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Pose de voie veineuse périphérique

Pose de voie veineuse périphérique

DEFINITION

La pose d'un voie veineuse périphérique consiste en l'introduction d'un cathéter dans une veine afin de permettre l'administration de solutés quand la voie orale n'est pas possible.

Il s'agit donc d'un geste invasif qui engendre des risques infectieux.

C'est un acte qui relève du décret du 11 février 2002 (cf articles 6 pour la pose et article 5 pour la surveillance)

 

II- MATERIEL

- Lingettes imbibées de produit de décontamination des surfaces
- Sac poubelle
- Collecteur à aiguilles
- Savon antiseptique + essuie- mains
- Protection
- Gants stériles
- Garrot
- Tondeuse ou des ciseaux
- Compresses stériles
- Antiseptique (prévoir le rinçage du produit si nécessaire) . VERIFIER QUE LE PATIENT N'EST PAS ALLERGIQUE!! Utiliser le même antiseptique pour les 2 détersions de la peau
- Cathéters courts (en prévoir 2)
- Pansement occlusif transparent stérile (vérifier que le patient n'y est pas allergique)
- Produits à perfuser (étiquetés)
- Tubulures, prolongateur, rampe de robinets en fonction des besoins

Remarque: Ne pas oublier de vérifier:
- la prescription datée , signée
- le dosage , le nom , l'intégrité , la date de péremption des solutés / solutions / médicaments et emballages

 

III- CHOIX DU CATHETER

Le choix du cathéter est fonction :
- du degré d'urgence (préférer un cathéter de gros calibre (16G) pour un remplissage vasculaire rapide)
- du capital veineux du patient (les veines ne sont pas toutes droites et longues, les traitements comme les anti- vitamine K augmentent le risque d'hématome.)


Il existe plusieurs tailles de cathéter. A chaque taille correspond une couleur et un diamètre en gauge et une longueur .
Par exemple :

Cathéter jaune : 24 G(gauge)
Cathéter bleu : 22 G
Cathéter rose : 20 G
Cathéter vert : 18 G
Cathéter gris : 16 G
Cathéter orange : 14 G

Plus les dimensions du cathéter sont petites, plus la taille en gauge est grande. En d'autres termes, le cathéter jaune est plus petit (en longueur et en diamètre) que le cathéter orange

De manière générale, les cathéter les plus couramment utilisés sont les verts, et les roses chez l'adulte ; les jaunes en pédiatrie .

Remarque: Il existe des cathéters :
- Radio-opaques/ radio-détectables
- Avec ou sans ailettes
- Avec ou sans site d'injections
Il existe aussi des valves anti -reflux (dispositif à placer directement sur le robinet , à la place d'un bouchon)

 

IV- TECHNIQUE DE POSE

La plupart des établissements de soins ont validé un protocole de pose de voie veineuse périphérique. Il convient donc de s'y référer.

Cependant, d'une manière générale , il faut :

· Vérifier l'identité du patient
· Informer et recueillir le consentement du patient , dans la mesure du possible. (En cas de refus, en informer le médecin prescripteur)
· S'assurer de la décontamination des surfaces de travail et du matériel à utiliser
· Procéder à un lavage de mains antiseptique
· Préparer de façon antiseptique et étiqueter les solutés et médicaments à administrer
· Connecter les tubulures , rampes de robinets , prolongateur à la perfusion et les purger. Attention : Veiller à garder l'extrêmité du prolongateur stérile (le laisser dans son emballage lors de la purge)
· Installer le patient confortablement
· Poser la protection sous son bras

Remarques:
- La peau doit être saine
- s'assurer qu'il n'y a pas de contre -indication à la pose d'une voie veineuse périphérique sur ce bras .
En raison du risque infectieux, il est préférable de ne pas perfuser du côté d'un curage ganglionnaire, (cancer du sein notamment).
En outre, on ne perfusera pas du côté choisi pour la réalisation d'une fistule artério -veineuse (hémodialyse chez l'insuffisant rénal).
- Si la perfusion est posée en vue de la réalisation d'un examen complémentaire, le choix du bras peut être déterminé dans le protocole de la préparation à cet examen

· Serrer le garrot et repérer la veine.
Choisir de préférence une veine sur l'avant-bras gauche du patient droitier (et inversement pour le gaucher) , la plus distale possible . Eviter la main (car douloureux , et souvent positionnelle) et le pli de coude
· Desserrer le garrot
· Tondre / couper les poils si besoin (afin d'assurer le maintien et l'étanchéité du pansement)
· Procéder à une première antiseptie de la peau (attention ! respecter le temps de contact de l'antiseptique avec la peau. A chaque antiseptique , ses conditions d'utilisation ! Renseignez - vous!)
· Préparer le matériel : ouvrir l'emballage des gants stériles , du cathéter , du pansement occlusif , des compresses stériles . Imbiber les compresses d'antiseptique
· Resserer le garrot
· Procéder à un nouveau lavage de mains antiseptique
· Enfiler les gants stériles
· Introduire le cathéter (biseaux vers le haut) : dès que le sang arrive dans le mandrin , faire glisser , sans forcer , le cathéter sur l'aiguille afin de le positionner dans la veine. (Attention : utiliser une nouvelle aiguille à chaque tentative)
· D'une main, desserrer le garrot (attention ! cette main n'est plus stérile ! ) et maintenir le cathéter de l'autre
· Jeter le mandrin dans le collecteur à aiguilles
· Raccorder le prolongateur : prendre la tubulure de la perfusion de la main déstérilisée, mais connecter l'extrêmité du prolongateur à l'aide de la main stérile.
· Raccorder le prolongateur
· Vérifier le débit et la perméabilité en ouvrant à grand débit le garde-veine
· Appliquer le pansement occlusif en couvrant bien le point de ponction . S'assurer de son hermétisme
· Fixer la tubulure en boucle
· Appliquer le pansement occlusif en couvrant bien le point de ponction et en fixant la tubulure en boucle
· Régler le débit de la perfusion selon la prescription
· Réinstaller le patient
· Ranger et décontaminer l'environnement
· Noter le soin , le calibre , la référence et le numéro du lot du cathéter dans le dossier du patient et le reprogrammer . Le cathéter doit être changer toutes les 72h (selon les protocoles , et selon l'état de santé du patient) . Les tubulures , rampes , et prolongateur seront changés à cette occasion.

Remarques:
- En cas d'urgence, le protocole ne sera pas appliqué , mais une nouvelle voie veineuse périphérique sera reposée dès que l'état du patient le permettra.
- Il existe des raccords stériles permettant le prélèvement sanguin lors de la pose du cathéter.
- Il existe aussi des pommades anesthésiantes à appliquer sur la peau avant ce soin . C'est moins traumatisant pour les enfants !
- Certains médicaments (comme la morphine) s'utilisent avec des tubulures anti - reflux . Elles doivent être directement raccordées au cathéter, sans raccord intermédiaire.

 

V- ASTUCES

· Serrer le garrot (ni trop, ni trop peu) de façon à ce que les veines gonflent suffisamment
· Ne pas craindre de serrer le garrot, sinon les veines ne gonfleront pas
· L'alcool modifié fait gonfler les veines
· Si œdème du bras, le surélever afin de le drainer et de faire ainsi apparaître les veines
· Al'inverse, si le bras n'est pas oedématié, le laisser pendre accentue le gonflement des veines du bras et de la main
· Dans l'urgence (notamment quand il y a chute de tension / hypovolémie), pas de temps à perdre! Piquer la première grosse veine trouvée, même si c'est en pli de coude! Car l'état du patient risque de s'aggraver très rapidement , et les veines seront vite introuvables.

 


VI- SURVEILLANCE

La surveillance est celle du risque infectieux essentiellement car il y a effraction de la peau . Elle ne peut donc plus remplir son rôle de barrière contre les germes . En outre, plus le cathéter reste longtemps en place, plus le risque infectieux grandit (souillures lors des injections intra- tubulaires répétées, prolifération des germes).

C'est pourquoi la surveillance doit être pluri-quotidienne :

· Etanchéité du pansement (à changer en cas de décollement , de fuites ou de souillure )
· Point de ponction : rougeur , douleur , chaleur , œdème , écoulement purulent , cordon rouge ou induré.
La présence d'un seul de ces signes impose le retrait du cathéter
· Fièvre , frissons , sueurs
· Extravasation (=diffusion du produit en sous-cutanée et non plus en intra-veineux) .Elle se manifeste généralement par une rougeur et un œdème en amont du point de ponction.
Certains médicaments peuvent même induire des nécroses (exemples: drogues vaso -actives , produits de chimiothérapie). C'est d'ailleurs pour cette raison que leur indication en voie veineuse périphérique est limitée.


Remarques :
- Les injections dans les tubulures doivent se pratiquer de façon antiseptique
- Pensez à faire participer le patient ! Demandez - lui de signaler toute fuite et toute douleur
- Veiller au bon écoulement des perfusions (tubulures non coudées, robinets ouverts). Sinon, la voie veineuse risque de se boucher.
- Le débit doit bien sûr être contrôlé régulièrement , afin d'assurer le respect de la prescription.


VII- RETRAIT DU CATHETER


- Se laver les mains
- Mettre des gants non stériles
- Retirer le pansement transparent et le cathéter
- Comprimer le point de ponction à l'aide d'une compresse
- S'assurer que le point de ponction ne saigne plus avant de laisser un pansement sec
- Noter le retrait du cathéter dans le dossier de soins

 

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