Clinical Care Topic Vascular Access Device Infusion Therapy – Neonates

PVAD

The number of venipuncture attempts should be limited to a maximum of 3 to 4. Neonates who are considered difficult to obtain venous access should have an advanced starter perform the procedure. The following algorithm is designed to assist in clinical decision making regarding the number of attempts and the recommended starter. Additional, site-based guidelines may be available with regard to specific gestational age recommendations.

PVAD insertion is considered a two-person procedure. The person performing the skill shall have a minimum of one assistant to help restrict the patient movement, comfort the neonate, and handle the specimen.

An extension set is attached to the after insertion to decrease catheter manipulation at the site with the IV tubing changes, as well as to establish a saline lock if necessary.

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Vein Dilation & Identification Techniques 1. A tourniquet is an important tool for visualizing ; often the second nurse uses their hand as a tourniquet by gently squeezing above the site. 2. Placing a warm compress on the site for several minutes can dilate veins to make them more visible. 3. Placing the limb in a dependent position can increase dilation of the . 4. Use of a commercial vein viewer can make vein position more visible. 5. Use of a trans-illuminator (the light shines through the limb tissue) can make vein position more visible.

Insertion Techniques Maintaining good traction on skin with non-dominant hand is vital to stabilizing the blood vessel. Meanwhile, the device should be held in the dominant hand for insertion.

Direct Method • Hold the needle bevel up while inserting it at a 10 to 15-degree angle from the skin in the direction of blood flow o If the needle is removed from the catheter, NEVER re-insert it, because it can cause shearing of the catheter and an embolus to the neonate • When blood appears in the flashback Figure 1 Two-Person PVAD Insertion chamber, release the tourniquet, level the device, and slowly advance the catheter while pulling the needle back into the safety cover o Blood may not appear when using a very small vessel or when the neonate has poor peripheral circulation; can proceed if confident in vessel but monitor for tissue swelling when flushing the catheter

Indirect Method This alternate method can be used when veins are small and rolling or skin is tough or fragile. The needle is held at a similar angle from the skin but is inserted beside the vein. The catheter is then inserted laterally into the vein.

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Butterfly PVAD Considerations 1. Only scalp veins should be used for butterfly PVAD insertion. • It is not recommended to use a butterfly set in extremities for anything other than blood withdrawal. • Scalp vessels are subjected to less movement and have a relatively flat surface allowing for improved stabilization of the sharp metal needle. 2. Palpate the selected vessel to ensure it does not pulsate (). 3. Palpate vein to ensure that it refills with blood and observe the direction of the flow to ensure the vein is not damaged. 4. Needle insertion is in the direction of blood flow; generally, vessel flow is from the top of the head toward the neck. 5. Consider size and length of vein. • The size and length of the vein determines the length of butterfly needle that should be used. • The metal needle requires a straight vessel for advancement. 6. Hypertonic solutions and/or chemically irritating drugs are best infused into larger veins with brisk blood flow to reduce the incidence of thrombophlebitis. 7. Minimize the mobility of the neonate as required. 8. Obtain assistance from another nurse to allow for smoother insertion of butterfly PVAD decreasing the risk of trauma to the neonate. 9. Do not position the head of the neonate where pressure will be exerted on the PVAD site. 10. When using a scalp vein, it is necessary to remove a small amount of hair with disposable-head clippers or a razor around the site to secure the device without taping hair.

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Troubleshooting PVAD Insertion

Problem Possible Causes Possible Solutions No flashback Lack of flashback Place bevel directly on top of the vein may be normal Reposition yourself or neonate depending on Ensure adequate lighting catheter and neonate Swelling with Reposition the vein and stabilize infusion Catheter not in vein Lower catheter with flashback then push

catheter off prior to removal of needle Ensure adequate dilation of vein Rapidly filling Vein trauma Decrease insertion angle pocket of blood Poor condition of Reduce amount of force used at the insertion veins Reduce angle on device immediately after site Catheter too large flashback Neonate Use a smaller catheter anticoagulated Smoothly separate needle from catheter Awareness of manufacturer recommended pre- insertion requirements Unable to Damaged vein (e.g. Choose a different vein advance from vesicant Keep the catheter and needle as a unit until you catheter into medications) determine it is within the vein vein Resistance from a If catheter is on a valve, pull needle back slightly valve and attempt to advance with solution flowing slowly To correct angle, pull back on the entire device, lower the catheter angle and advance catheter prior to removal of needle

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