Peripheral intravenous catheters. Peripheral venous catheterization

Peripheral intravenous catheters:

classification and features of pharmaceutical care

N. B. Yarko, B. P. Gromovik, E. N. Eliseeva, N. V. Galayko, Lviv National Medical University. D. Galitsky, Odessa State Medical University

Peripheral intravenous catheters (infusion cannulas, PVVC) are used for patients who require immediate and/or intensive long-term infusion therapy, as well as for patients with “heavy”, poorly visualized veins. The use of infusion cannulas at the pre-hospital stage makes it possible to comfortably transport the patient without fear that the needle will “come out” of the vessel or pierce its opposite wall and complicate the patient’s condition with infiltration or hematoma.

Considering the disappointing results of a survey of pharmacists and nurses regarding the consumer properties of PVVC, the purpose of this publication was to summarize data on indications, contraindications, structure and features of the use of infusion cannulas.

As can be seen from the data in Table 1, intravenous catheters are characterized by four main types of indications and three groups of contraindications.

The presence of a wide range of PVVC made it necessary to develop their classification depending on the material of manufacture, structure, size and color coding (Fig. 1).

The materials for the manufacture of PVVC are thermoplastic and strong, have a high degree of biocompatibility and a low coefficient of friction. They ensure that catheters, with proper care, can be used for 48–120 hours. Depending on the material of manufacture, there are polyurethane (vialon) and fluoroplastic (Teflon) PVVC. In this case, two types of fluoroplastic are used: polytetrafluoroethylene (PTFE-Teflon) and an analogue of Teflon - fluorinated ethylene propylene (FEP-Teflon).

According to their structure, PVVC can be ported or non-ported. Their structure always contains such basic elements as a catheter, a guide needle, a plug and a protective cap. A venesection is performed using a needle, and a catheter is inserted at the same time. The plug is used to close the catheter opening when infusion therapy is not performed (to avoid contamination), the protective cap protects the needle and catheter and is removed immediately before manipulation. For easy insertion of a catheter (cannula) into a vein, the tip of the catheter has the shape of a cone. The ratio of the catheter tip to the beginning of the needle bevel or trim value is characteristic of each catheter size.

Ported PVVCs have an additional injection port for administering drugs without additional puncture. With its help, needle-free bolus (intermittent) administration of drugs is possible without interrupting the intravenous infusion.

In addition, catheters may be accompanied by an additional design element - “wings”. Not only do they securely secure the PVVC to the skin, but they also reduce the risk of bacterial contamination by preventing direct contact between the back of the catheter plug and the skin.

Table 1: Indications and contraindications for the use of PVVC

Some manufacturing companies offer accessories: mandrin or obturator (used to protect the internal lumen of the catheter from blood clotting in it and the formation of blood clots after infusion), additional Luer-Loc plugs, sterile dressings.

In order to reduce friction, and therefore pain during installation, the catheter and needle are coated with a lubricant (silicone). Some manufacturers equip catheters with a radiopaque strip to ensure effective monitoring of their location in the vein.

PVVC are characterized by size, which refers to the outer diameter of the catheter (needle) and the length of the cannula (in mm). At the same time, according to the measurement system of the American Association of Medical Instrument Manufacturers, the outer diameter of the catheter (needle) is given in gauge (G), and its length in inches (inch - in). The gauge size (for example, 14 G) corresponds to the number of cannulas (in our case, 14) that fit in a tube with an internal diameter of 1 inch. In turn, 1 in equals 25.4 mm, i.e. a 14 Gx1.77 in catheter has a length of 45 mm.

For all PVVCs, depending on the size, color coding is mandatory in accordance with the ISO 10555 standard. It should also be noted that the size of the catheter is directly related to the area of ​​its use, as well as with the flow rate (outflow) of the liquid, which, depending on the manufacturer, is the same for PVVCs sizes may vary.

Since the catheters under study belong to “single-use” products (disposable use), they must be sterile, pyrogen-free, non-toxic, and since they come into direct contact with blood, biocompatible and hypoallergenic. In addition to the general quality requirements, there are also a number of functional requirements: the needle must be sharp, elastic, without burrs; the plug should not be disconnected from the catheter sleeve without permission; The injection port cover should open and close without any force.

Taking into account the insufficient level of knowledge of pharmacists and nurses in caring for PVVC, we have developed a flow chart of pharmaceutical care when using catheters in the departments of a medical institution, aimed at doctors and nurses. As can be seen from the data in Figure 2, pharmaceutical care can be divided into eight stages.

The patient’s informed consent to the manipulation is certified by his signature, must be entered into the inpatient’s medical record (form No. 003–0) and is the second stage in choosing a PVVC. Before the procedure, the patient should be checked for allergies to the administered drugs.

At the third stage, issues of choosing a catheter are considered depending on the material of manufacture, structure and size, as well as the recommended areas of application of certain catheters, the possibility of additional administration of drugs and the duration of the required cannulation.

The appropriate PVVK is selected taking into account:

• the size, condition and blood flow of the accessible veins, since the cannula should never completely occlude the vein;
• the length of the cannula, which should correspond to the approximate length of the straight section of the corresponding vein; local anatomy;
• required infusion rate: high infusion rate necessitates the installation of PVVC in veins of larger diameter;
• the type of liquid being infused, since potent irritating drugs must be injected into larger vessels for more intensive dilution with blood;
• predictable duration of administration, since the use of a smaller PVVC will minimize irritation of the vein

The fourth stage is the choice of venipuncture site. PVVC should be installed in veins:

• well palpable with high blood filling;
• limbs of the non-dominant side of the body;
• on the side opposite to the one where the surgical intervention was performed;
• with the maximum possible diameter.

Avoid bending areas (joint area), veins of the lower extremities close to arteries, irritated as a result of previous catheterization, fragile and sclerized veins, lymphadenoma areas, infected areas and cracks in the skin, as well as the median cubital vein, which must be left for sampling venous blood.

The fifth stage covers the installation of PVVC, for which you should check its sterility and expiration date, as well as prepare all the necessary auxiliary materials (as a rule, a sterile tray containing cotton wool, a skin disinfectant, a syringe with 0.9% sodium chloride solution, sterile bandages and plaster). According to the appointment sheet, the doctor (nurse) must identify the patient, wash thoroughly, cover all lesions on the skin, put on protective gloves (latex, latex-free, chain mail), treat them with a disinfectant, if necessary, put on a medical mask and goggles, take a comfortable position and begin the process of installing the PVVC. The venipuncture site and adjacent skin areas should be thoroughly treated twice with a disinfectant solution. In this case, the area of ​​the skin should correspond to the size of the future dressing. The treatment is carried out from the site of the planned installation of the catheter in one direction or in a circular motion in the outer direction from it and wait until the antiseptic dries. The treated area must not be touched.

Once again making sure that the packaging is not damaged and the PVVC is not expired, using the symbols (markings), open the packaging in the manner prescribed by the manufacturer. If necessary, unfold the “wings” and take the PVVC in the most convenient way. It is strictly forbidden to remove the needle from the catheter before venipuncture, since not only will the trim be disrupted and venipuncture will be difficult to perform, and the patient will experience severe pain, but damage to the catheter itself is also possible. Next, the vein is fixed and inserted at a slight angle of the PVVC, while the bevel of the needle should be directed upward. A successful venipuncture, which means that the needle is in the vein, is indicated by the appearance of blood in the reverse flow imaging chamber.

After this, the PVVC along with the needle is slowly advanced a few millimeters further into the vein into which the tip of the cannula enters, after which the guide needle is fixed with one hand, and the catheter is advanced with the other, thus removing it from the guide needle, or the needle is slowly pulled back. guidewire and advance the cannula into the vein faster. If you used a tourniquet, you need to remove it. It is prohibited to re-insert the guide needle into the cannula while it is in the vein - this can lead to damage to the walls of the cannula. To prevent blood from leaking out of the PVVC, you need to press the vein with your finger slightly above the tip of the cannula. Next, the guide needle is completely removed and the infusion system is connected to the PVVC or closed with a plug. For disposal purposes, the guide needle is placed in a sharps container. To confirm the efficiency of operation and the correct position of the PVVC, it should be washed (preferably with a 0.9% sodium chloride solution). To ensure the dryness of the installation site, the absence of possible infection and mechanical phlebitis, and the appropriate service life of the PVVC, a sterile dressing should be applied.

Table 2: Recommendations for preventing possible complications when using PVVC

At the sixth stage, to prevent infection, it is necessary to inspect the PVVC installation site daily, both before and after infusion therapy. Wet and contaminated dressings should be replaced, adhering to antiseptic requirements, including the use of gloves. The installation time of the PVVC must be recorded in the appointment sheet (form 004/4), and its replacement must be carried out every 48–120 hours. IV systems are removed every 24 to 48 hours. Before and after each administration of drugs, the PVVC should be flushed with a heparinized hypertonic solution to check the effectiveness of the system.

Complications may occur during the use of PVVC: hematoma (both during installation and during catheter removal), infiltration, thromboembolism, air embolism, phlebitis and septicemia (purulent phlebitis). If the PVVC is installed correctly, the likelihood of complications is very low. To prevent possible complications, you should follow the recommendations given in Table 2.

The seventh stage covers the issues of withdrawal and disposal of PVVC. Removal of the catheter is associated with the end of the prescribed treatment (planned removal) and with complications: infiltration, phlebitis, infection (unscheduled or emergency removal). Before removing the PVVC, the healthcare worker must wash their hands, wear protective gloves, and remove all catheter bandages. It is forbidden to use scissors in this case, because this can lead to cutting of the PVVC and, as a result, to an embolism. Cover the catheter site with a dry, sterile cotton cloth and then remove it. To prevent blood from leaking into the subcutaneous tissue, press firmly on the area where the catheter was located for 2–3 minutes. If bleeding persists, raise the patient's arm. If necessary, apply a sterile dressing to the catheterization site. Always check the integrity and absence of damage to the removed catheter. Used catheters are subject to chemical disinfection and disposal.

The eighth stage concerns the installation of the next PVVC, which may be due to special indications, continuation of treatment, and undesirable venous reactions. Special indications for re-insertion of PVVC are accidental non-sterile touching of connections or elements of equipment of a direct intravenous line during manipulation, as well as after blood transfusion, if permanent venous access is necessary. It has been proven that after a blood transfusion, the formation of a fibrin sheath around the catheter increases the risk of infection. The choice of the sequence of PVVC installation sites is individual for each patient and should take into account not only the anatomy and mobility of the patient, but also the factors that are covered in the third stage of pharmaceutical care. In this case, it is necessary to adhere to the rules: first, venipuncture should be performed in the distal veins of the upper extremities, followed by movement in the proximal direction relative to the previous installation site.

Conclusions

1. Considering the importance of complete awareness of pharmaceutical and medical specialists, issues of indications, contraindications, structure and features of the use of peripheral intravenous catheters are summarized.

2. A classification of peripheral intravenous catheters is proposed depending on the material of manufacture, structure, their size and color coding.

3. A flow chart of pharmaceutical care has been developed for the use of peripheral intravenous catheters in departments of medical institutions, which provides for the prevention of complications when using infusion therapy and, therefore, helps to improve the quality of medical care for inpatients.

(Literature)

(1) Order of the Ministry of Health of Ukraine dated June 22, 1993. No. 223 “Instructions on the collection, containment and disposal of vicoristic viruses of disposable solids from plastic materials.”

(2) The role and place of the clinical examiner in medical and preventive care (methodological recommendations). Designers: A. B. Zimenkovsky, V. M. Ponomarenko, O. Yu. Grem. - K., 2005. - 27 p.

(3) Creamer. E. Infection Control, Part 6: Peripheral IV Cannula Infection Complications // World Irish Nursing.- 1998.- Jul/Aug, 6 (6).- P. 15–16.

(4) Fuller. A, Winn C. Selecting Equipment for Peripheral Intravenous Cannulation // Professional Nurse.- 1999.- No. 14 (4).- P. 233–236.

(5) http://www.basko.spb.ru/pdf/infusion.pdf

(6) http://www.finnmed.ru/catalogue5.php?i=1&r

(7) http://www.garant1.ru/products/100/

(8) http://www.hemoplast.ua/rus/_kateter_inside.php

(9) http://www.reepl.ru

(10) http://www.rusanesth.com/Genan/kat_jnj.htm

(11) http://www.portex.ru/cathy.htm

(12) http://www.rusmedtorg.ru/priceimg/cateter.html

(13) http://www.vogt-medical.kiev.ua/ruk_pvk.htm

(16) Lippincott J. B. Plummer’s Principles & Practice of Intravenous Therapy // Fifth Edition. - 1993. - Weinstein. S.M.- P. 90–95.

The intravenous catheterization procedure is performed by a qualified nurse with appropriate professional skills. At the same time, high standards of hygiene and catheter placement rules must be observed.

Indications for placement of a peripheral intravenous catheter (PVC)

• Frequent administration of intravenous medications.
• Administration of anesthesia during surgery.
• Parenteral nutrition.
• Maintaining fluid balance when it is impossible to take liquids orally.
• Regional anesthesia.

Vein selection

PVK is installed only in peripheral veins. The priorities are:

• veins of the non-dominant side of the body (for left-handed people - right, for right-handed people - left);
• clearly visible veins;
• veins with the largest diameter;
• veins on the side opposite to the surgical intervention;
• a straight section of vein with a length corresponding to the length of the cannula.

The veins of the inner surface of the forearm and the back of the hand are most suitable for installing PVC. The catheter is selected taking into account the size of the vein, the properties of the infusate, the required speed of its administration, and the duration of the catheter's stay in the vein.

Select the smallest catheter size that provides the required insertion rate in the largest peripheral vein. The cannula should not completely cover the vein.

How to place an intravenous catheter?

At a distance of 10-15 cm above the catheterization site, a tourniquet is applied and the patient is asked to work with his fingers to better fill the vein. The catheterization site is selected by palpation, treated with a skin antiseptic and allowed to dry on its own. The vein is not palpated again.

To fix the vein, it is pressed with a finger below the site of intended catheterization. Taking a catheter of the required size and removing the protective cover, make sure that the cut of the catheter needle is in the upper position.

The catheter on the guide needle is inserted at an angle of approximately 15 0 to the skin and the appearance of blood in the indicator chamber is observed. As soon as blood appears, further movement of the needle is stopped (this is only possible when it is removed from the vein).

The guide needle is fixed with one hand, and with the other hand the cannula is slowly moved from the needle to the end (while the guide needle is not yet removed from the catheter). Do not reinsert the guide needle into the catheter located under the skin; this may compromise its integrity, and surgery will be required to remove fragments.

Then the vein is clamped and the needle is finally removed from the catheter.

If, after removing the needle, it turns out that the vein is lost, the catheter is completely removed from under the skin, the PVC is collected under visual control and the installation procedure is repeated from the beginning.

After inserting the catheter into the vein and removing the guide needle, the catheter is closed with a plug, placing it through the port (ported catheter) or connecting the infusion system (non-ported catheter) and secured to the skin using a special bandage or adhesive tape.

Advantages of PVC.

Indications for peripheral vein catheterization.

Contraindications to catheterization of peripheral veins.

Types of catheters.

Types of catheters.

Device of catheters.

Manipulation technique:

STEP 1. Selecting the puncture site.

STEP 1. Selecting the puncture site.

STEP 2. Select the type and size of catheter.

STEP 3. Placement of a peripheral venous catheter

STEP 6. Daily catheter care

Removal of the venous catheter

Subsequent venipunctures

Possible complications:

Air embolism

Thromboembolism

Phlebitis

Intravenous catheters are special medical instruments made in the form of a tube. Their main purpose is to administer various types of medications, as well as rinse blood vessels and various channels, and administer infusions. There are several other names by which these instruments may be known - PVVC or infusion cannulas. If patients require long-term and/or immediate infusion therapy, then the peripheral type of instrument is usually used - among other advantages, it allows the patient to be transported without fear that the needle will come out of the vessel.

About the tool

Each catheter looks like a tube and is equipped with a needle. A needle is inserted into the human vein cavity, and the liquid enters the human body through a tube. To avoid problems with fixation, the catheter is usually secured to the skin either with suture material or with a regular tape. The catheter can usually be inserted into the arms, neck or head. But it is not recommended to use such devices in the leg area, otherwise there will be negative consequences.

Indications

There are several different situations when an intravenous catheter is necessary. Here are the main ones:

1. emergency conditions in which the fastest possible access to the human bloodstream is required;
2. the need for transfusion of certain blood components;
3. providing parenteral nutrition;
4. overhydration or simply hydration of the body;
5. the need for rapid and very precise administration of the drug in the required concentration.

Variations

There are several different classifications of catheters. The first is based on hardness - there are soft and hard types.

Soft ones are made of polyvinyl chloride or rubber. They are used primarily for surgical or therapeutic purposes, when it is necessary to perform any actions that will be aimed at improving the health/condition of the patient. To carry out diagnostics, rigid catheters, which are not very suitable for surgical purposes, are often used. In addition, plastic or rubber variations are more durable because metal is rarely used in this area.

Another classification is based on the type of vein into which the catheters are inserted. There are two types:

• Arterial. As the name implies, they solve various medical problems related to arteries.
• Venous. They allow you to get into the veins and carry out various procedures there.

Catheters can be classified by type of application. There are those that are focused on exclusively short-term use. There are central peripheral ones, which can be installed, for example, in the veins of the arms.

There may also be a catheter with an additional port. Such catheters are convenient because additional drug-type solutions can be administered without reinserting the needle, and therefore there is no need to further damage tissue. If the catheter is not equipped with an additional port, then the needle must be reinserted each time.

Ports - advantages and disadvantages

Many people believe that models with an additional port are universally optimal, and that there is no point in choosing anything else - but there is a double opinion here. If there are no ports, then the price goes down and the likelihood of contamination becomes much less, so in many situations the simpler option will be much preferable. But when a model with an additional port is really really needed, it is when an IV is placed. For IV drips, a peripheral catheter with a port is almost always placed, since it is easier to repeatedly insert the needle without irritating the patient's skin.

Dimensions

The classification of catheters by size can be a little confusing. The fact is that they are not classified according to typical centimeters or inches, they are measured in special units, geichs. To make it easier to distinguish them, different sizes come in different colors. For example, the maximum size is 2.0 by 24 mm, which is size 14. The most popular is perhaps size 18, which has dimensions of 1.3 by 45 mm. Size 18 is used very often for a variety of purposes. In addition to 18, a popular size is green, 87, which allows red blood cell transfusion at a rate of about 80 ml per minute.

There are many other sizes that should definitely be selected by the doctor based on the patient's specific problem.

Application

Any trained nurse knows how to use catheters. First, the injection site is treated and a tourniquet is applied there, which helps fill the vein with blood. Next, the peripheral catheter is taken into the hand and inserted into the vessel. Of course, it must be precisely selected depending on the requirements imposed by the patient’s condition, as well as in direct dependence on the presence/absence of a dropper. The correct material is selected, for example, metal or plastic, as well as the size, for example, 18 or 14. If, during insertion, the visualization chamber of the catheter (its special section) fills with blood, then the insertion was successful. Next, fixation is carried out using a bandage or adhesive plaster - but the insertion site into the skin is not sealed, otherwise infectious phlebitis may develop. Finally, the installed intravenous catheters are flushed, which avoids the formation of blood clots in the vessel where they are installed.

Some more details on this topic in the video below:

Water for injection – liquid for diluting drugs

Target: A peripheral venous catheter is inserted into a peripheral vein and provides access to the bloodstream, allows for long-term infusion therapy, and reduces the incidence of psychological trauma (especially in children) associated with numerous punctures of peripheral veins.

When choosing a catheter, the following rules should be considered: :

ü The catheter should cause the least discomfort to the patient;

ü Ensure optimal infusion rate (drug administration);

ü The length of the catheter must correspond to the length of the straight section of the vein being used;

ü The diameter of the catheter must correspond to the diameter of the selected vein (catheters of smaller diameter give ...
the possibility of better blood flow around the catheter and dilution of the drug with blood; large-diameter catheters can close the lumen of the vein or damage the inner lining of the vein).

ü Orange– for rapid blood transfusion;

ü Grey— for transfusion of blood and its components;

ü Green– for blood transfusion or administration of sick volumes of fluid;

ü Pink– for the administration of large volumes of liquid, rapid administration of contrast agents during diagnostic procedures;

ü Blue– for long-term intravenous drug therapy in children and adults (small veins);

ü Yellow– for newborns, chemotherapy.

The duration of operation of one catheter is 3 days. When operating the boat, strictly follow the rules of asepsis and antiseptics. The connection points of the catheter with the system for intravenous drips and the plug must be thoroughly cleaned of blood residues and covered with a sterile napkin. Monitor the condition of the vein and skin in the puncture area. To avoid thrombosis of the catheter with a blood clot, fill it with heparin solution. To avoid migration of the catheter, constantly monitor the reliability of its fixation.

Indications: 1. administration of medications to patients who cannot take them orally; if the drug must be administered in an effective concentration and accurately, especially if the drug can change its properties when taken orally;

2. Cases when emergency administration of a drug or solution may be required;

3. Frequent intravenous administration of drugs;

4. Blood collection for clinical studies carried out at time intervals (for example, determination of glucose tolerance, drug levels in plasma and blood;

5. Transfusion of blood products;

6. Parenteral nutrition (except for the administration of nutritional mixtures containing lipids);

7. Rehydration of the body (restoration of water and electrolyte balance).

Contraindications: The catheter should not be inserted into: 1. Veins that are hard to the touch and sclerotic (their inner lining may be damaged); 2. Veins of the flexor surfaces of the joints (high risk of mechanical damage); 3. Veins located close to arteries or their projections (there is a risk of puncture of the artery); 4. Veins of the lower extremities; 5. Previously catheterized veins (damage to the inner wall of the vessel is possible); 6. Small visible but not palpable veins; 7. Veins of the surface of the arms, median ulnar veins (usually they are used to draw blood for testing); 8. Veins in a limb that has undergone surgery or chemotherapy.

Workplace equipment: sterile gloves, clean gloves, mask, safety glasses, waterproof apron, bottle of intravenous drug, bottle of 0.9% sodium chloride solution, heparin, file for opening ampoules, scissors, sterile tweezers, sterile dressing material in the package ( cotton balls, gauze wipes), adhesive plaster, two sterile disposable 0.5 ml syringes, a bottle of disinfectant solution for treating ampoules and vials, a bottle of antiseptic for treating the patient’s skin and the hands of medical staff, containers with a disinfectant solution for disinfecting waste material, containers for waste material, a splint, an instrument table, containers with a disinfectant solution for surface treatment, clean rags, a hemostatic clamp.

Possible complications:

General: septicemia, embolism (catheter embolism), air embolism, anaphylactic shock.

Local: phlebitis (inflammation of a vein), thrombophlebitis (inflammation of a vein with the formation of a blood clot), tissue infiltration and necrosis, hematoma, catheter blockage, venous spasm, damage to a nearby nerve.