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1
Peripheral Venous Cannulation Study Guide Year 4
Clinical Skills Teaching & Learning Centre Written by: Clinical Skills Lecturing Team
Reviewed by: Dr Jamie Fanning, Theme Lead for Clinical Examination & Procedural Skills
July 2020
2
Contents Glossary ....................................................................................................................................... 3
Learning Objectives ..................................................................................................................... 4
Introduction .................................................................................................................................. 5
Indications ................................................................................................................................ 6
Surface Anatomy: Upper Limb ..................................................................................................... 7
Vascular Anatomy: Upper Limb ................................................................................................ 7
IVC Insertion Sites: Upper Limb................................................................................................ 8
Other Anatomical Considerations ............................................................................................. 9
History ........................................................................................................................................ 10
Preparation ................................................................................................................................ 11
Patient safety ............................................................................................................................. 11
Equipment .............................................................................................................................. 12
Cannula .................................................................................................................................. 13
Cannula Gauges, Flow Rate and Applications ....................................................................... 14
Considerations & Complications ................................................................................................ 18
Practical Procedure .................................................................................................................... 20
Documentation ........................................................................................................................... 29
Visual Infusion Phlebitis Score (VIP) ...................................................................................... 29
Picture Credits ........................................................................................................................... 31
References and Further Reading ............................................................................................... 33
Appendix 1: Clinical Skills Sharps Management ........................................................................ 36
3
Glossary
ANTT Aseptic non touch technique
Bifurcation Division into two branches of a blood vessel
Cannula A tube that can be inserted into the body, often for the delivery or removal
of a fluid or for gathering samples
Central Line A generic description for an intravenous catheter / cannula inserted into a
large, central vein
CVC Central Venous Catheter
Extravasation The leakage of fluid into the surrounding areas, especially blood or blood
cells from vessels.
Flashback Blood in the chamber of the cannula, once the needle first punctures the
vein
G Gauge
Hickman Line A type of tunnelled central line inserted under the skin of the anterior chest
wall
IV Intravenous
IVC Intravenous Catheter / Cannula
Lymphoedema Chronic condition that causes swelling in the body’s tissues
Midline A long catheter inserted into a peripheral vein.
Peripheral Line A generic description for an intravenous catheter / cannula inserted into a
smaller, peripheral vein
Phlebitis Inflammation of a vein
PICC Peripherally Inserted Central Catheter / Cannula
Stylet A slender probe / the needle that guides the cannula into the vein / artery
Thrombosis The formation of a blood clot inside a vessel
Thrombophlebitis A blood clot that occludes the vessel
US Ultrasound
USG Ultrasound Guided
VAD Vascular Access Device
VIP Visual Infusion Phlebitis.
VIP Score A score that identifying phlebitis, enabling healthcare workers to remove
intravenous catheters at the first indication of phlebitis
4
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
5
Introduction
Cannulation is classed as an invasive procedure, NICE(29) define an example of an
interventional procedure as making a cut or a hole to gain access to the inside of a patient’s
body. The majority of patients within a hospital setting will require insertion of some form of
vascular access device during their stay, whether that is to receive intravenous fluids,
intravenous medications or to allow for investigations to be performed. These vascular access
devices can be subdivided, firstly by the type of vessel which they sit within:
1. Intra-Venous – used for IV fluids, IV medications, venous blood sampling, monitoring or
to give IV contrast (within radiology).
2. Intra-Arterial – used within critical care settings by an experienced clinician for
continuous, invasive blood pressure monitoring and arterial blood sampling.
Intravenous devices are then further classified according to their location; either central
(inserted into a large, central vein) or peripheral (inserted into a small, peripheral vein).
Central lines are long cannula, often with multiple lumens and are used for invasive monitoring,
blood sampling and delivery of multiple drugs or drugs which could be harmful if given via small
peripheral veins. These lines are generally reserved for use in more specialist, critical-care
areas and should only be inserted by people trained to do so as the risks associated with these
devices are potentially much more serious. To reduce the risk of complications, they are
generally inserted under x-ray or ultrasound guidance. The types of central lines which you will
see in practice, include:
- Internal Jugular, Subclavian and Femoral CVCs
- PICC lines (peripherally inserted central catheter)
- Tunnelled lines (e.g. Hickman)
- Implanted ports (e.g. Portacath)
This study guide focuses on peripheral venous cannulation, which is where a short flexible tube
(cannula / catheter) containing a needle stylet is inserted into a peripheral vein. The needle
stylet is removed and the cannula is secured in place with a dressing to provide a route of
intravenous access. Peripheral cannulae do carry less risks than central lines, however they
can only stay in for a relatively short period of time (usually several days) due to infection risks
and as they are only a single-lumen and inserted into a smaller, peripheral vein simultaneous
administration of multiple drugs is limited and not all drugs can be given this way.
6
Midlines
If a patient needs a cannula for more than three days, then they need to have a midline. This is
a long peripheral catheter (ranging from 10-25 cm in length) inserted commonly into the
cephalic vein. It may be a single or double lumen and is inserted by medics or IV nurse
therapists
Indications
The predominant indications for peripheral cannulation are therapeutic, for example;
• IV bolus or infusion of medications
• IV bolus or infusion of fluids
• Administration of nutritional products
• IV infusion of blood products
• During anaesthesia
Peripheral IVCs can also be used for diagnostic reasons, especially within the radiology
department where intravenous contrast is sometimes given for specific tests.
7
Surface Anatomy: Upper Limb
It is possible to insert a cannula into any peripheral vein that has a large enough diameter and is
sufficiently straight to allow insertion of the cannula and stylet, however in practice they are
most commonly inserted into the veins of the antecubital fossa, forearm and the dorsal aspect
of the hand. The exceptions to this are paediatric patients and patients with difficult IV access,
when other veins may be used.
Vascular Anatomy: Upper Limb
Figure 11
8
IVC Insertion Sites: Upper Limb
Cephalic vein (figure 2 & 3) – On the lateral aspect of the distal forearm runs the cephalic vein,
which is arguably the ideal choice of site for an IVC and was historically referred to as the
“Housemans Friend”, in recognition of its reliability as the go-to site for junior doctors needing to
cannulate an unwell patient. It is generally a desirable site because:
- Readily identified / located.
- Easily accessed.
- Larger / straighter vein, allowing for insertion of even a wide-bore cannula.
- Not on a joint so it does not restrict the patient’s movement and does not cause the
cannula to bend and occlude.
Basilic vein (figure 3) – Whilst also
generally readily identified and easily
accessed, with its more medial location
this site is favoured less by patients as it
can easily catch on things, particularly
their clothing. Due to the presence of
communicating vessels and an increased
number of valves, it can also be more
difficult to cannulate the basilic vein.
Median Cubital vein (figure 3) – As the largest superficial vein of the forearm this is the
preferred site in the emergency setting when a wide-bore cannula is required, however it is
close to other important structures (brachial artery and radial nerve) and therefore carries with it
an increased risk of complications. As it is sited over the elbow joint it also significantly reduces
the patient’s mobility and repeated flexion of the joint can increase the risk of occlusion.
Figure 2
Figure 3
9
Dorsal Venous Network - (figure 4) – Due to the bony
nature of the hand, the dorsal metacarpal veins are often
very superficial, prominent and readily identified as well as
easy to access. For the patient, however, this site tends to
be more painful on insertion and whilst in use and this can
limit their mobility more.
Other Anatomical Considerations
Skin - During cannulation the catheter and needle stylet pass through the skin, thereby
breaching the body’s natural defence against infection and giving opportunity for
microorganisms, such as staphylococcus epidermis, that are part of the natural skin flora, to
enter the blood stream. This highlights the importance of good skin decontamination and ANTT
prior to a cannulation attempt and also the need for continued care and vigilance for any signs
of surrounding redness, which may indicate developing cellulitis or phlebitis.
Veins – Both veins and arteries are made up of 3 concentric layers; the inner tunica intima, the
middle tunica media and the outer tunica externa (figure 5).
- Tunica Externa – this outer, protective,
collagenous layer also contains nerves and is
thicker in veins than arteries.
- Tunica Media – the middle layer is predominantly
smooth muscle which is controlled by the
vasomotor nerves of the sympathetic nervous
system. Contraction of this smooth muscle results
in vasoconstriction and conversely relaxation
results in vasodilation. If the patient is anxious the
resultant sympathetic reaction (the fight or flight
response) could cause vasoconstriction and make
cannulation difficult. It is, therefore, important to
reassure your patient and stop if necessary. As a
student, you should have no more than 2 attempts at cannulation. If unsuccessful you
should then stop and seek senior advice.
- Tunica Intima – this inner layer of endothelium gives rise to the bicuspid valves which are
present at intervals along the vessel lumen and can contribute to difficulties with advancing a
cannula into the vein or reducing flow from the cannula. The intima and valves can also be
damaged during cannulation and this should be avoided through selection of an
appropriately sized cannula and avoidance of valves were possible (they can sometimes be
palpated when selecting an appropriate site).
Figure 4
Figure 5
10
History
Prior to any clinical procedure you should have obtained a sufficient history from the patient or
their notes to allow you to safely undertake the procedure, this is especially true of peripheral
venous cannulation.
The most important question which you need to answer before undertaking the procedure is:
- Why is the patient having the cannula inserted and is it necessary? This is particularly
important as it may determine the size (or gauge) of the cannula and the site you choose to
insert it.
Other questions, or features of the history which would be relevant, include:
- Current anticoagulation? This could increase the risk of complications.
- Allergies? Specifically to latex, skin prep and cannula dressings.
- Have they had a cannula inserted previously? This can help when explaining the
procedure to them and gaining their consent.
- If they have recently had a cannula inserted, what was the site? To allow you to avoid
using the same site again.
- Does the patient have a preferred side?
- Left or right handed? You may choose to place the cannula into the non-dominant arm to
keep their dominant arm more mobile.
- Do they have a previous history of breast cancer, it is important to establish which side
this was on because some patients, generally those who have required axillary lymph node
surgery, will have been advised not to have venepuncture or venous cannulation performed
in the arm on that side?
- Any reasons not to use a specific arm? Examples could include extensive dermatological
conditions, cellulitis, limb weakness, lymphoedema and traumatic injury.
- Do they have a history of fainting with needles?
11
Preparation
Patient safety
• Introduce yourself
• Check the patient’s identity and allergies
• Explain what you want to do
• Gain informed consent
• Consider an appropriate chaperone. If the patient needs to get undressed, for example
their top is tight fitting, or they are having an infusion and they need to wear a gown, then
a chaperone would be appropriate.
• Position the patient appropriately – consider moving and handling – patients will often be
on a bed/trolley because if they need a cannula they’re likely to be unwell, about to have
a procedure or may be prone to fainting
• Wear Personal Protective Equipment as required.
• Wash your hands before and after you touch the patient (as per WHO(50) guidelines)
On first meeting a patient introduce yourself and confirm that you have the correct patient with
the name and date of birth, if available please check this with the name band, written
documentation and the NHS number/ hospital number/ first line of address.
Allergies - Check the patient’s allergy status (including latex, chlorhexidine, dressings).
Consent - Ensure the procedure is explained to the patient in terms that they understand, gain
informed consent and ensure that you are supervised, as appropriate. Allow the patient to ask
any questions that they may have and discuss any past problems (e.g. needle phobia/ fainting/
bleeding/ anti-coagulant medication history). Also consider the patient’s own personal
preference (e.g. choice of arm) or issues preventing the use of 1 arm (e.g. lymphoedema). Your
explanation of the procedure to the patient should include why they are being cannulated.
PPE / Sharps – You must don appropriate personal protective equipment as you will come into
contact with bodily fluids and ensure you use and dispose of sharps safely.
If you sustain a needle stick injury during the procedure follow the guidance in Appendix 1.
Patient Positioning / Exposure - For this procedure the patient should sit or lie on the bed /
couch. For comfort a pillow behind their arm to support it would be beneficial. Due to the nature
of the procedure some patients may faint, so ensure they are sitting or lying in a safe position
i.e. not sitting leaning forward or lying on the edge of the bed / couch.
They do not need to undress, but you will need to gain access to their arm.
12
Equipment For this procedure you will need;
1. Hand wash
2. Gloves (sterile/ non sterile dependent on Trust policy)
3. Apron
4. Procedure tray
5. Optional dressing towel to put under the arm or create a sterile field
6. Skin cleaning solution – usually Chlorhexidine Gluconate 2% in 70%
Alcohol
7. Tourniquet
8. Cannula (appropriate size)
9. Cannula dressing
10. Sterile gauze
11. Bung or Extension set
12. Saline for flushing cannula
13. Sharps bin
14. Pen for documentation
Sterile cannula pack
Some Trusts will provide sterile cannula packs (Figure 6 & 7) which may include all of the items
required for cannulation, but often does not contain the cannula and saline flush.
Skin Prep
The skin needs to be cleaned, this may vary depending on which Trust you are in, so please
check first. ChloraPrep® (containing Chlorhexidine Gluconate 2%) should be applied for 30
seconds and then given 30 seconds to dry as per manufacturer’s instructions. Do ensure the
skin is dry before commencing procedure.
• This may be done before gloves are applied.
• ANTT(1) suggests that the skin should not be re-palpated after cleaning, otherwise
sterile gloves should be worn - please refer to individual trust policy
Tourniquet
A tourniquet (figure 8) is used to assist in finding potential veins suitable for cannulation and is
first applied to find a suitable vein, before being released whilst the skin is cleaned, and then
applied for a second time to complete the procedure.
The tourniquet used should be capable of being released with one hand and should be a
disposable ‘single-use’ tourniquet to reduce the spread of infection.
Figure 7
Figure 6
13
Figure 8 shows three different disposable tourniquets
with differing methods of attachment:
- White – this tourniquet is kept in place by an adhesive
tab, which allows the tourniquet to be tightened and
released when needed.
- Pink – this tourniquet has a small stud that passes
through a hole at the other end of the tourniquet to
keep it tight on the patient’s arm. There are a variety
of holes to adjust the length / tightness.
- Purple – This is a plain band that requires a slip knot to be tied to hold it in place. It is easy
to release by pulling the end of the tourniquet.
Cannula
Peripheral cannula come in a variety of shapes and sizes and will vary from Trust to Trust.
Generally they can be grouped according to:
- Ported versus Non-Ported (figures 9 & 10)
The cannula used commonly across the North West Trusts is a ported cannula, such as the one
in figure 9, which has a port on top through which stat dose medications may be occasionally
given. The ports are rarely used except in emergencies due to the increased infection risk,
extension sets with more than 1 lumen can be attached to the infusion port.
You may also come across a non-ported cannula (figure 10), there is no port due to the
increased infection risk, but with the introduction of extension sets, IV medications and fluids
can be administered.
Figure 8
Figure 10
Figure 9
14
With modern needle-safe cannula, once the needle
stylet is removed from the cannula a clip covers
the end of the needle (figure 11). Care should still
be taken and it should be disposed of immediately
in the sharps bin.
Figure 11
Cannula Gauges, Flow Rate and Applications
Cannula are available in a variety of gauges as seen in figure 12 and table 1. The larger the
gauge the smaller the needle, for example a 14 G needle is bigger than an 18 G needle. You
need to ensure you have the right size cannula for the application.
Figure 12
15
Colour Size Approximate
Flow Rate
Crystalloid
(cannula may
vary from Trust
to Trust)
Approximate
Time to Infuse
1L of
Crystalloid
Common
Applications
Orange 14G 350ml/min 2 minutes and
51 seconds
Used in theatres
or emergency for
rapid transfusion
of blood
Grey 16G 215 ml/min 4 minutes 39
seconds
Used in theatres
or emergency for
rapid transfusion
of blood
Green 18G 104 ml/min 9 minutes 37
seconds
Transfusion of
blood products
(although can go
through smaller)
and large
volume infusions
Pink 20G 62 ml/min 16 minutes and
8 seconds
Infusions 2-3
litres a day and
intermittent
bolus
Blue 22G 35 ml/min 28 minutes and
34 seconds
Poor Access,
default size if
don’t need
bigger
Yellow 24G 24 ml/min 41 minutes and
40 seconds
Paediatric
patients or very
poor access
Table 1
16
Cannula Dressing
You will see various cannula dressings
across different clinical settings (figure 13),
however they should all adhere to NICE
guidance (22 & 28) which recommends the
use of a sterile, transparent,
semipermeable polyurethane dressing to
cover the intravascular insertion site and
they should:
• Provide an effective barrier to
bacteria.
• Securely fix the cannula.
• Be sterile.
• Be waterproof.
• Adhere well.
• Be comfortable for the patient.
• Be clean and free from blood once in situ
Extension Set
Once the needle stylet is removed from the
cannula, it is necessary to apply a single, one-way
bung or an extension (figure 14). These extensions
can be single or multi-lumen with one way valves at
the end of each lumen and a clamp that must be
clamped off between each use (figure 15).
Saline Flush
After insertion, the cannula should be flushed with a small bolus of 0.9% normal saline to check
patency of the device and prevent clot formation within its lumen. A similar flush should also be
used after drug administration to ensure there is no residual drug left within the cannula.
Figure 15
Figure 14
Figure 13
17
This saline flush will typically be a volume of 5ml and
may come as a pre-filled saline flush (normally Posi-
Flush®) or as a separate ampoule of saline which you
would draw up as you would a drug for injection.
Some of the pre-filled syringes are sterile only on the
inside of the syringe (figure 16), others are completely
sterile (figure 17), so ensure that you know your
device and know how to handle it, reducing any
contamination.
Ultrasound
The other piece of equipment which you may see in
use within clinical practice is ultrasound, which is being
increasingly used for ultrasound-guided vascular
access. The use of ultrasound is particularly beneficial
in patients with difficult IV access or when obtaining IV
access in a site which has more risk of significant
complications.
Figure 18 shows an ultrasound probe being held over
the antecubital fossa to identify underlying vessels, as
seen in figures 19 and 20.
Figure 16
Figure 17
Figure 18
Figure 20 Figure 19
18
Considerations & Complications
Site
When selecting the most appropriate position to site the cannula, it is important to avoid these
sites, where possible:
• Thrombosed, fibrosed or sclerosed veins
• Inflamed, bruised or painful areas
• Areas of thin or fragile skin
• Near bony prominences and joints
• Near sites of infection or oedema including a history of lymphadenopathy
• Renal fistula
• Areas near to a recent cannulation
• Dominant arm
• Moles or skin lesions
• Limbs with weakness following CVA
Complications
As NICE(29) has described this as an invasive technique this procedure does carry with it
numerous risks that range from minor localised bruising to potentially fatal sepsis. It is important
to be aware of these complications to allow you to gain informed consent from the patient and
also to help you minimise the risks wherever possible.
If a complication does occur, ensure it is documented clearly in the patient’s notes and discuss
it with your supervisor immediately so that the appropriate action can be taken.
The potential complications of peripheral venous cannulation include:
• Pain - consider application of topical or local anaesthetic, especially for wide-bore cannula.
• Bleeding/haematoma - this is more likely if the patient is on anti-coagulants. In the event of
bleeding or a haematoma apply gauze and direct pressure.
• Accidental arterial puncture - in which case you should apply pressure and document it.
• Damage to a nerve ligament or tendon - if signs of pain or altered sensation develop, you
should remove the cannula immediately, seek senior advice and document the incident.
• Infection - if ANTT is not applied or if the patient has an underlying infection.
• Phlebitis - acute inflammation of the tunica intima which can lead to sepsis.
• Skin damage - patients on long-term steroids often have more fragile skin and this can be
damaged by the tourniquet or removal of the dressing.
• Allergy – this could be to the skin cleaner, latex gloves or to the tape/dressings.
• Needle stick injury – needle-safe devices reduce this risk.
19
• Needle phobia - consider administering topical or local anaesthetic prior to cannulation.
• Thrombosis – they are often minor and go unnoticed.
• Chemical irritation – pain and discomfort caused by the infused drug or fluid, e.g. 50%
Dextrose. Always refer to the BNF prior to administration of a new drug.
• Mechanical irritation – pain and discomfort caused by movement of the cannula. This can
be reduced by choosing an appropriate size cannula and a non-joint site.
• Air Embolus - when air enters the blood stream e.g. through a non-primed infusion set.
• Infiltration - is when the fluids or medications
administered via the cannula are deposited in
the surrounding tissues, rather than into the
vein. This is caused by incorrect placement of
the cannula or when the tip of the cannula has
migrated out of the vein and into the surrounding
tissues (tissued). In this situation the arm would
become swollen, painful and cold to the touch.
In some cases blisters can also develop (figure
21). If this happens you should remove the
cannula immediately, report and document
the incident appropriately.
• Extravasation – is injury to tissues and
structures (Fig 22) caused by the leakage of
infused drugs or fluids from the vessel and
into the surrounding tissues. The patient will
feel pain and the skin will be warm to the
touch. Immediately stop the infusion and
seek senior advice immediately regarding
further management. Do not remove the
cannula as it may be possible for the senior clinician to use this
to remove some of the displaced fluid.(40)
Further reading listed in the references, Upton et al (1979)
Figure 21
Figure 22
20
Practical Procedure
There will be clinical variance in practice, and you are expected to follow local policy in clinical
practice. Once you have performed all of the patient safety checks and gained informed
consent, you should then gather together all of the required equipment and check their expiry
dates before continuing with the procedure in this sequence:
1. Wash tray/trolley.
2. Wash hands using Ayliffe technique.
3. Prepare equipment, protecting all key parts:
a. Open dressing and all other equipment
b. Prepare 0.9% saline flush and draw it up if there is no pre-filled flush.
c. Prime extension set (if it is policy to wear sterile gloves this may be
done once you have donned your gloves)
4. Don an apron.
5. Apply tourniquet to identify vein and release tourniquet.
6. Clean skin with Chlorhexidine Gluconate 2% in 70% alcohol (22 &27)
7. Reapply tourniquet.
8. Wash hands using Ayliffe technique.
9. Don gloves.
10. Insert cannula and release tourniquet
11. Safely dispose of the needle stylet immediately into a sharps bin.
12. Attach bung or extension.
13. Secure cannula and flush.
14. Apply dressing
15. Document date on dressing and document the procedure.
1. You need to ensure your trolley is properly cleaned using the appropriate cleaning
solution, this may vary from Trust to Trust, so please check. Start cleaning the top of the
trolley on the furthest edge and work your way towards you. Then clean the legs to the
second shelf and clean that shelf the same as the first. Move down to finish cleaning the
legs.
2. Ensure you use the Ayliffe technique each time you wash your hands.
3. Cannulation, as an invasive procedure, should utilise an ANTT approach and protect
key-parts and key-sites throughout the procedure. Some key parts and sites during
cannulation include the syringe tip (of the saline flush), the cannula tip and the patient’s
skin.
- Figure 23 – Patient’s skin being contaminated with non-sterile gloves
- Figure 24 – Cannula tip being contaminated
- Figure 25 – Unsheathed sharp and a cannula being contaminated by an un-gloved finger
- Figure 26 – Extension set end being contaminated.
21
a. Open dressing and all other equipment
To keep key parts sterile, the equipment can be kept in their open wrappers
(figures 27&28) or by placing them on a sterile field (figure 29) Retain the
wrapper for documentation.
The cannula and ChloraPrep ® can be opened and left in the
packaging until needed, as it is sterile (figure 27)
Figure 28
Figure 24 Figure 26 Figure 23 Figure 25
Figure 29
Figure 27
22
b. Draw up / prepare 0.9% saline flush
Most Trusts use Posiflush (figure 16 & 17) which is a syringe prefilled with saline 0.9%. If
your Trust does not have Posiflush, you will need to draw up the saline from an ampoule.
This is covered in the injection study guide.
c. Prime extension set
Before the extension set is
connected to the patient, it must be
primed (flushed through) with 0.9%
normal saline to avoid the
administration of an air embolus.
Once the extension set is
flushed you can leave the
flush attached until it has
been attached to the
cannula and the cannula
flushed. After priming the
extension set the cap
should be left on (figure 30),
this protects the key parts.
The procedure can be
done wearing gloves or
with clean hands, ensuring no key parts are contaminated. The extension set can be kept inside
its sterile pack (figure 31) or opened onto a sterile field, follow individual Trust policy, again
maintaining key parts.
4. Don an apron
- An apron must be worn for this procedure to protect from contamination. The apron can
be donned at various stages in the process, as long as it is worn prior to putting the
needle into the patient’s arm. It may be easier to put it on near the start, so you do not
forget!
5. Apply tourniquet to identify vein and release tourniquet.
- The tourniquet is applied approximately 8cm above the chosen site (figure 32) – in this
case; the upper arm.
Figure 30
Figure 31
23
Figure 32
- The tourniquet should not be so tight as to cause pain or impede arterial blood flow
(check pulse is present if unsure).
- You should visibly inspect the area and gently palpate with a finger to identify suitable
veins.
- If the veins are not prominent, then consider:
• Positioning the arm below heart level helps dilate the vein
• Light tapping or rubbing may be useful but never slap the vein
• Localised warming at the site helps encourage vasodilation and venous
engorgement.
• Fist clenching can help, as it engorges the veins, but be cautious when taking
blood from the cannula as it can cause pseudo hyperkalaemia, especially in
conjunction with tourniquet use(3,13).
- The longer a tourniquet is left in-situ the more likely complications are to occur and you
should not leave a tourniquet on for more than 60 seconds. If necessary, release and
then re-apply the tourniquet until a suitable vessel is found.
- Once you have identified a suitable vein, release the tourniquet.
6. Clean skin (with Trust recommended solution)
This is usually performed with Chlorhexidine Gluconate 2% in 70% alcohol (22, 27)
- Crack the ChloraPrep ® (figure 33) by squeezing it firmly between your
index finger and thumb.
Figure 33
24
- Clean skin for 30 seconds, using a cross hatch motion and leave to dry
(figure 34)
- Do not re palpate skin, unless wearing sterile gloves.
7. Reapply tourniquet – as detailed above.
8. Wash hands using Ayliffe technique
9. Don gloves
This will vary from Trust to Trust. Some Trusts use sterile gloves and some use non-sterile,
you must adhere to your trust guidelines. It does not matter if you wear sterile or non-sterile
gloves, what does matter is that you do not contaminate the key parts.
10. Insert cannula and release tourniquet
- Unsheath the needle, open the wings on the cannula (Figure 35).
The cannula and the introducer need to be kept together,
otherwise the introducer needle could pierce the plastic cannula.
Note the finger position in Figure 35.
- Stabilise the vein by applying traction below the insertion site, this
anchors the vein in position. Maintain sharps safety at all times.
- Angle cannula at ~30 degrees (figure 36)
Figure 34
Figure 36
Figure 35
25
- Puncture skin and watch for flashback (blood) in the clear
chamber as the tip enters the vein (figure 37),
- Reduce the insertion angle of the cannula (figure 38) to
prevent puncturing the posterior wall of the vein, at this
point some cannula manufacturers advocate advancing the
whole cannula a few millimetres further (flash back should
be seen in the lumen of the cannula), ensure you are
familiar with the specific equipment being used as to
whether this step is required. The tourniquet can now be
removed. It can be moved after the initial flashback, but the
movement can make the cannula come out of the vein.
- Hold the needle introducer with one hand and advance the
cannula off it and into the vein with the other hand (figure 39).
Once the introducer has been withdrawn, you should not
reinsert the introducer due to the risk of damage to the
cannula.
- Apply pressure to occlude the lumen of the vein just distal to
the tip of the cannula but not contaminating the skin under
where the dressing will sit(1) – this will prevent the cannula from
leaking blood when you remove the stylet/introducer. (It is
worthwhile to have sterile gauze available to mop up any
leakage.) Please note that some of the non- ported cannulas,
such as Figures 37-9 have a valve that prevents blood leakage, but most other cannulas do
not have this.
11. Safely dispose of the needle stylet immediately into a sharps bin
- Whilst occluding the vein, remove the needle stylet from the cannula and place it directly into
a sharps bin. Note Figure 39 is not occluding the vein, as this is the non- ported cannula with
the valve in place.
Figure 38
Figure 37
Figure 39
26
12, 13 & 14. Attach bung or extension
- Apply extension set or bung without letting go of the cannula and
then secure the cannula in place:
13 &14. . Secure cannula
For the dressing in Figure 40, apply as follows:
- Remove the panel with adhesive strips on (figure 40), this can be
prepared at the start when you are opening your equipment.
- Apply the adhesive strips to secure the cannula in place, with 1
over each wing. Do not let go of the cannula until at least one side
is taped down (figure 41) and ensure that you do not touch or
cover the insertion point.
- Apply the dressing ensuring the clear half is over the cannula
insertion point leaving it visible and completely covered (figure 42).
- Remove the outer part of the top of the dressing (figure 43).
Figure 40
Figure 41
Figure 42
Figure 43
27
Flush Technique
To flush the cannula use an intermittent small bolus technique: by pulsating the delivery of the
fluid a turbulent flow is created, removing debris from cannula
lumen. In this image (figure 44) the flush is attached to an
extension set. Please note that the cannula can be flushed
before the dressing is applied as long as the cannula is secure.
- 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, following Trust
guidelines.
Cannulas should be flushed every time before and after use, there could be severe
consequences if drugs are left in the cannula or extension set.(31)
16. Document date on dressing and document the procedure
- Complete the necessary documentation. Write the date on the dressing (Figure 45 & 46),
placing it away from the insertion point and then document the cannula insertion within the
patient’s medical notes.
- The dressing should then be assessed every shift and changed if dirty.
Figure 45
Figure 44
Figure 46
28
Connecting Giving Sets
In addition to protecting the key parts during insertion, it is also vital during
subsequent use of the cannula and prior to administration of any fluid or
drug, to clean the bung of the extension set with alcohol or CHG in alcohol
(unless against manufacturer’s instructions) (28) for 30 seconds, as detailed
in the Trust policy, and allowed to dry (figure 47).
Removing the dressing or cannula
The dressing must be carefully removed while avoiding unnecessary movement of the cannula.
By using the stretch and release method it will avoid the unnecessary movement of the cannula.
It also prevents damage to the skin. Gently lift the edge of the dressing and place the fingers of
the other hand on top of the dressing, which will support the skin. Gently stretch the dressing
straight out and parallel to the skin. This will release the adhesion of the dressing to the skin. As
the dressing is loosened stretch and relax the dressing while continually supporting the skin
adhered to the dressing. Following removal of the cannula a sterile gauze, semi- permeable
dressing must be applied to the site of cannula removal and left on for 24 hours(21, 28) . Some
trusts require the insertion site to be cleaned with ChloraPrep® or CHG 2% following removal.
The date of removal must be documented.
Differences in Clinical Practice
Whilst in clinical practice you will undoubtedly see different techniques and equipment used and
this will often be due to clinician preference, trust policies or the clinical context / environment. It
is important 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.
Cannulation equipment and policy does vary from Trust to Trust and it is your responsibility to
ensure that you are familiar with local policy and equipment before carrying out the procedure
on a patient.
Figure 47
29
Documentation
As with all procedures, it is essential to fully document the insertion of a cannula within a
patient’s medical record and in current practice it is commonplace to use pre-printed stickers to
document IVC insertion with examples of these stickers seen in figure 48. More recently there
has been a move toward electronic documentation.
Insertion documentation should include:
• Indication
• Use of personal protective equipment
• Skin preparation
• Insertion point
• Attempts at insertion
• Dressing type
• Lot number of cannula
• Flush (type/volume)
After insertion, the peripheral venous cannula should be monitored regularly thereafter (every 8
hours) for signs of complications, further documentation should accompany these reviews with
the cannula being removed if there is a problem identified or if it is no longer required.
Monitoring documentation should record:
• Number of days since insertion
• Phlebitis (VIP) score – for early recognition and triggered management of phlebitis
Visual Infusion Phlebitis Score (VIP)
Phlebitis (inflammation of a vein – as in figure 49) is a
recognised complication of peripheral venous
cannulation and can be identified by redness, pain, heat
and/or swelling and a palpable venous cord.
This can be transient and caused by the drugs or fluids
being administered through the cannula or by movement
of the cannula within the vein. Figure 49 should not be
seen in practice as the cannula should have been removed far earlier.
More worryingly, it can also be infective phlebitis which can progress to sepsis if not recognised
and treated early.
Figure 48
Figure 49
30
Various scoring systems have been develop to help practitioners recognise IVC-related phlebitis
at an early stage and the majority of NHS Trusts have adopted the VIP scoring system (figure
50) which was developed by Jackson20 and is recommended by NICE27
Some VIP scores have been adapted to suggest that cannulas should be removed if the patient
is scoring 1 on the scale.
Figure 50
31
Picture Credits
1. Figure 1 : Venous anatomy of arm. Standring, Susan, MBE, PhD, DSc, FKC, Hon FAS,
Hon FRCS, Gray's Anatomy, Chapter 48, 797-836.e1
2. Figure 2: Clinical Skills Teaching and Learning Centre, University of Liverpool
3. Figure 3: Clinical Skills Teaching and Learning Centre, University of Liverpool
4. Figure 4: Clinical Skills Teaching and Learning Centre, University of Liverpool
5. Figure 5: Structure of a vein By File:Vein.svg: Kelvinsongderivative work: Begoon - This
file was derived from: Vein.svg:, CC BY-SA 3.0, Vein Wikimedia
6. Figure 6: Clinical Skills Teaching and Learning Centre, University of Liverpool
7. Figure 7: Clinical Skills Teaching and Learning Centre, University of Liverpool
8. Figure 8: Clinical Skills Teaching and Learning Centre, University of Liverpool
9. Figure 9: Clinical Skills Teaching and Learning Centre, University of Liverpool
10. Figure 10: Clinical Skills Teaching and Learning Centre, University of Liverpool
11. Figure 11: Clinical Skills Teaching and Learning Centre, University of Liverpool
12. Figure 12: Clinical Skills Teaching and Learning Centre, University of Liverpool
13. Figure 13: Clinical Skills Teaching and Learning Centre, University of Liverpool
14. Figure 14: Clinical Skills Teaching and Learning Centre, University of Liverpool
15. Figure 15: Clinical Skills Teaching and Learning Centre, University of Liverpool
16. Figure 16: Clinical Skills Teaching and Learning Centre, University of Liverpool
17. Figure 17: Clinical Skills Teaching and Learning Centre, University of Liverpool
18. Figure 18: Clinical Skills Teaching and Learning Centre, University of Liverpool
19. Figure 19: Clinical Skills Teaching and Learning Centre, University of Liverpool
20. Figure 20: Clinical Skills Teaching and Learning Centre, University of Liverpool
21. Figure 21: Infiltration. © Clinical Skills Ltd: Clinical skills.net: care and maintenance of a
peripheral IV cannula [Accessed 14/08/20]
22. Figure 25: Extravasation. © Clinical Skills Ltd: Clinical skills.net: care and maintenance of a
peripheral IV cannula [Accessed 14/08/20]
23. Figure 23: Clinical Skills Teaching and Learning Centre, University of Liverpool
24. Figure 24: Clinical Skills Teaching and Learning Centre, University of Liverpool
25. Figure 25: Clinical Skills Teaching and Learning Centre, University of Liverpool
26. Figure 26: Clinical Skills Teaching and Learning Centre, University of Liverpool
27. Figure 27: Clinical Skills Teaching and Learning Centre, University of Liverpool
28. Figure 28: Clinical Skills Teaching and Learning Centre, University of Liverpool
29. Figure 29: Clinical Skills Teaching and Learning Centre, University of Liverpool
30. Figure 30: Clinical Skills Teaching and Learning Centre, University of Liverpool
31. Figure 31: Clinical Skills Teaching and Learning Centre, University of Liverpool
32. Figure 32: Clinical Skills Teaching and Learning Centre, University of Liverpool
33. Figure 33: Clinical Skills Teaching and Learning Centre, University of Liverpool
34. Figure 34: Clinical Skills Teaching and Learning Centre, University of Liverpool
35. Figure 35: Clinical Skills Teaching and Learning Centre, University of Liverpool
32
36. Figure 36: Clinical Skills Teaching and Learning Centre, University of Liverpool
37. Figure 37: Clinical Skills Teaching and Learning Centre, University of Liverpool
38. Figure 38: Clinical Skills Teaching and Learning Centre, University of Liverpool
39. Figure 39: Clinical Skills Teaching and Learning Centre, University of Liverpool
40. Figure 40: Clinical Skills Teaching and Learning Centre, University of Liverpool
41. Figure 41: Clinical Skills Teaching and Learning Centre, University of Liverpool
42. Figure 42: Clinical Skills Teaching and Learning Centre, University of Liverpool
43. Figure 43: Clinical Skills Teaching and Learning Centre, University of Liverpool
44. Figure 44: Clinical Skills Teaching and Learning Centre, University of Liverpool
45. Figure 45: Clinical Skills Teaching and Learning Centre, University of Liverpool
46. Figure 46: Clinical Skills Teaching and Learning Centre, University of Liverpool
47. Figure 47: Clinical Skills Teaching and Learning Centre, University of Liverpool
48. Figure 48: Clinical Skills Teaching and Learning Centre, University of Liverpool
49. Figure 49: Permission for use of image kindly given by: BMJ Publishing Group Ltd. BMJ
Case Reports, Oct 3, 2016, Copyright © 2016, Copyright © 2020 BMJ Publishing Group Ltd.
All rights reserved.
50. Figure 50: VIP score. © Clinical Skills Ltd: Clinical skills.net: care and maintenance of a
peripheral IV cannula [Accessed 14/08/20]
33
References and Further Reading
(1) ANTT (2018) ANTT Theory. Available at: ANTT [Accessed 14/08/2020]
(2) B. Braun (2017); B. Braun Peripheral Cannulation and Venepuncture, Training Programme
Workbook. B. Braun Medical Ltd
(3) Bailey IR, Thurlow VR. Is suboptimal phlebotomy technique impacting on potassium results
for primary care? Ann Clin Biochem 2008;45(3):266-269.
(4) Brooks, N. (2014) Venepuncture and Cannulation: A practical guide. Keswick: M&K.(5)
Cummings-Winfield, C & Mushani-Kanji, T, (2008). Restoring patency to central venous access
devises. Clinical Journal of Oncology Nursing, 12 (6), 925-934.
(6) De Verteuil, A. (2011) ‘Procedures for Venepuncture and Cannulation’, in Phillips, S.,
Collins, M., and Dougherty, L. (eds.) Venepuncture and Cannulation. Chichester: Wiley-
Blackwell.
(7) DH, (2010). Clean Safe Care. High Impact Intervention: Central Venous Catheter Care
Bundle and Peripheral IV Cannula Care Bundle. Department of Health, London.
(8) Dougherty L. Peripheral cannulation. Nursing standard 2008;22(52):49-58.
(9) Dougherty L, Lister S. The Royal Marsden manual of clinical nursing procedures. : John
Wiley & Sons; 2015.
(10) Dougherty L. Obtaining peripheral venous access. Intravenous Therapy in Nursing Practice
2008:225-270. In: Dougherty, L. and Lamb, J. (eds) Intravenous Therapy in Nursing Practice,
2nd edn. Blackwell, Oxford.
(11) Ernst, D.J. (2005) Applied Phlebotomy. Lippincott Williams and Wilkins, Philadelphia, PA.
(12) Finlay, T., (1997). Intravenous Therapy. Blackwell Science, Oxford.
(13) Garza, D. and Becan-McBride, K. (2010) Phlebotomy Handbook: Blood Specimen
Collection from Basic to Advanced, 8th edn. Pearson, Upper Saddle River, NJ.
(14) Goode, C.J. et al, (1991). A meta-analysis of effects of heparin flush and saline flush:
quality and cost implications. Nursing Research, 40 (6), 324-330.
(15) Goodwin, M.L & Carlson, I, (2010). The peripherally inserted central catheter: a
retrospective look at three years of insertions. Journal of Intravenous Nursing, 16 (2), 92-103.
(16) Hadaway, L, (2000). Peripheral IV therapy in adults, in Self Study Workbook. Hadaway
Associates, Georgia.
(17) Health and Safety Executive. Health and Safety (Sharp Instruments in Healthcare)
Regulations 2013. London: Crown Copyright, 2013.
34
(18) Higginson R. (2011). How to prevent, identity and treat phlebitis in patients with a venous
cannula. Phlebitis: treatment, care and prevention. Nursing Times, 107 (36), 18-24.
(19) INS (2011). Infusion Nursing Standards of Practice 2011. Journal of Infusion Nursing, 34
(1), Supplement.
(20) Jackson A.(1998) Infection Control:a battle in vein infusion phlebitis. Nursing Times, 94; 4,
68-71
(21) Josephson DL. Intravenous infusion therapy for nurses: Principles & practice. : Cengage
Learning; 2004.
(22) Loveday, H P., Wilson, J A., Pratt, R J., Golsorkhi, M., Tingle, A., Bak, A., Browne, J.,
Prieto, J., and Wilcox, M. (2014) ‘epic3: National Evidence-Based Guidelines for Preventing
Healthcare-Associated Infections in NHS Hospitals in England’, Journal of Hospital Infection,
86(S1), pp. S1–S70.
(23) Maki, D.G et al, (1991). Prospective randomised trial of povidone-iodine, alcohol and
chlorhexidine for prevention of infection associated with central venous and arterial catheters.
Lancet, 338 (8763), 339-343.
(24) McCallum, L. and Higgins, D. (2012) Practice education; Care of peripheral venous
cannula sites Nursing Times; 108: 34/35, 12-15; Nursing Times: care of peripheral venous
cannula [Accessed 14/08/2020]
(25) Meeder AM, van der Steen, Marijke S, Rozendaal A, van Zanten AR. Phlebitis as a
consequence of peripheral intravenous administration of cisatracurium besylate in critically ill
patients. Case Reports 2016;2016.
(26) NHS Clinical Evaluation Team (Aug 2018); Clinical Review Single Use Tourniquets NHS
supply chain clinical review [Accessed 28/03/2020]
(27) NICE; Clinical guideline [CG139]: (March 2012); Healthcare-associated infections:
prevention and control in primary and community care.
(28) NICE,; Clinical Guidance [CG139] ; Peripheral Access Devices; NICE guidance Vascular
Acccess Devices [Accessed 14/08/20]
(29) NICE; Nice interventional procedures guidance: Nice interventional procedures guidance
[Accessed 14/08/20]
(30) NICE; (March 2016) NICE summary of Cochrane review conclusions NICE Cochrane
systematic review [Accessed 28/03/2020]
(31) NPSA (2008) Reducing Risk Of Overdose With Midazolam Injection In Adults.
NPSA/2008/RRR011. National Patient Safety Agency, London.
(32) NPSA (2017) Confirming removal or flushing of lines and cannulae after procedures; NPSA
Safety alert re flushing cannulae [Accessed 14/08/20]
35
(33) Perucca, R, (2010). Peripheral venous access devices, in Infusion Nursing: An Evidence-
Based Approach, 3rd edn (eds M. Alexander, A. Corrigan, L. Gorski et al.) Saunders Elsevier,
St Louis, MO, PP.456-479.
(34) Phillips, L. (2005) Manual of IV therapeutics. 4th ed. FA Davis, Philadelphia.
(35) Pratt, R.J. et al (2007). National evidence-based guidelines for preventing healthcare-
associated infections in NHS hospitals in England. Journal of Hospital Infection, 65 (Suppl 1),
S1-64.
(36) Rice, B., Tomkins, S., & Ncube, F. (2015). Sharp truth: Health care workers remain at risk
of bloodborne infection. Occupational Medicine, 65(3), 210-214.
(37) RCN (2010). Standards for Infusion Therapy, chapter 3. 3rd edn. Royal College of Nursing,
London.
(38) Ryder, M. (2001). The role of biofilm in vascular catheter related infections. New
Developments in Vascular Disease, 2 (2), 15-25.
(39) Skarparis, K. and Ford, C. (2018) ‘Venepuncture in adults’, British Journal of Nursing,
27(22), pp. 1312 – 1315.
(40) Upton, J. et al. (1979) Major Intravenous Extravasation injuries. The American Journal of
Surgery, 137(4), 497-506. Science direct Vol 137, Issue 4 Pg 497-506 [Accessed 28/03/2020]
(50) WHO (2009); WHO guidelines on hand hygiene in Health Care; WHO Hand hygiene tools
[Accessed 28/03/2020]
(51) World Health Organization. (2010). WHO guidelines on drawing blood: Best practices in
phlebotomy World Health Organization.
36
Appendix 1: Clinical Skills Sharps Management If you sustain a sharps injury in clinical practice, please also adhere to Trust policy, if you
sustain an injury in CSTLC, such as in The Learning Zone please also adhere to the CSTLC
policy.
Remove
• Remove sharp
• Sharps with unknown contaminants may need to be retained for analysis
Squeeze it
• Squeeze the site to make it bleed
Wash it
• Wash the site thoroughly with soap under running water
• Do not scrub
Dry it
• Dry the site thoroughly
Dress it
• Apply a dressing to the site
Report it
• Report the injury to your supervisor and manager of the clinical area
• Dr Beddoes(ebeddoes@liv.ac.uk) must be emailed with all injuries sustained in clinical practice.
Document it
• Complete an incident form
• Attend Occupational Health or Accident and Emergency Department
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