Peripheral Venous Cannulation · 2020. 8. 19. · 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

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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

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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

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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

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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

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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.

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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.

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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

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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

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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

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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?

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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.

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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

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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

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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

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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

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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

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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

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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.

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• 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

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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.

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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

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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

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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

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- 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

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- 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, semipermeable

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



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
















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















https://commons.wikimedia.org/w/index.php?curid=65694762

https://www.clinicalskills.net/sites/default/files/atoms/files/CARE-AND-MAINTENANCE-OF-A-PERIPHERAL-IV-CANNULA_P1-P6.pdf




32














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




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.

http://www.antt.org/ANTT_Site/theory.html

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]

https://www.nursingtimes.net/care-of-peripheral-venous-cannula-sites/5048404.article

https://www.nursingtimes.net/care-of-peripheral-venous-cannula-sites/5048404.article

https://wwwmedia.supplychain.nhs.uk/media/Clinical-Review-for-Single-Use-Tourniquets-August-2018.pdf

https://wwwmedia.supplychain.nhs.uk/media/Clinical-Review-for-Single-Use-Tourniquets-August-2018.pdf

https://www.nice.org.uk/guidance/cg139/chapter/1-Guidance#vascular-access-devices

https://www.nice.org.uk/guidance/cg139/chapter/1-Guidance#vascular-access-devices

https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-interventional-procedures-guidance

https://www.nice.org.uk/savingsandproductivityandlocalpracticeresource?id=2601

https://www.nice.org.uk/savingsandproductivityandlocalpracticeresource?id=2601

https://improvement.nhs.uk/documents/1922/Patient_Safety_Alert_-_Confirming_removal_or_flushing_of_lines_and_cannulae_af_EVC1Yb2.pdf

https://improvement.nhs.uk/documents/1922/Patient_Safety_Alert_-_Confirming_removal_or_flushing_of_lines_and_cannulae_af_EVC1Yb2.pdf

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

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(50) WHO (2009); WHO guidelines on hand hygiene in Health Care; WHO Hand hygiene tools

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phlebotomy World Health Organization.

http://www.sciencedirect.com/science/article/pii/0002961079901211

https://www.who.int/infection-prevention/tools/hand-hygiene/en/

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([email protected]) must be emailed with all injuries sustained in clinical practice.

Document it

• Complete an incident form

• Attend Occupational Health or Accident and Emergency Department

Documents

Peripheral Venous Cannulation · 2020. 8. 19. · 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