatment and patient discharge while minimizing cost as well as restarts.

 

Maintaining the health of our patients veins and arteries has become an important issue as patients now come to hospitals more acutely ill, living longer, often having chronic conditions. According to the Centers for Disease Control (CDC) selection of the right device inserted into the right location is paramount to reducing complications, specifically infection.

Selecting the correct device is based upon the patients diagnosis, infusion therapy needs, and the length of time the patient will need these treatments and/or medications. Once the correct device is selected, assessment of the patients needs as well as the patients veins is essential.

If the device is a central line has your staff followed CDC recommendations in using Central Line Bundles. Central Line Bundles should be applied to all care and maintenance procedures.

Peripheral intravenous starts are the most common invasive procedure amongst hospitalized patients in America as about 310 million Americans receive a Peripheral IV while during their hospital stay.

 

Before 2012; nurses and facilities were typically require to change a patients IV site every 72-96 hours as recommended by the Standards of Practice of the Infusion Nurses Society.  However, as of 2012 the Infusion Nurses Society recommends that IV sites be changed as clinically indicated by the nurse.  However, what does clinically indicated mean?  We have asked over 100 nurses and each of them has given us a different answer.  None of their responses have been quite consistent.

 

Training

 

It is important to have annual training in IV Therapy and the new standards of practice in order to maintain their competency as well as a consistency in this procedure that may cost patients as well as hospitals a lot of time and money. Nurses need to understand what clinically indicated means and when to apply them to real life situations.  They also need to understand the medications they are administering through the venous access devices whether peripherally or centrally. 

Do your nurses understand that the osmolarity of medications and fluids matter? Do they understand the importance of the medications Ph? Do they know the medications dosage, contraindications, and more? Are you nurses securing the IV catheter with the proper device? Are they selecting a good vein as well as the proper location?  All of these issues play into restarts.

 

 

 

 

 

References

 

1. McNeill EE, Hines NL, Phariss R. A clinical trial of a new all-in-one peripheral-short catheter. J Assoc Vascular Access. 2009;14(1):46-51.
   
2. Rosenthal, K. (2005). Get a hold on costs and safety with securement devices. Nursing Management. 36(5). 52-53.
3. Smith B. Peripheral intravenous catheter dwell times: a comparison of 3 securement methods for implementation of a 96-hour scheduled change protocol. J Infus Nurs. 2006;29(1):14-17.
4. Infusion Nurses Society. Infusion nursing standards of practice. Journal of Infusion Nurs.
 

Huber Needles and Implanted Ports

 A Huber Needle is a specially designed hollow needle used with implanted ports. A Huber needle has a long, beveled tip that is inserted through the patients skin as well until it accesses the silicone septum the implanted port's reservoir. The beveled tip of a Huber needle will not remove a core of silicone from implanted port as this is the way it is designed.  This design will allow as much as 2000 needle sticks into the implanted port’s reservoir without having to be changed. Dr. Ralph L. Huber, a dentist, designed the sharp, beveled, directional needle tip and Dr. Edward B. Tuohy, an anesthesiologist, refined it for use in spinal catheters.

Huber needles are used to access ports implanted under the skin of patients who may be suffering from a chronic illness, such as cancer, pancreatitis, or has the need for repeated access to veins for blood withdrawal.  These patients often need the implanted port for infusion of medication, nutritional solutions, blood products, and other various types of treatment.  However, these implanted ports must be accessed and thus comes into play the Huber needle. These needles should be designed to penetrate the port without cutting and dislodging any silicone cores from the ports into which they are inserted.

There are several manufactures that design and produce Huber needles. Bard Access has designed and produced the SafeStep© as well as Smith-Medical has designed and produced the Gripper Plus©

 

 

Uses of Implanted Ports

·         To deliver total parenteral nutrition in those unable to take (adequate) food orally for a long periods of time.

 

·         To deliver chemotherapy to cancer patients (Chemotherapy is often toxic, and can damage skin and muscle tissue)

 

·         Provide a method of delivering drugs quickly and efficiently through the entire body via the circulatory system.

 

·         To deliver coagulopathy therapy

 

·         To withdraw blood in patients who require frequent blood tests

 

·         To deliver antibiotics to patients requiring them for a long time or frequently

 

·         Delivering medications to patients with immune disorders.

 

·         For delivering radiopaque contrast agents, which enhance contrast in CT imaging.

 

Types of Implants

There are many different types of implanted ports. The particular type selected is based on the patient's specific medical conditions.

Portals:

• can be made of plastic, stainless steel, or titanium
• can be single chamber or dual chamber
• vary in height

Catheters:

• can be made of biocompatible, medical-grade polyurethane or silicone
• can vary in length (cm)
• can vary in diameter (mm)

ImplantedPorts can be put in the upper chest or arm. The exact positioning itself is variable as it can be inserted to avoid visibility when wearing low cut shirts, and to avoid excess contact due to a backpack or bra strap. The most common placement is on the upper right portion of the chest, with the catheter itself looping through the right subclavian vein down towards the patient's heart. It can also be situated on the muscle that sits on the ribs with the tube coming up towards the heart.

Risks

1. Infection - a severe bacterial infection can compromise the device, it this occurs it may require surgical removal of the implanted port and can seriously jeopardize the health of the patient.
2. Thrombosis - formation of a blood clot in the catheter may block the device and thus it may become inoperable.  However, if this occurs the port maybe flushed with saline and or Ateplase and this is performed by a nurse trained in administering this medication.
3. Mechanical failure - It is possible that part of the system could break; usually the attached catheter may break off or become dislodged from the port’s reservoir.  Many patients are asymptomatic and mechanical failure is discovered because of an inability to flush or withdraw fluids from the port. In those rare instances intervention surgery is required to withdraw the failed vascular access device.
4. Respiratory Issues - Attempts to gain access to the subclavian vein or jugular vein can injure the lung, possibly leading to a complication known as Pneumothorax.
5. Arterial Damage - The subclavian artery can be inadvertently punctured as well as the carotid artery; however, this is rare, since attempts to access the nearby jugular vein are increasingly done with ultrasound guidance.

Extravasation Malpractice-Protect Against It

  Protect Against It

Yahoo news report “The Law Offices of Kenneth A. Wilhelm uses expert testimony to prove medical negligence in the case of a day-old infant who suffered permanent injuries as a result of improper IV administration. The Law Offices of Kenneth A. Wilhelm, a New York personal injury law firm, has successfully obtained an $800,000 verdict on behalf of their client, a day-old infant, who suffered permanent scarring and injury Extravasation malpractice case: Law firm secures $800,000 verdict.

The child was admitted to the Montefiore Medical Center in the Bronx on Jan. 13, 2006, a day after he was born. The law firm filed a complaint in the Supreme Court of the State of New York, Bronx County (Index # 8785/2007) against the hospital alleging that the child, who was scheduled to undergo spina bifida surgery the following day, was not properly monitored by nurses at the hospital while he was receiving intravenous fluid in preparation for the surgery.”

Click here for the full story.

This case as well as many other types of IV Therapy cases are won on the basis of medical negligence or malpractice.  So what is medical negligence? "Medical malpractice is professional negligence by act or omission by a health care provider in which the treatment provided falls below the accepted standard of practice in the medical community and causes injury or death to the patient, with most cases involving medical error. Standards and regulations for medical malpractice vary by country and jurisdiction within countries. Medical professionals may obtain professional liability insurances to offset the risk and costs of lawsuits based on medical malpractice"

So what are the standards for Infusion Therapy? Standards are recommended by the

 Infusion Nurses Society

Infiltration and extravasation are complications that can arise with the administration of intravenous therapy solutions and or medications. They typically involve unintended leakage of a  solution or medication into the surrounding tissue. Severity of injury ranges from local irritation to amputation. While immediate action using appropriate measures (ie, dilution, extraction, antidotes, and supportive treatments) can decrease the need for surgical intervention, many injuries may be prevented by following established policy and procedures based upon the Infusion Nurses Society Standards of Practice.

---

Infiltration is the inadvertent leakage of a nonvesicant solution into surrounding tissue; whereas extravasation is the inadvertent leakage of a vesicant solution into surrounding tissue.

An extravasation injury can arise while administering IV solutions high in osmolarity and Ph as well as caustic medications and may lead to devastating consequences if not properly diagnosed. A health care provider's failure to assess and treat this complication in a reasonable time-frame can lead to further devastation and injury to the patient as well as medical malpractice lawsuit.

Failure to properly diagnosis an extravasation injury may lead to:

• loss of limb;
• need for amputation;
• disability; and/or
• disfigurement.

 Treatments 

Heat and Cold 

• Heat induces vasodilation, increasing drug distribution and absorption and decreasing local drug concentrations
• Cold causes vasoconstriction, localising the extravasation and allowing time for local vascular and lymphatic systems to disperse the agent.
• With the exception of vinca alkaloids, topical cooling seems to be more effective than topical warming in the management of cytotoxic and non-cytotoxic vesicants

 Antidotes

Surgery

 

Introduction to Intravenous Therapy for Health Professionals By Fulcher, Eugenia M./ Frazier, Margaret Schell (Google Affiliate Ad) 

 

 

REFERENCES

1. www.surgeons.or.th/ejournal/files/Vol27_No1_19.PDF

    
2. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006;29(1)(suppl):S1-S92
3. www2.kumc.edu/pharmacy/.../Extravasations%20diagram.pdf
4.  
   The 2011 Infusion Nurses Society Standards of Practice  
   
   
   
   
    
   
   

 

Look! Listen! and Feel!

Medical personnel automatically think of CPR when it comes to the saying Look! Listen! & Feel!

However, they should also think about Infusion therapy as well.

So many times nursing staff attempt to perform an IV catheter on a patient and without fail they do not succeed on the first time.  Why does this happen?

Many times the nurse looks for the vein and fails to listen to the patient and fails to feel for the vein. 

It is very important to not attempt an IV Catheter on the first look.  Every patient has a vein; however, sometimes those veins may be hard, they may take a curve, or even stop short of what they appear to be at first glance.  Learning your patients anatomy can help save their veins and help you as a medical professional become more successful in your infusion therapy skill.

Look 

When looking for a vein on your patient; try and look for the most straight vein. Do not just stick the first vein you see.  Look at every vein first and try and pick the best vein possible that will make it easy for you and the patient.  Patients are afraid of pain most of the time and if you listen to them as well they will show you the best veins they have as well as share their horrible past experiences. 

 Introduction to Intravenous Therapy for Health Professionals By Fulcher, Eugenia M./ Frazier, Margaret Schell

Listen

Listen to your patients before you stick them with a needle.  They can tell you where they typically get stuck and which is the best vein for them and for you.  Most of the time they will remember the previous person who either drew their blood or stuck them for an IV catheter and they can recall whether it was a good or bad experience.  This is important because it may be a key factor in you preventing anxiety.  Increased anxiety can cause the patient to have vaso-constriction which in turn will make it more difficult for you to start and IV on that particular patient. 

Iv Therapy Notes By Phillips, Lynn D.

 

Feel 

The last thing the healthcare worker should do before attempting to insert an IV catheter is to Feel. 

Feeling for the veins is the single most important issue and step one can take in order to be successful.  How does the vein feel?  Hard, soft?  Does it take a quick turn? Is it long enough?  measure your catheter in comparison to the vein; do you need to take an indirect approach versus and direct approach? 

 I. V. Therapy

So remember; when performing IV Therapy it is a skill that can improve with practice and technique.  Do not take you patient and their veins for granted as this may be you one day in the bed getting poke multiple times by a nurse who failed to

LOOK! LISTEN! AND FEEL! 

Don't be Vain with your Veins

If you have drawn blood or started IV's for any length of time; one knows that you cannot be vain when it comes to your patients veins

Veins will collapse or shrink or blow; due to many reasons within our control and some beyond our control. If the provider does not prepare the patient and keep the patient calm the patient may panic. If the provider does not use the right equipment samples will hemolyze. Parents who may be scared will not hold their children and the kids will kick.

Difficult venipunctures are simply a part of the everyday task that every nurse working may face. If you think that your day will be perfect every day you come to work and draw blood or start an IV then you are vain.

There are so many different patients, illnesses, and other factors that will play into your success at drawing blood or starting your infusion therapy. Drawing blood from drug addicts, obese people, critically ill patients, geriatric patients, and pediatric patients will definitely take a toll on you if you are not aware of the potential pit-falls with each patient you attempt to perform venipuncture on. Nurses are so focused on the task at hand that we forget the most important part of our job; and that is our Patients.

Patients who are critically ill are often the most difficult draws because they are subject to more blood withdrawal than most other patients and they are typically suffering from fluid overload or severe dehydration. So why not just use their IV lines to draw their blood?

The problem is when you draw blood from a line, you save the patient from the pain of a stick, or even yourself from the challenge of a difficult draw; however, the test results can be erroneous due the nurse not flushing the lines before drawing a sample, medications, hemolysis, and many other factors that we often do not think about at the time of the process.

Another big problem with blood draws and intravenous starts may be that the patient has fragile veins that blow more easily than normal. What about small children; their veins have not yet quite developed and if one attempts to use a large catheter in a small vein; guess what? POP, goes the vein. Or how about a geriatric patient that has high blood pressure and their veins have weakened over time and again the provider attempts to use a larger catheter in these types of veins. You got it; POP. When a provider fails to realize this, they are merely setting themselves up for failure as well as potentially causing the patient get a hematoma. What if you miss or cause injury; wheat do you do?

The standard is to try again at another site, which may produce the same result if you did not learn from the first mistake. However, if you are unsuccessful two times you should move along and let another provider attempt the stick. Also, think about how you may get a geriatric patient to clench their fist to help the draw may be pointless because they may be weak or have little muscle mass to do so.

Should I Use a Tourniquet?

The use of a tourniquet is up to the nurse attempting the venipuncture. The sole purpose of the tourniquet is to make the veins more visible and easier to palpate. On the other hand, using a tourniquet with weak or underdeveloped veins can cause the veins to blow when the needle is inserted. Leaving the tourniquet on longer than one minute prior to venous access can also cause hemolysis which may result in erroneous lab samples as well. Whenever finding and accessing a vein takes longer than one minute, it should be released and two minutes should be allowed to pass before reapplying it so that the blood can return to its normal state.

Drug Addicts

Initiating IV Therapy or venipuncture on patients with a history of drug abuse can be quite difficult as scarification of both skin and veins are a common problem. When the drug addict has repeatedly punctured their skin with a needle, it will build up scar tissue over time leaving limited use of their veins for blood withdrawal and IV Therapy.

Children

Children are often scared of the doctor’s office and/or needles and by nature this makes it very difficult for the nurse as well as the patient/parents. Kids seem to want to watch the needle going into their skin and thus this can make them even more nervous. So we don’t want to give them the chance to watch. Avoid this by concealing the needle as well as reducing their fear by talking, coaxing, and comforting them throughout the procedure.

Distraction can be a highly effective tool when drawing blood or starting an IV in any patient. Sit down, look at the patient eye-to-eye, talk with them, hold their hand, and understand their culture and how they may tolerate pain. Explain the procedure to them in understandable terms.

Assistance

There are several types of assistive instruments on the market today that can help detect veins, such as Accuvein AV300, Veinlite, and the vein Viewer. The technical term for these devices are call "Tissue illuminators" and some have been around for a while. The handheld Accuvein AV300 came out in 2009 and costs about $4,000. The Veinlite is likely to be the least expensive one but also it is not as effective, and last the Vein Viewer is the most effective on the market today as well as the most expensive one too.

What Can One Do

If the venipuncture proves extremely difficult because you cannot find a vein, think about warming up the patients arms with a warm blanket or towel. This will cause their vessels to vasodilate and move close to the top of the skin and make it easier to find. If you suspect the patient is suffering from dehydration ask the patient to drink water if they are not on fluid restrictions and return later to do the venipuncture. If the patient is suffering from fluid overload and shows severe signs of edema; you may have to push down the surrounding tissue to see the vein that you may want to access. This will be a difficult but not impossible task and you may need help in accomplishing this task. Help your patient to relax, keep them calm because once they get nervous their "Fight or Flight” response will kick in and their veins may disappear for quite some time.

IV Fluid Resuscitation

IV Fluid Resuscitation

The human body is composed of different fluid compartments and each compartment is important in regards to fluid resuscitation; however, each compartment must work in cohesion with the other.

Our bodies are made up of mostly water; and water is the key source of life. However, if the water in our bodies is not distributed correctly it can have a detrimental impact on the patient’s outcome.

The fluid compartments consist of the Intracellular Fluid Compartment (ICF), the Extracellular Fluid Compartment (ECF), the intravascular space, and the interstitial space.

The Intracellular Fluid Compartment contains about two-thirds of the body’s total fluid or 66%

according to the manual of Critical Care; whereas the Extracellular compartment consists of one-third or 33% our total fluid. The Extracellular compartment may be broken down further into the intravascular space and interstitial spaces. The intravascular space contains approximately 25% and the interstitial space contains about 75% as seen in the   

Figure 1.1

When assessing the patient the healthcare provider should use their critical thinking skills to determine the fluid needs of the patient; which fluid compartments are or will be affected, and what types of fluids would best be ordered to help achieve an optimal fluid distribution. Distribution of fluids will depend on the solute order and the concentration of said solute.

The human body’s serum osmolarity typically ranges from 285-295 in order to maintain homeostasis in these fluid compartments. The healthcare provider should assess the osmolarity of the crystalloids or colloids in order to help determine where and how they want to move the fluids from one compartment to another.

Crystalloids and Colloids

There has been a lot of debate over this particular issue in the healthcare setting for quite some time.

Why choose a crystalloid or a colloid or vice versa. “A critical review of the experimental and clinical studies comparing crystalloid versus colloid resuscitation essentially shows no physiologic difference in the two solutions.”

(Tranbaugh, & Lewis, 1983)
So, to answer our previous question; why a colloid versus a crystalloid; is not an easy one. The physician may choose to select a colloid for patients who are already deemed to be in pulmonary edema or have some type of cardiac issue that may hinder an effect fluid exchange at the capillary level. By given colloids the healthcare provider can limit the fluid intake; yet still achieve fluid resuscitation. On the flip side if the patient has not yet gone into full blown pulmonary edema and has good kidney function the provider may opt for the crystalloid as this is less expensive and research has determined that neither has an advantage over the other; except cost. Crystalloids are less expensive than colloids; so the healthcare provider should outweigh the benefits versus the risk as well as a simple cost analysis.

In order to be effective in managing the redistribution of fluids the healthcare provider must understand what types of fluids are either crystalloids and or colloids and how that may affect the movement of fluids across the different compartment membranes.

Before selecting a colloid versus a crystalloid the healthcare provider must paint an overall picture of the patient’s condition and underlying disease process.

Crystalloids

According to the Tabers Medical Dictionary a Crystalloid is a solution in which crystals can or may form; but is able to diffuse across cellular membranes. Crystalloids are the most common fluids used in the healthcare setting. The following are some examples of the most common solutions in the crystalloid category.

Normal Saline

Lactate Ringers

Dextrose 5%

Normal Saline

Normal Saline is composed of 154 milliequivalents (mEq/L) of Sodium and 154 milliequivalents of Chloride. The ph is 6.0 and the osmolarity is approximately 308. Normal saline is the main solution of choice when administering a blood product. (Raoof, George, Saleh, & Sung, 2008)

Lactate Ringers

Lactated Ringers is composed of 130 milliequivalents of Sodium, 4mEq of Potassium, 109 mEq’s of Chloride, and 28mEq’s of Lactate. The ph is approximately 5.1 and the osmolarity is approximately 273. (Raoof, George, Saleh, & Sung, 2008)

Dextrose 5%

Dextrose 5% is composed of 140 mEq’s of Sodium 5 mEq’s of Potassium, 98 mEq’s of Chloride, and 50 grams of Dextrose. The ph is 4.0 and the osmolarity is around 252. (Raoof, George, Saleh, & Sung, 2008)

Colloids

Again, according to Tabers Medical Dictionary a colloid is a “glue-like substance, such as a protein or starch… or a substance used as a plasma expander in place of blood.” (Wilbur, 2009) The following are some examples of colloid solutions.

1. Albumin
2. Hetastarch
3. Dextran

Albumin

Albumin is produced in a couple of varieties; typically 5% and 25%. Albumin “is made from pooled human plasma, which undergoes ethanol fractionation, ultrafiltration, and pasteurization.” (Raoof, George, Saleh, & Sung, 2008) Albumin 5% contains no preservative and is a clear, slightly viscous liquid; it is almost colorless or slightly yellow tint. (FDA.gov, 2006) It is mainly used to expand the intravascular volume whereas Albumin 25% is typically used for hypoproteinemia. Albumin 5% is composed of 154 mEq’s of Sodium and 50 grams of Albumin and has a ph level of 6.6 as well as an osmolarity of 290.

Hetastarch (Hespan)

Hetastarch is another type of plasma expander and is similar in properties to Albumin. If given; it can sometimes cause an increase in the serum Amylase; which may throw healthcare professionals for a loop into thinking the patient may be suffering from pancreatitis. Hetastarch is composed of 154 mEq’s of Sodium with a ph level of 5.5 as well as an osmolarity of 310.

Dextran

Dextran is also a plasma expander; however, it is higher in molecular weight than Hespan. The amount of expansion it provides to the vascular system depends on the amount and rate of infusion. Just like with Albumin; Dextran is provided in a couple strengths; typically 40 or 70. Dextran 40 is composed of 154 mEq’s Sodium, a ph level of 6.7, as well as an osmolarity of 320. Whereas Dextran 70 is composed of 154 mEq’s Sodium, a ph level of 6.3, and an osmolarity of 310.

Crystalloids versus Colloids

So, what is the best choice for fluid resuscitation? Crystalloids or Colloids? The problem is it takes a larger amount of crystalloids to resuscitate a patient fully; on the other hand it only takes a small amount of colloids. Colloids however are more expensive and can expand the intravascular space fairly rapidly. Depending on what the patient’s medical condition is and the end goal of the fluid resuscitation will depend on whether the healthcare provider administers a crystalloid or colloid. For example if a patient arrives to the emergency room or ICU and as in hypovolemic shock; the goal of fluid replacement would most likely be attained by administering a crystalloid. On the other hand if the patient is septic and has been diagnosed with septic shock the provider may give a colloid or crystalloid.

Monitoring FluidStatus

In a normal healthy patient the body’s blood volume is typically 70ml/kg or 4.9 liters for a patient who weighs 70kg. There are many methods to monitor and asses a patient’s fluid status; however it is difficult to pinpoint the exact amount of fluid loss. Healthcare providers may choose to perform a venipuncture and obtain a serum osmolarity or the physician may opt to insert a central line a monitor the patients central venous pressure (CVP) otherwise known as right atrium pressure. In a normal healthy adult; the CVP should normally range from 6 to 8 cm of water. The lower the CVP the more dehydrated the patient may be; whereas the higher the CVP the patient will most likely present with fluid overload. If the healthcare provider is using the serum osmolarity to judge the fluid status one must first remember that early we stated the normal range usually falls between 285-295 mOsm/kg. The higher the serum osmolarity the more dehydrated the patient may present; whereas the higher the serum osmolarity the more likely the patient will present with symptoms of fluid overload. Another option that healthcare providers have at their disposal is the complete blood count (CBC). The provider may assess the hematocrit. If the patient presents with a hematocrit greater than 45 they may also be suffering from fluid overload.

Conclusion

The goal of fluid resuscitation is to hydrate the cells in order to maintain a normal blood pressure and pulse rate. Both crystalloids and colloids have their place in fluid resuscitation, but the healthcare provider must look at the overall picture and use critical thinking skills in order to administer the correct fluids, at the correct rate, and the correct amount. The healthcare provider should assess the patient and determine the goal of the fluid resuscitation needed and then make a decision on the correct fluid to administer. The healthcare provider should also look at the risk versus the benefits as well as the cost analysis.

References

1. Raoof, S, George, L, Saleh, A, & Sung, A. (2008). Acp manual of critical care. New York:

McGraw-Hill Professional.

2. Wilbur, C. (2009). Taber's Cyclopedic Medical Dictionary. Philadelphia: F A Davis Co.

3. "Albumin 5%." Albumin 5%. FDA.gov, 02 Oct 2006. Web. 2 Apr 2011.

http://www.fda.gov/downloads/biologicsbloodvaccines/bloodbloodproducts/approvedproducts/li

censedproductsblas/fractionatedplasmaproducts/ucm056844.pdf

4. Nursing i.v. drug handbook. (2005). Philadelphia: Springhouse Pub Co.

5. Tranbaugh, RF, & Lewis, FR. (1983). Crystalloid versus colloid for fluid resuscitation of

hypovolemic patients.

Medline, 1-10(0195-878X), Retrieved from

http://www.ncbi.nlm.nih.gov/pubmed/6349305

The Art and Science of Teaching

Did you know that as nurses we perform over 300 million peripheral IV's in America every year?  This is a lot of IV starts especially if you think about how many people exist in America. 
That is nearly one IV for every American.

How do nurses learn to perform IV Therapy?  New graduates nurses get little to no hands on training or exposure to IV Therapy in nursing school and thus makes them ill-prepared once they get onto the floor.

There is a lot of controversy over how to teach student nurses on the Art and Science of inserting an intravenous catheter. There have been studies that have proven that computer-based training produces a more successful outcome versus the traditional hands on training of peer-to-peer groups or the use of mannequin arms.

The Infusion Nurses Standards of Practice also discourages the use of peer-to-peer practice as well.  The problem with this issue is that the computer based programs can cost up to $12,000 and not every business or school has the funds to purchase such equipment.  Some in the Infusion industry have also stated that using "healthy subjects" is not a good idea and that it may be the same equivalent as practicing on mannequin arms.

The issue with this mind-set is that the students need to build confidence in starting peripheral intravenous and they need to feel the success of learning how to start them without difficulty before getting onto the floor and trying a more difficult patient.  Sick patients may have a low blood pressure or suffer from extreme dehydration and this may cause their veins to become flattened causing increase difficulty for the new nurse to accomplish this task.

The Art and Science of Teaching comes with experience and not every nurse with experience can teach in a way that student nurses feel comfortable. The Art and Science of Teaching or Pedagogy is a special gift that instructors need in order to build confidence in the students.

Anyone who knows us or has attended one of our classes; know that our instructors love to teach and are very careful and patient with the students.Our instructors try and make the course fun, interesting, and most of all we instill confidence in our students.  We teach them how to get comfortable with themselves as well as the situation they will be placed in to perform IV Therapy.
Enroll in a class today and enjoy the Art and Science of Teaching of IV therapy. 

To Bone or not to Bone

Being a member of the INS and AVA I have learned a lot in and out of these organizations and received a lot of support from many.  On the other hand their have been instances when certain nurses laugh at topics when attempting discuss alternatives to Infusion therapy.  Infusion therapy can be done with more than just a peripheral IV catheter or a central venous access device such as a PICC line or Sub-clavian line.

These types of vascular access devices are great and have brought a lot of medical advances to the forefront; however, there is one device that is continually overlooked and even mocked; yet it has the same benefits and less complications than most if not all the other vascular access devices.

The recognition of the intraosseous (IO) vascular access device in fluid resuscitation and stabilization of patients has been underrated for quite some time. Intravenous therapy alone has made significant strides in the past forty years. The need to administer a wide variety of fluids and medications in to a patient and affect their circulatory system is critical in the resuscitation of patients in an emergent situation regardless of their underlying disease process. Rapid vascular access is required for many conditions to include but not limited to hypovolemic shock, trauma, anaphylactic shock, cardiac arrest and many more conditions.

There have been several “leading national and international organizations” that have published position statements as well as performed research studies to advance the cause of the IO. The IO has served to change the standard of care in the emergency room in regards to the quick need for vascular access, but also is making strides to the way we care for patients in the intensive care units (ICU’s) medical-surgical units, and beyond.
Among the leading organizations who state that the IO can play a significant role in the care of patients in need of resuscitation is the American Heart Association (AHA), addressing vascular access in cardiac arrest patients¹, the Infusion Nurses Society (INS)², the Emergency Nurses Association (ENA)³ and the American Association of Critical-Care Nurses (AACN) all endorsing the INS position statement.² The intraosseous device is recognized by these professional organizations due to the significant time savings that patients benefit from in emergency situation as well as the minimal complications in relation to central venous catheters and peripheral venous catheters.
The Intraosseous device allows healthcare professionals to decrease the time required to achieve access as well as administer necessary intravenous fluids and medications needed for resuscitation or stabilization of a patient throughout the different areas of nursing. The AHA came to the conclusion that a peripheral intravenous catheter (PIV) and an intraosseous device (IO) can administer equally and predictably the same pharmacological effects and in fact the IO device has a direct correlation to the central venous system and fluids and or medications can be sent to the central venous system within seconds not minutes.

To learn more about the IO devices, uses, and complications visit us at Central Valley Medical and Pedagogy to learn more.


References
1. American Heart Association (AHA). http://www.heart.org
2. Infusion Nurses Society (INS). http://ins1.org
3. Emergency Nurses Association (ENA) http://www.ena.org
4. Vidacare Corporation. EZ-IO. http://vidacare.com
5. Brown, Philips, Campbell, Miller, Proehl, and Youngberg. "Recommendations for the use of Intraosseous Vascular Access for Emergent and Non-Emergent Situations…." Journal of Infusion Nursing. 36.6 (2010): Print.
6. Waismed. Big-Gun. http://www.waismed.com
7. Pyng Medical. Fast1. http://www.pyng.com
8. Von Hoff DD, Kuhn JG, Burris HA, Miller LJ. Does intraosseous equal intravenous? A pharmacokinetic study Am J Emerg Med. 2008;26:31-8.
9. Phillips L, Proehl J, Brown L, et al. Recommendations for the use of intraosseous vascular access for emergent and nonemergent situations in various health care settings: a consensus paper. 2010. J Inf Nurs. 33:346-51.