Placing peripheral catheters is something technicians do everyday. With this article I hope I can give you some new techniques on placing them aseptically which will help them run trouble free. These are techniques that will decrease the chance of insertion site infection, thrombophlebitis, catheter occlusions, fluids going subcutaneously and patients licking and chewing their catheters.
- Wash your hands. The most common source of contamination for IVC is the hands of personnel.
- Choose the vein. Don’t just choose ANY peripheral vein. There is definitely a hierarchy when it comes to which veins are best for IV catheter placement.
Cephalic vein - These are usually the first choice due to the superiority for ease of placement, ease of maintenance and decreased likelihood of urine and fecal contamination.
Medial branch of the cephalic vein - Sometimes the cephalic accessory vein can be used but it is not ideal. Even though it is often easier to see than the cephalic, it is a smaller vein. Also, due to the angle, it is difficult to tape the catheter in alignment with the vein. Using this accessory vein often requires tape to be placed over the animal’s carpus which is uncomfortable and can lead to peripheral edema (mega-paw). A misaligned catheter can kink easily, decreasing the lifespan of the catheter and putting pressure on the vein wall, increasing likelihood of thrombophlebitis.
Saphenous vein - Both the medial and lateral saphenous veins can be used in dogs. The medial saphenous can work great for cats but the lateral is often too small. Be vigilant to monitor for urine and fecal contamination on those saphenous catheters.
- Clip the IV catheter site. Careful of clipper burn. Make sure to hold the clipper blade as flat to the skin as possible to decrease the chance of clipper burn. Clipper burn will increase inflammation leading to possible bacterial infections and increase the chance your patient will want to lick and chew at the catheter site. Note: Make sure you clip well below your intended catheter insertion point.
- Scrub the insertion site. There are many different antimicrobial cleansers to cleanse the skin. The most common types that we use are Chlorhexidine/alcohol and Betadine/alcohol. Whichever you choose make sure to do a succession of 3 scrubs. How the scrub is stored can also have an effect on bacterial contamination. Jars full of wet gauze (even if it is gauze soaked in scrub or alcohol) can harbor resistant bacteria that will transfer to your IV catheter site. It is best to wet your gauze with scrub and alcohol just prior to using it on your patient.
- Chlorhexidine Scrub - It is both bactericidal (kills bacteria) and bacteriostatic (inhibits more bacteria from growing). It is minimally affected by the presence of organic debris on the skin surface. It can potentially cause mucosal irritation in cats if they groom a prepped area. Chlorhex is NOT deactivated by alcohol (a common misconception).
- Betadine Scrub - Similar to Chlohex in its bactericidal effect however lacks any residual effect (it is NOT bacteriostatic). It is deactivated by any organic debris on the skin. Can be irritating to the skin surface. Betadine is NOT deactivated by alcohol (a common misconception).
- Alcohol - Rapid onset bactericidal, but not bacteriostatic. Its use is recommended to increase the bactericidal activity of Chlorhexidine and Betadine scrub solutions.
- Catheter insertion: After all the trouble we have gone through clipping and cleaning there a few things we often do that will completely undo our aseptic technique. Be careful of the following pitfalls:
- Feeling for the vein with our finger over the insertion point. If you have to feel, feel way above your insertion point. Better yet, feel before you start your surgical scrub.
- Dragging the catheter through hair. Wherever you decide to make your insertion point, make sure there is a healthy inch below that point that has been clipped and prepped accordingly. It is ingrained in technicians to place the catheter as low as possible on the leg in case we need to attempt another placement. But watch for two things when placing an IV catheter very low on the cephalic vein. If placed too low it can cause a lot of movement in the catheter whenever the carpus or the tarsus is bent. This can lead to catheters inching out. The other problem is mega-paw. Cats especially are prone to mega-paw with very low placed cephalic catheters due to the way they sit with their front feet tucked under. The tape directly over their carpus gets really tight when the paw is tucked under.
- Placing a finger directly over insertion point after catheter is placed. I see this all of the time. Techs will do this when pulling the stylet out of the IVC in order to stop blood from gushing out while they plug in the male adaptor plug. YIKES! All of the scrubbing for nothing! Here is a little secret…. you (or your assistant) can put a finger over the vein approximately where the end of your catheter is. You won’t contaminate the insertion site and it works.. Not a drop of blood will come out of the catheter if done right!
- Applying tape over bloody skin/hair. Dried blood makes a delicious medium for all sorts of bacteria to grow. A simple wipe with a chlorhex solution soaked gauze works wonders.
- Taping: There are many ways that an IV catheter can be taped. My only recommendation is that each practice decide which way they are going to tape and stick to it. This makes it easy for the next person to take down the tape and inspect the insertion site if needed, or to loosen tape due to mega-paw. Speaking of mega-paw, always be careful not put tape on too tight. Tight tape can not only cause painful mega-paw it can potentially occlude the catheter causing the fluids to go SQ. Also watch out for those patients that are really dehydrated (5% or more) Often the tape you put on so carefully can become really tight as you patient rehydrates.
- IV Catheter Maintenance: Peripheral catheters can be left in for approximately 3-7 days depending on the catheter type. (There are certain IV catheters that are much easier on the vein and can be left in longer then the typical 3 days.) At least once daily the site should be visually and manually inspected for signs of purulent/serous discharge, pain/resistance on injection, swelling above or below the catheter, and ropiness of a vessel that can signify thrombophlebitis. Also, if the patient develops a fever of unknown origin the catheter should be closely inspected and possibly pulled. And last by not least; patients that have been good then suddenly decide to lick or chew at their catheter could have an underlying problem with that catheter. Always inspect the catheter carefully for leaking/infection etc before just putting an e-collar on them.
By taking the right approach to cleanliness and IV catheter management you can increase the life of the IV catheter and the comfort of the patient.
What protocols do you implement in your hospital to avoid infections and other problems with IV catheters?