Things we should know But Dont

1
Basics of working with IVs

• Things we should know But Dont
• LogAN THOMAS
• MS4, 11/2008

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IV Basics

• Basic IV set-up
• EKG leads
• Needle gauges
• Drawing saline
• Mixing powder medication for IV administration
• Drawing medications from a glass vial
• Drawing medication from a ampule
• Drawing Propofol
• Labeling medications
• Giving medication through an IV
• Driving the bed
• Setting up IV tubing
• Changing the Fluid bag
• Getting Air out of the IV line
• Drawing a blood gas
• Starting a unit of blood

• Reference Outline

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• Basic IV set-up

4
EKG leads

• Remember white on right, smoke over fire, snow
  on the grass
• White goes on the right side of the patient with
  the white lead over the green lead, black over
  brown over red on the left.
• The brown lead is a V5 lead, and should go
  slightly lateral to the V4 lead, which would be
  inferior to the nipple.

5
How to tell the gauge of the needle
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Drawing saline option 1

• Drawing off the IV from a stopcock
• Turn the white stopcock so that the off hand is
  directed toward the patient (otherwise you will
  just draw back blood from the IV).
• Insert the syringe directly into the stopcock
  mechanism and screw on.
• Draw back on plunger to 20cc.
• Turn stopcock so off hand is facing
  perpendicular to IV tube, and screw off syringe.
• Cap and label syringe if not used immediately.

7
Drawing saline off the IV from a port with a
stopcock

• Turn the white stopcock so that the off hand is
  directed toward the patient (otherwise you will
  just draw back blood from the IV).
• Insert the syringe directly into the stopcock
  mechanism and screw on.
• Draw back on plunger to 20cc.
• Screw off syringe,
• Turn stopcock so off hand is facing
  perpendicular to IV tube.

8
Drawing Saline option 2

• Drawing off the fluid bag with needle
• If it is a new bag, you will have to remove the
  blue cap that covers the needle port.
• Attach the needle to the syringe with a twist.
• Insert needle into needle port (to the left of
  the IV tubing port when facing the bag) and draw
  back 20cc.
• Pull needle out.
• Disconnect needle and discard in sharps if not
  needed for mixing powder medication.

9
Drawing saline off the fluid bag with a needle

• Remove the blue cap that covers the needle port.
• Attach the needle to the syringe with a twist.
• Insert needle into needle port (to the left of
  the IV tubing port when facing the bag)
• Draw back saline
• Pull needle out, disconnect from syringe, and
  dispose in sharps container

10
Drawing saline option 3

• Drawing off the IV from an access point without
  stopcock
• These points are sort of purple in color and are
  at about a 45degree angle from the tubing itself
  and do not have a stopcock attached.
• Wipe port off with alcohol
• In order to avoid drawing blood back from the IV,
  kink the IV tubing just below the access point
  and twist the syringe onto the access point.
• These point are sometimes a little harder to
  twist onto than the stopcocks, so you have to
  push a little bit while you twist.
• Keep the tubing kinked and draw back 20cc.
• Disconnect the syringe and then unkink the tubing
• Cap and label if not immediately used.

11
Drawing saline out of a port

• kink the IV tubing just below the port
• twist the syringe onto port
• Keep the tubing kinked and draw back saline/LR
• Disconnect the syringe
• unkink the tubing

12
Mixing powder medication for IV administration

• Read the powder label and make sure it is the
  correct med, and check the expiration date on the
  bottle.
• Use 20cc syringe and a large bore (usually 20
  guage (pink)) needle that are both located in the
  blue drawers.
• Draw up 20cc of saline/LR.
• Once you have 20cc of saline/LR, attach the
  needle with a twist (may already be on depending
  on how you got your LR) and take the plastic cap
  off the powder medication
• Insert the needle through the grey seal (Style
  points for holding the medication bottle
  upside-down and pushing the needle up into it).
• Push about 10cc into the bottle. It is a closed
  system, so you will create pressure, so then
  allow that 10 cc to come back into the syringe.
  Push the liquid back and forth until you have
  dissolved all of the powder into the liquid.
• Before you pull out the needle, make sure you
  have limited the vacuum by pushing air into the
  bottle. It is a very common mistake to have the
  newly mixed medication spray all over you when
  you pull out the needle
• Eliminate any air that may be left in the syringe
  and disconnect the needle and put it in the
  sharps container.

13
Mixing powder medication

• Draw up 20cc of saline/LR,
• attach the needle with a twist to the syringe
• Uncap medication bottle
• Insert the needle through the grey seal
• Push about 10cc into the bottle. then allow that
  10 cc to come back into the syringe.
• Push the liquid back and forth until you have
  dissolved all of the powder into the liquid.
• Pull the needle out of the bottle
• Eliminate any air that may be left in the syringe

14
Drawing medication from a glass vial

• Supplies syringe that will accommodate the
  amount of fluid in the vial, large gauge needle
• Twist the needle on the syringe
• Pop the colored plastic cap off the vial
• Uncap needle and turn bevel-side down, hold vial
  upside-down
• KEY pull back the plunger and put some air in
  the syringe or you will create a vacuum when you
  pull the medication out of the vial and it may
  squirt the medication all over you
• Stabilizing vial and the needle with your hand,
  push needle through grey rubber seal
• Draw back medication until vial is empty.
• Pull needle out of vial, disconnect needle from
  syringe and put in sharps bin
• Label and cap medication if not immediately used.

15
Drawing medication from glass vial

• Pop the colored plastic cap off the vial
• Uncap needle and turn bevel-side down, hold vial
  upside-down
• Put air in the syringe
• Stabilizing vial and the needle with your hand,
  push needle through grey rubber seal
• Draw back medication until vial is empty.
• Pull needle out of vial, disconnect needle from
  syringe and put in sharps bin
• Label and cap medication if not immediately used.
  

16
Drawing medication from a ampule (sealed glass
vial)

• Put a large bore needle on the syringe.
• Break vial top off by grabbing top and bottom of
  vial and snapping away from you.
• For this, DO NOT put air in the syringe or you
  will spill the medication
• Stabilize the needle with your hand, insert it
  bevel-down into the vial, and draw back the
  plunger until the vial is empty.
• Discard the broken vial (top and bottom) and the
  needle in the sharps container.
• Cap and label the medication if it is not being
  given immediately.
• Note Some medications from vials can be drawn up
  with out a needle. Just turn the vial
  upside-down, insert the syringe and draw back
  (the medication wont spill out unless you squirt
  air into it)

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Breaking open the vial

• Break vial top off
• Put a large bore needle on the syringe.
• DO NOT put air in the syringe
• Turn the vial upside-down
• Insert needle bevel-down
• Draw back medication
• Discard sharps
• Cap and label the medication if it is not being
  given immediately.

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Drawing a medication from a sealed glass vial

• Break vial top off
• Put a large bore needle on the syringe.
• DO NOT put air in the syringe
• Turn the vial upside-down
• Insert needle bevel-down
• Draw back medication
• Discard sharps
• Cap and label the medication if it is not being
  given immediately.

19
Drawing up propofol

• Supplies syringe, propofol spike, and propofol.
• Take the metal seal off the propofol by pulling
  back on the metal tab
• Open the spike, and take the cover off the spike
  without touching it
• Push the pointed end of the spike through the top
  of the propofol bottle
• Connect the syringe to the spike and draw back
  desired dose (usually 20cc). You do not need to
  put air in the syringe for this vial, it has a
  valve that does it for you.
• Disconnect the syringe from the spike and cap and
  label the medication with the time since it
  cannot be used after 6hrs.
• Recap and leave the spike in the bottle.

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Drawing up propofol Spiking the bottle

• Take the metal seal off the propofol by pulling
  back on the metal tab
• Open the spike
• Push the spike through the top of the propofol
  bottle
• Connect the syringe to the spike and draw back
  desired dose (usually 20cc).
• You do not need to put air in the syringe for
  this vial, it has a valve that does it for you.
• Disconnect the syringe from the spike and cap and
  label the medication (often with the time if it
  is going to be a long case since it cannot be
  used after 6hrs).
• Leave the spike in the bottle capped.

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Drawing up propofol

• Take the metal seal off the propofol by pulling
  back on the metal tab
• Open the spike
• Push the spike through the top of the propofol
  bottle
• Connect the syringe to the spike and draw back
  desired dose (usually 20cc).
• You do not need to put air in the syringe for
  this vial, it has a valve that does it for you.
• Disconnect the syringe from the spike and cap and
  label the medication (often with the time if it
  is going to be a long case since it cannot be
  used after 6hrs).
• Leave the spike in the bottle capped.

22
Labeling Meds

• Place the label along the hash marks on the
  syringe, but not covering the numbers so you can
  read the label as you are giving the dose
• Include name of medication and concentration
• Label with date and time it was drawn up
  (especially for propofol because it is only good
  for 6 hours).

23
Giving a medication through an IV

• Medication prepared in a syringe (see above about
  mixing)
• CONFIRM THAT THE MEDICATION AND DOSE YOU ARE
  GOING TO GIVE ARE WHAT YOU WANT TO GIVE VERBALLY
  AND VISUALLY
• Turn stopcock hand labeled off away from the
  patient
• Connect the syringe with a twist to the right to
  the stopcock
• Push the plunger and give the desired amount of
  medication. Disconnect the syringe.
• Switch the stopcock arm so that off is
  perpendicular to the patient
• CONFIRM THAT THE MEDICATION AND DOSE YOU GAVE ARE
  WHAT YOU WANTED TO GIVE
• Flush the medication into the patient by opening
  the rolling fluid stopcock and letting some LR/NS
  run into the line.
• Close the fluid stopcock.

24
Giving IV medication

• Medication prepared in a syringe
• Turn stopcock hand labeled off away from the
  patient
• Connect the syringe with a twist to the right to
  the stopcock
• Push the plunger and give the desired amount of
  medication.
• Disconnect the syringe.
• Switch the stopcock arm so that off is
  perpendicular to the patient
• Flush the medication into the patient by opening
  the rolling fluid stopcock and letting some LR/NS
  run into the line.
• Close the fluid stopcock.

25
Driving the Bed

• Brake is on so the bed wont move.
• To release the break, push down on the green side
  of the pedal until it locks into a neutral
  position (all four wheels move) or slanted down
  to the right to steer from behind.

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Driving the Bed

• Neutral Bed position
• All four wheels move
• Use this for parking the bed.
• For example, sliding this bed next to the OR
  table.

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Driving the Bed

• Steer position
• Use this to push the bed from behind
• For example pushing the bed down the hallway.

28
Setting up IV tubing Filling the Burel

• When setting up an IV, you need to get the drip
  chamber about ½ filled with IV solution. If you
  just hang the bag and open the IV it wont work.
  To get the Burel ½ filled
• Make sure the IV is closed (close the IV roller
  clamp)
• Invert the drip chamber, open the IV roller
  clamp, let the drip chamber fill half way
• Turn the drip chamber back to its right position
  and let the IV prime until liquid is coming out
  of the IV and the air bubbles are cleared
• Close the IV roller clamp.

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Filling the Burel Option 1
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Filling the Burel Option 2

• Make sure the IV is closed (close the IV
  roller/wheel clamp)
• Squeeze the drip chamber until it fills
• Open the IV wheel clamp

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Changing the fluid bag

• First and foremoststop the flow of fluid by
  closing the stopcock. This will limit the amount
  of air that is sucked into the tubing.
• Get your new bag ready (usually top drawer of the
  large beige drawers) by taking it out of the
  plastic wrap and taking off the blue cap that
  covers the sterile opening. Hang the bag next to
  the old one.
• Pull the tubing out of the empty bag (there is no
  screw mechanism). The white end that has a bevel
  on it should be sterile and shouldnt touch
  anything.
• Push the white end of the IV tubing into the
  clean circle opening on the bag. You have to push
  pretty hard and should feel a slight loss of
  resistance once it is actually in.
• Open the stopcock and make sure the fluid is
  flowing.
• Some residents/attendings like to keep track of
  fluid bags by piling them under the red biohazard
  waste trash, others just throw them away.. So
  just check with them.

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Changing the fluid bag

• Close the stopcock or kink the tubing
• Pull the tubing out of the empty bag
• Push the white end of the IV tubing into the
  clean circle opening on the bag.
• Open the stopcock and make sure the fluid is
  flowing.
• Some residents/attendings like to keep track of
  fluid bags by piling them under the red biohazard
  waste trash, others just throw them away.. So
  just check with them.

33
How to get air out of the IV tubing

• There are a lot of ways to get air out of an IV
  line, but this is the most common
• Place a 10-20ml syringe on a port that is
  downstream from the bubble
• Turn the stopcock off to the patient (open
  towards the bubble).
• Draw back on the syringe until you pull back the
  air.
• Return the stopcock to a position so your IV
  flows (note you can clear the air from the
  syringe and reinject the fluid you drew off).

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How to get air out of the IV tubing
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Drawing Air out of the IV line

• Turn the stopcock off except towards bubble and
  stopcock attachment. Place a 10-20ml syringe on
  the stopcock
• Draw back on the syringe until you pull back the
  air.
• Return the stopcock to a position so your IV
  flows (note you can clear the air from the
  syringe and reinject the fluid you drew off).

36
Drawing a Blood Gas

• Gather materials 3cc syringe with needle, green
  blunt end needle, patient sticker, alcohol wipe,
  heparin.
• Attach a needle to syringe and draw up about 1 cc
  of heparin. Pull the needle out of the heparin
  bottle, and then pull the plunger all the way
  back to spread the heparin throughout the
  syringe. Then squirt out the heparin into the
  trash or onto a towel. Disconnect the needle. The
  syringe is now prepped or heparinized.
• Connect the green-capped blunt ended needle to
  the syringe.
• Clean the blood gas port with the alcohol wipe.
• Open the stopcock in front of the large syringe
  that is in series with the pressure line tubing.
• Pull back 10cc of blood into the large syringe to
  make sure that the blood sample is not diluted
  with saline.
• Close the stopcock to prevent drawing blood from
  the syringe
• Uncap the green-capped blunt-ended needle and
  insert it into the port, draw back about 2 cc.
  Remove the needle from the port.
• Open the stopcock. Push the blood in the syringe
  in series with the tubing back into the patient
  and lock the handles of the syringe by clicking
  them forward until they latch.
• Pull the red pigtail on the iv tubing near
  where it connects to the IV pole to flush fluid
  until the line no longer has blood in it
  (prevents clotting of the line).
• Label your blood gas syringe with a patient
  label.

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Drawing a Blood Gas

• Heparinize needle
• Clean port with alcohol
• Open stopcock
• Draw back blood
• Close stopcock
• Access port with needle, draw back 1-2 mL blood,
  pull needle out of port
• Open stopcock
• Push blood back into patient
• Flush
• Label syringe

38
Starting a unit of blood

• Unfortunately students are NOT allowed to check
  in blood products if asked, please let the
  resident know you are not allowed by OHSU policy.
  However, if the blood has already been checked
  in, you can hang it.
• This is usually connected to a hotline that is
  set up before the case.
• Make sure the roller clamp on the IV tubing is
  closed (there are two rollers one on the saline
  bag line and one on the blood line.. Close both).
  This will limit the amount of air that is sucked
  into the tubing.
• Then open the zip-lock type closure that covers
  the sterile opening.
• Push the white end of the IV tubing into the
  clean circle opening inside the opened ziplock.
  You have to push pretty hard and should feel a
  slight loss of resistance once it is actually in.
  Save the cap from the end of the IV tubing.
• Open the roller clamp on the blood side and make
  sure the blood is flowing.
• Most residents/attendings like to keep track of
  blood bags by piling them under the red biohazard
  waste trash, others just throw them away.

39
Starting a unit of blood

• Check in unit of blood
• Close stopcocks
• Open the zip-lock type closure that covers the
  sterile opening.
• Push the white end of the IV tubing into the
  clean circle opening inside the opened ziplock.
• Open the stopcock and make sure the blood is
  flowing.
• Keep track of blood bag