year 5 mh linical skills session peripheral venous annulation · peripheral venous cannulation is...
TRANSCRIPT
Year 5 MBChB
Clinical Skills Session
Peripheral Venous Cannulation
Authors:
The Clinical Skills Lecturer Team (2020)
Reviewed & ratified by:
Year of review
Learning objectives
To understand reasons for undertaking cannulation
To understand hazards of cannulation including needle stick guidelines
To understand the principles of ANTT (Aseptic non touch technique) and management of a cannula
To be able to carry out cannulation safely and within Trust guidelines
Definition:
Peripheral venous cannulation is where a small flexible tube (cannula) containing a needle stylet is inserted into
a peripheral vein. This then provides intravenous access to allow administration of medicines intravenously etc.
(Dougherty 2008).
Vascular anatomy left anterior forearm;
Images of Shoulder girdle and arm; Standring, Susan, MBE, PhD, DSc, FKC, Hon FAS, Hon FRCS, Gray's Anatomy, Chapter 48, 797-836.e1
By File:Vein.svg: Kelvinsongderivative work: Begoon - This file was derived from: Vein.svg:, CC BY-SA 3.0,
https://commons.wikimedia.org/w/index.php?curid=65694762
The tunica externa contains nerves and is thicker in veins than arteries, the tunica media is predominantly
smooth muscle, but is partially regulated by the vasomotor nerves of the sympathetic nervous system.
Contraction of the smooth muscles results in vasoconstriction and conversely relaxation results in vasodilation.
The tunica intima has valves formed from the folds of the intima and there are many in the peripheries to
promote the upwards flow of blood. (Marieb & Hoehn 2007).
Legal Implications
NHS trust have two forms of liability:
o Direct liability – the Trust itself is at fault
o Vicarious or indirect liability – the Trust is responsible for the faults of others.
When you perform peripheral cannulation you will be measured by the same standard as other health
professionals that have this skill, you have a duty of care and cases of negligence can be brought if you fall
below the standard of care. Ensure that you are supervised at all times and that you are aware of the Trust
policies when you are in clinical practice.
Indications for peripheral venous cannulation:
The common indication for peripheral cannulation is predominantly therapeutic.
For example;
o Administration of medications, fluids, nutritional products, blood products or anaesthesia. This could be
routine or urgent.
Further training is required before you do;
o Blood transfusion (currently in 5th year)
Considerations prior to cannulation;
Consider your safety and patient safety at all times.
o Skin Microorganisms such as Staphylococcus epidermis can be found on a patient’s skin as part of their
natural skin flora, these microorganisms can become pathogenic if they enter the blood stream. You
therefore have the responsibility to ensure the patient’s skin is cleaned and not recontaminated prior to
insertion of the cannula. (Loveday et al 2014)
o Tunica Intima, can be damaged if the cannula is too large for the vein, so choose an appropriate
cannula
o Tunica Media, if a patient is anxious, they may have a sympathetic reaction and the veins could spasm
or contract, making cannulation difficult, (Josephson 2004). Try to reassure your patient and stop if it
isn’t working.
o Damage to valves in the vein, avoid bifurcations of the veins and palpate the vein as you can normally
feel the valves, and try to avoid, these could be damaged permanently.
o Needlestick, ensure needle safe devices are used and see below on needle stick injuries.
o Phobia, check for patient phobias and support patient to lie down if appropriate.
o Infection, this is a big problem for patients ensure ANTT followed.
Needle stick injury
Care should be taken at all times to prevent needle stick injuries. If you come across unsafe practice, you
should inform your supervisor.
What happens if you sustain a needle stick?
There will be a policy in the Trust that you are working in and the School of Medicine has a Health and Safety
code of practice available on the School’s Intranet.
However there are some vital first steps:
o Squeeze it, make it bleed
o Wash it under running water
o Dry it
o Apply a dressing
Then report it and document it thoroughly.
This needs to be reported on the ward / area that you are working, an incident report will be filed and you
may be sent to Occupational Health or Accident and Emergency for further tests. You must report it to the
Nurse in Charge and / or your supervisor.
You will then need to complete an incident report form from the University’s School of Medicine;
Contact Departmental Safety Coordinator: Dr Emma Beddoes, email: [email protected]
If you need any further support please contact the Wellbeing team at the school.
Sharps
Sharps disposal goes into a sharps box, there are various coloured lids. The lids dictate what can go into the
bin:
o Orange - for sharps with no medication contamination
o Yellow - for sharps including medication contamination
o Purple - for sharps and cytotoxic drugs, eg; chemotherapy
The sharps bins are for:
o Needles and syringes (do not disconnect - dispose as one)
o Suture needles
o Scalpel blades
o Glass vials if no option otherwise
o Cannulas
o some trusts request that ChloraPrep ® and removed cannulas always go into sharps- follow your
Trust’s policy.
In order to reduce sharps injury, be aware of HSE regulations (2013) and:
o NEVER attempt to re-sheath a needle
o Always ensure that lid is fitted correctly and the sharps bin is signed, stating the date it was put
together
o Activate needle safe devices prior to disposal, and never try to adapt equipment.
o Do not overfill the boxes past the fill line, as this is a safety hazard. Image below is from the Learning
Zone with artificial blood…..
o Close the bin lid firmly when full, and sign the label on the front to
confirm you have locked it.
o Irrespective how full the box is, change it every 3 months
o DO NOT DISPOSE OF SHARPS in clinical waste bags!
Incorrect disposal of sharps may cause injury or death
Rice et al (2015) found that sharps injuries increased by 67% over a 10 year period prior to the latest
regulations.
Patient Safety Considerations
Cannulation is an invasive and sometimes uncomfortable routine procedure, occasionally a patient may have
developed a needle phobia due to previous experiences, and you should discuss this when gaining consent,
assist the patient into the most comfortable position. If the patient does not give informed consent then you
should not be practicing venepuncture, always consult your supervisor.
Many clinical practices have different equipment, depending on training and organisational decisions,
therefore you need to know how to use the cannulation system that your clinical placement uses. If you don’t
know how to use it - DON’T USE IT.
Complications
Some other complications are listed below;
o Infection, if ANTT is not applied or if the patient has an underlying infection
o Phlebitis, this is acute inflammation of the tunica intima and can potentially lead to septicaemia
o Allergy, check that the patient is not allergic to the skin cleanser (normally Chlorhexidine Gluconate or
CHG) and reactions to tape or dressings are common
o Mental health – phobia, consider administering topical anaesthetic prior to sampling.
o Medical device failure, this would need reporting, please do not alter any equipment prior to use as
this would affect the way it is licensed to be used.
o Skin damage (often from tourniquet if skin is fragile)
o Thrombus
o Bruising, increased risk if patient is on anticoagulants or the needle goes through the vein.
o Pain, consider topical anaesthetic
o Chemical Peripheral vein irritation, hypertonic solutions (eg: 10% Dextrose) can often irritate
peripheral veins, you should know the osmolarity of anything being infused into the vein.
o Mechanical Peripheral vein irritation, avoid siting a cannula over a joint and again choose an
appropriate sized cannula for the vein.
o Infection, if ANTT is not adhered to.
o Emboli, if a large volume of air enters the patient’s blood stream normally through IV infusion sets.
o Infiltration or extravasation, these will be discussed later in this study guide.
o Venepuncture hazards,
o Accidental arterial puncture, apply pressure and document.
o Damage to a nerve ligament or tendon, remove immediately if signs of pain, loss of sensation
etc and document incident.
o Haematoma, apply pressure on the haematoma site, this is worse if the patient is on anti-
coagulants.
o Chemical Peripheral vein irritation, hypertonic solutions (eg: 10% Dextrose) can often irritate
peripheral veins, you should know the osmolarity of anything being infused into the vein.
o Mechanical Peripheral vein irritation, avoid siting a cannula over a joint and again choose an
appropriate sized cannula for the vein.
o Infection, if ANTT is not adhered to.
Ensure any complications are documented clearly in the patient’s notes and that complications are reported to
your supervisor immediately.
ANTT
Cannulation should utilise an Aseptic non touch technique (ANTT) approach, ANTT minimises the transmission
of virulent pathogenic organisms in sterile or aseptic procedures. Understanding and adhering to the concept of
ANTT is paramount in patient and staff safety. The aim of ANTT is asepsis, which is done by “protecting Key-
Parts and Key –Sites from microorganisms” carried by the person doing the procedure. (ANTT Clinical Practice
Framework, Principle 2, 2018)
The increase of antibiotic resistant bacteria requires clinicians to prevent the spread of infection and practicing
ANTT with good hand hygiene can contribute to this.
ANTT is practiced when:
o Carrying out invasive clinical procedures, such as taking blood,
o Maintaining indwelling medical devices, such as a peripheral venous cannula,
o When handling equipment and carrying out procedures involving key parts and key sites,
(Loveday et al, 2014)
“Key parts are the critical parts of procedure equipment, that if contaminated are most likely to cause
infection.” (ANTT Clinical Practice Framework, Safeguard 2, 2018)
Some key parts:
o Syringe tip, needles, tip of a cannula, patient’s skin, catheter tip, wounds, rubber seals on IV lines, drug
bottles, etc.
(ANTT, 2018)
Contamination of key parts
Below are some images of contaminated key parts:
Differences in Clinical Practice
Differences may be due to clinician preference, trust policies and clinical context (e.g. patient on ward, separate
from equipment area).
You need to understand the concepts of the technique so that once on placement, you can be flexible with the
procedure in any given circumstance, and comply with local trust policy.
Putting an unsheathed needle in a tray or touching the part that goes into the patient
Cannulation equipment and policy varies from Trust to Trust. Ensure that you are familiar with local policy and
equipment before carrying out the procedure on a patient.
Phlebitis and Infection
Phlebitis is the inflammation of a vein, or more specifically its inner lining, the tunica intima (RCN, 2010)
Clinical Signs of Phlebitis:
o Redness
o Pain
o Heat and or swelling
o Palpable Venous Cord
Types and causes of phlebitis
o Chemical phlebitis - the drugs or fluids being administered can cause irritation to vein.
o Mechanical phlebitis - too big a cannula in too small a vein, movement of the device once sited, eg; over
a joint.
o Infective phlebitis - poor aseptic technique on insertion, contamination of the infusion line.
Visual Infusion Phlebitis Score (VIP).
Many NHS Trusts have now adopted the VIP scoring system developed by Jackson (1998), as recommended by
NICE and epic3 Guidance (NICE 2012 and Loveday et al 2014). Various charts are used for scoring and most are
based on Jacksons’s recommendations as published in the Nursing Times 2011(Higginson).
Permission for use of image kindly given by:
BMJ Publishing Group Ltd. BMJ Case Reports
Phlebitis as a consequence of peripheral intravenous
administration of cisatracurium besylate in critically ill patients
Annelijn M Meeder,Marijke S van der Steen,Annemieke
Rozendaal,Arthur R H van Zanten
Oct 3, 2016
Copyright © 2016, Copyright © 2020 BMJ Publishing Group Ltd.
All rights reserved.
Procedure/ examination
Patient Safety
Featured in Higginson (2011)
On first meeting a patient introduce yourself, confirm that you have the correct patient with the name and
date of birth, if available please check this with the name band and written documentation such as the NHS/
hospital number/ first line of address.
Check the patient’s allergy status, especially conscious of Chlorhexidine Gluconate (CHG 2%). Ensure the
procedure is explained to the patient in terms that they understand, gain informed consent and ensure that you
are supervised, with a chaperone available as appropriate. Allow the patient to ask any questions that they may
have and discuss any past problems (e.g. fainting/ bleeding/ anti-coagulant medication history). Assist patient
into a comfortable position, as appropriate to the procedure. If the patient has a history of fainting, they may be
positioned better on a trolley, ask the relatives if they have any problems with needles. Also consider the
patient’s own personal preference (e.g. choice of arm) or issues preventing the use of 1 arm, eg; lymphoedema.
Your explanation of the procedure to the patient should include why they are being cannulated. Don personal
protective equipment as you are coming into contact with bodily fluids (Loveday 2014) and use sharps in
accordance with HSE (2013).
Be aware of hand hygiene and preventing the spread of disease, WHO (2009) https://www.who.int/infection-
prevention/tools/hand-hygiene/en/
As with any invasive procedure, please ensure all steps are checked with your supervisor.
Site Selection
Common insertion sites
Cephalic vein – readily accommodates a large-gauge cannula and, by virtue of its position on the forearm
provides a natural splint (Weinstein and Plumer 2007), does not restrict patients movements as avoids area of
joint flexion
Basilic – awkward position (see above) and has a tendency to have many valves (Dougherty 2008, Hadaway
2000), patient may easily knock cannula on furniture
Dorsal venous network - allows for cannulation proximally along the veins when resiting the device
(Weinstein and Plumer 2007), reduces patient mobility and is more painful on insertion
Median cubital – Close to brachial artery and radial nerve, avoid unless experienced. Greatly reduces patient
mobility.
The superficial veins of the lower limbs -may also be cannulated, but these tend to be avoided as they are
associated with a higher risk of infection and embolism (RCN, 2010).
Several factors must be considered when selecting a site for peripheral venous cannulation.
The risk of infection or phlebitis can be reduced if the following is considered:
o The general condition of the veins
o Avoiding points of flexion on insertion
o The type of drug to be administered (determined by the osmolality or pH)
o Speed of drug delivery
o Duration of intended therapy
o The size of the cannula versus the size of the vein.
Sites to avoid if possible
o Thrombosed, fibrosed or sclerosed veins
o Inflamed, bruised or painful areas
o Areas of thin or fragile skin
o Near bony prominences and joints
o Near sites of infection or oedema including a history of lymphadenopathy
o Renal fistula
o Areas near to a recent cannulation
o Dominant arm
o Moles or skin lesions
o Limbs with weakness following CVA
Difficulty accessing Vein
There are patients where you will struggle to find a vein, whilst you are practicing this skill, it is recommended
that you only attempt venepuncture when you feel happy that you can access the vein. You should be
supervised at all times and do not attempt venepuncture more than twice on a patient who has given informed
consent.
You may also come across ultrasound guided vascular access, this is often used in hospital to access vessels that
are difficult to find for a variety of reasons, and you should have the opportunity to see this used during your
clinical placements. Short video available to show pulsation of artery on the website.
Cannulation equipment
o Equipment may all be in a cannula sterile pack (including or excluding cannula, flush and cleaning
solution)
o Cannula (Appropriate size)
o Cleaning solution e.g. swabs or Chloraprep®
o Sterile gauze
o Cannula dressing
o Tourniquet
o Gloves (sterile/ non sterile dependent on Trust
policy)
o Apron
o Extension set
o Saline for flushing cannula (most are pre- filled)
o Optional dressing towel to put under arm or create a sterile field
o Procedure tray
o Sharps bin
o Pen for documentation
Example of a cannula pack
Some equipment that you may see
Tourniquets
Only one tourniquet is used the photo is purely to
compare fastenings
Using a Tourniquet
A tourniquet must not be left on for more than 60 seconds (NHS Clinical Evaluation Team 2018)
A tourniquet is used to assist in finding potential veins suitable for cannulation, it can be applied twice once to
find a suitable vein, it must then be released whilst the skin is cleaned, and reapplied prior to the procedure.
The tourniquet used should be capable of being released with one hand. Most trusts use disposable ‘single use’
tourniquets to reduce the spread of infection- these should be used.
The tourniquet is applied approximately 8cm above the chosen site. This will usually mean it is applied to the
upper arm. The tourniquet should not be so tight as to cause pain or impede arterial blood flow (check pulse is
present if unsure). Please be aware if a patient has delicate skin that could bruise or tear and exercise extreme
caution.
Occasionally patients have very large veins that are easy to palpate, you do not need to use the tourniquet to
identify veins in this instance, and you may not require it for cannulation.
Fist clenching as a means of emphasising location of veins is not recommended as this can cause pseudo
hyperkalaemia, especially in conjunction with tourniquet use. (Bailey and Thurlow, 2008; Garza, D. and Becan-
McBride, K, 2010)
If a tourniquet is left in situ for too long, it can also affect the clotting around the insertion site and increase the
risk of phlebitis.
If the veins are not prominent, then consider:
o Positioning the arm below heart level helps dilate the vein
o Light tapping or rubbing may be useful but NEVER slap the vein
o The use of a warm pack helps encourage vasodilation and venous filling (Brooks, 2014).
Commonest type of device currently used in North West Trusts
Safety Device activated
Non-ported Cannula
Cannula gauges, flow rate and applications
Practical procedure
Sequence of events, this can vary between Trust sites, please follow Trust policy:
o Understand the need for cannulation
o Do patient safety checks and gain informed consent
o Gather equipment, checking expiry dates
o Wash tray/ trolley
o Wash hands using Ayeliffe technique
o Prepare equipment, protecting all key parts, ie:
o Prepare Normal Saline flush
o Prime extension set, you may leave syringe attached so that key parts are protected
o Open dressing and all other equipment
Colour Size Flow Rate
Crystalloid
Common Applications
14G 350 ml/min
Used in theatres or emergency for rapid transfusion of blood or
viscous fluids
16G 215 ml/min
Used in theatres or emergency for rapid transfusion of blood or
viscous fluids
18G 104 ml/min
Transfusion of blood products, parenteral nutrition and large
volume infusions.
20G 62 ml/min Infusions 2 – 3 l per days and intermittent bolus injections.
22G 35 ml/min Poor access.
24G 24 ml/min Paediatric patients or very poor access.
o Don an apron (can be done any time prior to procedure)
o Use tourniquet to identify vein and release tourniquet.
o Clean skin with Trust recommended solution (usually Chlorhexidine Gluconate2% in 70% alcohol)
product needs 30 seconds of cleaning to activate, and allow at least 30 seconds for product to dry
(Loveday et al 2014). CONFIRM THAT THE PATIENT IS NOT ALLERGIC TO THE CLEANING SOLUTION
BEFORE USE!
o While skin is drying reapply tourniquet
o Wash hands using Ayeliffe technique
o Don gloves
o Insert cannula and release tourniquet
o Dispose of needle stylet immediately into a sharps bin
o Secure cannula and flush
o Apply dressing
o Document date on dressing and document the procedure.
Equipment;
Approximately 5ml (Trust dependent) of 0.9% Normal Saline Flush should be used to “flush” a cannula. Most
Trusts in the region have a pre- drawn flush available, normally Posi-Flush®. If you are at a trust that doesn’t,
you will have to draw up Normal Saline as you would when drawing up a drug for injection, maintaining ANTT.
– On insertion cannulas should be flushed immediately
– During intermittent therapy they should be flushed after each use
– 0.9% Sodium chloride is acceptable (Goode et al 1991)
Some of the pre-filled syringes are completely sterile, others are only sterile on the inside of the syringe like
the ones pictured above, so ensure that you know your device and know how to handle it, reducing any
contamination.
Prime extension set
Extension sets, can be single or multiple lumens they have a clamp that must be clamped off between each
use, the key parts must be protected at all times.
By protecting the key parts, this also means that prior to administration of fluid or drug the bung must be
cleaned with a wipe (follow Trust policy) for 30 seconds and allowed to dry.
Priming the extension set
You need to ensure that before you attach this to the patient the line of the extension set is primed to reduce
air emboli. You can leave the flush attached until the cannula is flushed and leave the cap on the extension set.
This procedure can be done wearing gloves or with clean hands and can also be done with the extension set
inside of its sterile pack (follow Trust policy) but always maintain key parts.
Flush Technique
The method adopted is called the “push/pause” technique:
by pulsating the delivery of the fluid a turbulent flow is created, removing debris from cannula lumen
(Cummings-Winfield & Mushani Kanji 2008, Goodwin & Carlson 2010, Philips 2005)
When flushing the cannula, warn the patient that they may feel a cold sensation in their arm, if they complain
of pain or you see bulging of the skin when administering the flush, stop immediately and remove cannula and
document incident. Secure the extension set after use follow Trust guidance.
Clean skin
Crack ChloraPrep ®
Clean skin for 30 seconds, using a cross hatch motion and leave to dry
Do not re palpate skin, unless wearing sterile gloves.
Insert cannula
After reapplying tourniquet, washing hands and donning gloves, anchor the vein below the insertion point.
Unsheath needle open the wings on the cannula.
Students should have no more than 2 attempts at cannulation, if unsuccessful seek advice.
Stabilise the vein by applying traction below the insertion site
(Dougherty 2008)
Angle cannula at ~30 degrees
Puncture skin and watch for flash back (blood) in the clear chamber
as the tip enters the vein, once flash back is visible, you can release
the tourniquet.
Reduce the Insertion angle of the cannula to prevent puncturing
the posterior wall of the vein (Perucca 2010) and introduce the
cannula a little more (flash back should be seen in the lumen of the
cannula).
Hold the needle introducer and advance the cannula off it and into
the vein, under no circumstances re-insert the introducer.
Apply pressure to the vein, distal to the tip of the cannula, if it is a
cannula that doesn’t have a valve in to prevent blood leakage. You
may consider having sterile gauze to mop up any leakage.
Safely remove the needle stylet or introducerimmediately into the
sharps bin.
Apply extension set without letting go of the cannula and either secure or flush. Apply the rest of the dressing.
The dressing.
NICE accredited epic3 guidelines (Loveday et al, 2014) recommend that staff should use a sterile, transparent,
semipermeable polyurethane dressing to cover the intravascular insertion site.
Dressings may differ from Trust to Trust but they should:
o Provide an effective barrier to bacteria
o Securely fix the cannula
o Be sterile
o Be waterproof
o Adhere well
o Be comfortable for the patient (Finlay 1997)
The dressing should be assessed every shift and changed if dirty using 2% chlorhexidine gluconate (CHG) in
70% isopropyl iodine (Loveday et al 2014).
Apply pressure for approximately 1 minute. Discourage the patient from bending their arm (Ernst 2000).
Applying the dressing
Remove the back with strips on, this can be done when
setting up the equipement, as long as you do not
contaminate the side strips.
Do not let go of the cannula until at least one side is taped down.
Ensure that you do not touch or cover the insertion point.
Apply dressing ensuring insertion point visible and
completely covered.
Remove the outer part.
Write the date on the dressing
Place the date on the hand away from the insertion
point.
When removing the dressing or cannula
The dressing MUST be removed using the stretch and release method.
-This avoids unnecessary movement of the indwelling cannula
-Prevents damage to the skin
Sterile gauze, semi- permeable dressing must be applied to the site of cannula removal and left on for 24
hours. Some trusts require the insertion site to be cleaned with ChloraPrep® or CHG 2% following removal
The date of removal must be documented
Documentation
Document the insertion of cannula. Examples of documentation is available on the next page, this varies from
Trust to Trust, and is now often electronic but the peripheral venous cannula should be monitored every 8
hours and removed if there is a problem or if it is not required.
Documentation often required:
o Phlebitis score
o Insertion point
o Attempts at insertion
o Skin Preparation
o Dressing used
o Lot number of cannula
o Amount of Flush used
o Use of personal protective equipment
Further Complications
Bleeding can occur especially if the cannula is removed accidentally, a haematoma can occur for many
reasons, but especially if the needle on insertion went through the vein.
Infiltration is where the cannula is poorly positioned or moves
into tissues (tissued) if the cannula for example went through
the vein. If fluid is infused the arm would become oedematous
and would be cold to the touch and can result in blisters,
remove the cannula immediately and report injury.
Extravasation of drugs that may cause
necrosis of the site and potential death. The
patient will feel pain and the skin will be
warm to the touch, Remove cannula and
report injury. Further reading listed below in
the references, Upton et al (1979)
Extravasation injury of balanced simulates the clinical condition of necrotizing fasciitis: A case report
Journal of Pediatric Surgery Case Reports. D'Acunto, Carmine; Neri, Iria; Purpura, Valeria; Orlandi, Catuscia; Melandri, Davide..
Published October 1, 2015. The extensive edema with large blisters on the dorsum of the right hand and wrist of the 2-month-old male
patient after extravasation of balanced electrolyte solution Copyright © 2019 Copyright © 2019 by Elsevier, Inc. All rights reserved.
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Meeder, A. M., van der Steen, Marijke S, Rozendaal, A., & van Zanten, A. R. (2016). Phlebitis as a
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