Intravenous Injection. Judith A. Perrigin, MT(ASCP),OD, 2016

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1 Intravenous Injection Judith A. Perrigin, MT(ASCP),OD, 2016

2 Why study IV injection? To pass NBEO & Med Lab practical To perform fluorescein angiography (FA) To view choroidal & retinal blood flow, RPE, blood- retinal barrier, etc. Possibly other uses as scope of practice expands

3 Med Lab practical exam You will be required to perform IV injection on the training arms. Know the NBEO guidelines. You will perform IV injection exactly as required by NBEO Even though there are some errors in the way it presently reads (In my opinion)

4 Follow CLIA,CDC, & OSHA Standards Establish, post SOP & infection control stds Maintain log of tests performed & blood work drawn Tests, date/time of draw, initials of collector and when results received, action taken, outcome. document any problems during injection or phlebotomy Require hepatitis injections for those handling contaminated waste Dispose of waste properly

5 Employ universal precautions Handwashing, gloves, protective eyewear, Use aseptic technique Disinfecting work area & instruments Non-aseptic technique can be cause for failure on NBEO

6 Accidents happen Follow up and evaluation required Develop and post written protocol: Document route of exposure and circumstances Provide tx and testing if needed Test source of blood for HBV & HIV infectivity If consent obtained

7 Gloves Required for finger puncture, most injections & NBEO Should fit snugly Latex no longer standard of care Highly recommended but not absolutely required for venipuncture Sometimes difficult to feel deep veins

8 The patient

9 Mandatory to have Signed informed consent Thorough hx regarding allergies, health conditions Emergency supplies and treatment ready UHCO never performs unless MD in clinic during the procedure

10 Who orders FA? Laws vary by province and state Texas: May use any pharmaceutical for ocular diagnostic purposes Some ODs stretch /interpret this to mean FA Ophthalmologist typically Who injects the dye? UHCO: technician injects, OD taking the photos & an MD present in clinic area

11 FA/IVF overview

12 Needle types Butterfly winged NBEO requires butterfly Non-butterfly

13 SESIP (Safety Engineered Sharps Injury Protection): required by OSHA Built in safety shield NBEO may use non-sesip Not SESIP SESIP

14 Needle sizes Length: generally ½ inch to 1 ½ Gauge: bore size, the smaller the gauge the larger the bore (lumen) 25 is tiny while 18 is large Typically use for routine veni-puncture 23 gauge commonly used for injection

15 Smaller number = bigger needle 18G 1.5 standard needle versus 23G.75 butterfly with safety shield

16 For fragile veins or difficult draws Use syringe &/or butterfly (winged) collection sets Use smaller gauge needle Do not use large vacutainer tubes

17 IV procedure These are things you must do on a real patient but are to assume have already been done on NBEO IC has been discussed and signed Patient s identity has been verified using 2 methods such as name, date of birth, last 4 digits of SS, address Nature of procedure & injection site verified by asking patient to verbalize his understanding of these issues

18 Also for NBEO assume Knowing exactly what is going to happen decreases anxiety, reassures patient Patient is male (Mr. Lee) and BP was found to be normal during pre-test work up Patient s eyes are fully dilated From this point on, you must actually perform everything else

19 Unsafe practices If you do anything which could pose a risk to yourself or the patient, the proctor can stop you & not allow you to go on with that procedure. If so, you will not receive any credit for that procedure. Cannot redo anything without repeating the entire procedure.

20 IV Procedure to be performed Show self confidence, professionalism Greet patient Wash & dry your hands thoroughly (15 sec) Properly prepare aseptic field with paper drape Shiny side down Once supplies assembled on drape, cannot place anything from table onto drape (Not aseptic)

21 Seat patient comfortably with arm supported on camera table Observe for signs of queasiness, fainting Do not inject until feeling better Use alcohol prep or smelling salts if needed Prepare dye in syringe

22 NA fluorescein Initially made from plant extract now a hydrocarbon salt of sodium powder highly soluble in water MW is large enough to prevent its escape from capillaries unless disruption is present Sensitivity/allergy rare but possible

23 Dye used 10% or 25% sterile liquid injectable ophthalmic sodium fluorescein Inject 5ml of 10% or 3ml of 25% UHCO uses 10% Angiofluor Lite (5ml) NBEO exam uses 3ml of 25% in 5 ml syringe

24 Preparing the medication / dye NBEO: Verbally confirm med name, conc, expir Open sterile dye vial aseptically Wipe with alcohol prep, allow to air dry Place vial on counter

25 Attach needle to 5 ml syringe Aspirate air bubble of slightly greater than 3 ml volume into syringe Place vial on counter Insert needle into vial without holding vial

26 Invert vial, expel air, and draw up slightly > than 3ml med Expel any air or excess med from the syringe: need exactly 3ml med

27 One hand scoop Recap using 1 hand scoop DO NOT hold cap with fingers Hold syringe vertically (cap up) to show examiner amount drawn

28 NBEO order At this point NBEO says explain purpose of procedure to patient Obtain hx including allergies to medications, latex, injectable dyes, tape Provide proper instructions to patient i.e. relax, review adverse reactions etc Palpate vein????? Tourniquet isn t on yet In real life palpate after tourniquet applied

29 Remove capped needle from syringe & drop needle directly into sharps box Apply butterfly needle to syringe & place syringe on drape

30 Apply tourniquet Clean tourniquet with alcohol & dry Roll up patient s sleeve Apply tightly 2-3 inches above elbow Will use the kind you have to tie Put on gloves Instruct patient (even Mr Lee) to open & close & then clinch fist

31 Puncture site Typically median anticubital, cephalic or median basilic vein near bend of elbow Palpate & trace veins with index finger Could use dorsal hand but may collapse, bruise, & more painful

32 Vein versus artery Venous collection preferred for most routine testing & dye injection Artery pulsates. Do not palpate with thumb Arteries deeper Arterial blood is bright red & foamy Arterial requires firm pressure to collection site for at least 5 minutes post-collection

33 Veins safer than arteries Injections into vein : travels to lungs first so small air bubbles can leave the blood via the lungs Not true for arteries

34 If vein not apparent Try the other arm Loosen or tighten tourniquet Flex arm Smack lightly (arm), rub with alcohol Warm arm If still no luck may need to drink 3-4 glasses of water

35 After vein selected, clean site in circular motion from inside to outer area Tourniquet should not be left on for more than 2 minutes at a time

36 Patient should have fist clenched

37 Hold skin & vein taut with non-needle hand Enter vein bevel up at degree angle. Must verbalize. Move in direction parallel to skin Blood will appear in tube when in vein May not appear automatically on training arm

38 Slowly pull back on plunger until blood completely fills tube & a little enters the syringe. You are replacing the air in the tube with blood.

39 If no blood or flow stops Maybe you missed Start over with new stick & new needle Alter angle bevel as may be pressed against the vein wall Move the needle slightly forward or back Re-anchor the vein

40 Can lightly tape needle in place but NBEO does not Remove tourniquet Keep syringe plunger angled upward/vertical to prevent injecting large air bubble (air that was in the tube) Maintain good control of infusion set. Do not release needle.

41 Photographer should be in position to begin & have already done test shots Inject small amount dye to check for extravasation (leakage into surrounding tissue) Verbalize If no extravasation, inject remainder of blood and dye at smooth steady rate

42 Remove needle while applying pressure with cotton ball. Apply pressure with sterile cotton ball Apply paper tape over cotton ball

43 Activate safety shield & place entire device in sharps box Put needle end in first If no safety shield (NBEO) VERY CAREFULLY place entire device into sharps box without recapping

44 NEVER Recap, bend, or break used needles Try to remove / retrieve anything from the sharps container! Place soft items (tissues, gauze, gloves, etc) in sharps box

45 Post-procedure State to NBEO examiner what to record in patient s record Drug, dose, delivery method, location of injection Begin IM procedure Observe patient closely Educate patient on possible side affects, tx Keep patient in-office until confident they are feeling well. Watch for signs of queasiness, fainting, anaphylaxis

46 To be expected side effects Mild skin, sclera discoloration for several hours Yellow urine for up to 36 hours

47 Possible mild side effects Nausea: most common Have a basin handy Hives, itching, sneezing Slight pain, bruising, or swelling at injection site Can occur even with a perfect stick

48 Fainting Vasovagal response Syncope Sniff smelling salts, alcohol pad, etc, lower head and/or elevate feet Hope it occurs before or after not during the photography Not an emergency Unless they fall and injure themselves

49 Signs preceding fainting Paleness Clammy skin (cold but sweating) Speaking incoherently Trembling Going down

50 Why might a patient faint? Anxiety, fear of needles or the test Low blood sugar (fasting or a diabetic) After revives offer juice, glucose tablet, etc Monitor closely until awake and coherent

51 IV Injection Most dangerous of all ways to ingest a drug as is rapid and impossible to reverse Bypasses body s natural filtering systems so all of it is absorbed So be prepared in case of emergency That s why you prepare IM epinephrine for NBEO

52 Serious risks & complications Less than 5% complication rate Need to be prepared for that 5% Anaphylactic shock Call on-site physician Administer emergency care Call for emergency personnel

53 NBEO order Follow grading sheets exactly!!! Not everything you have to say or do is on the evaluation sheet. Could change at any time so reread site often 5 minutes prep time to arrange arm, etc. 15 minutes testing including IM injection First fill both Fluor & epinephrine syringes NBEO Fake Fluor will be clear Perform FA then epinephrine IM You can place the arm as you wish Have all supplies on correct side Arm malfunctions can occur It s the examiners job to fix

54 How is phlebotomy different from IV injection? Tourniquet remains on until blood is drawn Blood is drawn into vacutainer tubes Safer because taking out not injecting

55 Collection tubes Generally plastic Vacutainer system Varying sizes & anticoagulants Expiration dated: do not use if expired Lose vacuum & may clot Type tube used varies by test

56 Color coded caps Red/ camouflage: serum, clot tubes. Some with serum separators (SST) & clot activators Invert several times after drawing Allow to clot for 30 minutes before centrifuging Used for many chemistries, lipids, serology, etc

57 Blood bank & drug screens redtop-without sst

58 Anticoagulated tubes Gently invert 8-10 X immediately after drawn Purple cap: EDTA Used for most hematology tests and Hgb A1C Blue cap: Na citrate. Coagulation tests such as prothombin time Grey: No fluoride & potassium oxalate for glucose preserves glucose for 5-7 days Black cap; sed rate

59 Palpate, clean same as for IV

60 Prior to removing needle, remove tourniquet and final blood tube: otherwise blood will spray everywhere Activate safety shield immediately after withdrawing from vein Gently invert tubes SST tubes 2 X, purple tops 5-6 times

61 Have patient apply pressure while you label tubes

62 For all serum tubes including SST: allow to clot for 30 minutes, then centrifuge for 15 minutes Anticoagulated tubes: do not centrifuge

63 Labeling & handling Requisitions also must show age, sex, hrs pp STAT if emergency Tubes & request forms must have: Full name, date, time of draw, id number, UPC stickers.

64 Ck Bill account Ck tests ordering (Health panel 7) etc Have patient sign at bottom left on form DO NOT fill your address Fill in patient name, my name as ordering physician, Patient SS #, date/time of draw & phlebotomist initials, under Client info put # hrs fasting\apply upcs to blood tubes

65 Place all tubes & requistiions in sealable BH bag but do not seal bag-our tech will seal it after inserting necessary paperwork Call lab for pickup Lab will send results next day

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