CANNULATION CANNULATION & &

VENESECTIONVENESECTION

LEARNING OUTCOMES OF LEARNING OUTCOMES OF THE WORKSHOPTHE WORKSHOP

• To be able to assess the patientTo be able to assess the patient

• To be able to take a blood sample using To be able to take a blood sample using a vacutainer systema vacutainer system

• To be able to site / change a cannulaTo be able to site / change a cannula

• To be able to name the complications of To be able to name the complications of cannulation and venesectioncannulation and venesection

Patient Assessment Patient Assessment

& & Vein SelectionVein Selection

THE ASSESSMENTTHE ASSESSMENTCONSIDER THE FOLLOWING POINTS:CONSIDER THE FOLLOWING POINTS:

• Age / size / history / condition / Age / size / history / condition / dependency of the patientdependency of the patient

• History of previous cannulation / History of previous cannulation / venesectionvenesection

• Type / length of treatment requiredType / length of treatment required

• Number of tests orderedNumber of tests ordered

• What medication is the patient on?What medication is the patient on?

• Fluid statusFluid status

• History of blood disordersHistory of blood disorders

Conditions that affect the Conditions that affect the position of the device: -position of the device: -• AmputationAmputation

• StrokeStroke

• Mastectomy or other Breast / Lymph Mastectomy or other Breast / Lymph SurgerySurgery

• Renal Fistula Renal Fistula

• Lymphoedema or CellulitsisLymphoedema or Cellulitsis

• Diabetes / Vascular Disease / ArthritisDiabetes / Vascular Disease / Arthritis

• Trauma / Fractures / BurnsTrauma / Fractures / Burns

• Social HistorySocial History

Questions to ask the Questions to ask the patientpatient• OBTAIN CONSENTOBTAIN CONSENT

• Have you had a cannula / blood test Have you had a cannula / blood test before?before?

• Were there any complications / adverse Were there any complications / adverse reactions?reactions?

• Do you have any allergies?Do you have any allergies?

• Consider needle phobiaConsider needle phobia

• Would you like a local topical anaesthetic Would you like a local topical anaesthetic before I insert the cannula or take blood? before I insert the cannula or take blood?

• Which is your dominant arm?Which is your dominant arm?

Attributes of an ‘ideal’ Attributes of an ‘ideal’ vein are: -vein are: -

• Be engorged, bouncy & softBe engorged, bouncy & soft

• Refill after it has been depressedRefill after it has been depressed

• Be visible Be visible

• Feel roundFeel round

• Be well supported by surrounding Be well supported by surrounding structuresstructures

• Be straight & ‘free of valves’Be straight & ‘free of valves’

Veins to be avoided are: Veins to be avoided are: --• Thrombosed, fibrosed or sclerosedThrombosed, fibrosed or sclerosed• Inflamed or bruised or painfulInflamed or bruised or painful• Thin or fragileThin or fragile• MobileMobile• Near bony prominences and jointsNear bony prominences and joints• Near sites of infection or oedemaNear sites of infection or oedema• AVOID THE VALVESAVOID THE VALVES• For For venesectionvenesection avoidavoid the arm with the arm with

an an IV line runningIV line running

Methods for improving Methods for improving venous access:venous access:

• Apply a disposable tourniquetApply a disposable tourniquet

• Lower the level of the arm below the heartLower the level of the arm below the heart

• Ask the patient to open and close their fistAsk the patient to open and close their fist

• Light tapping / rubbing of the veinsLight tapping / rubbing of the veins

• Warm compresses over the selected veinWarm compresses over the selected vein

• Warm waterWarm water

• Relax the patient / consider the environmentRelax the patient / consider the environment

WHICH VEIN?

Antecubital FossaAntecubital Fossa

Brachial Artery

Ulnar Artery

Radial Artery

Basillic

Cephalic

Median Cubital Vein

Veins Arteries Nerves

Radial

1st Intercostal

Ulnar

Median

BASILLIC

VEIN

DORSAL VENOUS NETWORK

CEPHALICVEIN

DORSAL METACARPAL VEINS

DIGITAL

DORSAL

VEIN

VEINS TO BE USED ARE:VEINS TO BE USED ARE:

• METACARPAL VEINSMETACARPAL VEINS

• CEPHALIC VEINCEPHALIC VEIN

• BASILIC VEINBASILIC VEIN

• MEDIAN CUBITAL VEINMEDIAN CUBITAL VEIN

GROUP EXERCISEGROUP EXERCISE

In pairs, use a tourniquet to identify In pairs, use a tourniquet to identify each others:each others:

• VeinsVeins

• ArteriesArteries

• ValvesValves

• LigamentsLigaments

CANNULA CANNULA SELECTIONSELECTION

Selecting the right Selecting the right cannulacannulaTwo key points to consider:Two key points to consider:

• What is the cannula going to used for?What is the cannula going to used for?

• The condition, location and size of the The condition, location and size of the vein selected?vein selected?

You should try to select the smallest You should try to select the smallest gauge possible that will accommodate gauge possible that will accommodate the intravenous therapy that is the intravenous therapy that is prescribed.prescribed.

ColourColour SizeSize FlowFlow

Ml/minMl/minUsesUses

BrownBrown 1414 275275 Rapid transfusions of whole Rapid transfusions of whole blood. Emergency situations.blood. Emergency situations.

GreyGrey 1616 173173 Rapid transfusions of whole Rapid transfusions of whole blood. Emergency situations / blood. Emergency situations / ObstetricsObstetrics

GreenGreen 1818 100100 Blood transfusionsBlood transfusions

PinkPink 2020 6060 IV infusions. Bolus’IV infusions. Bolus’

BlueBlue 2222 2525 Bolus’. Maintenance infusionsBolus’. Maintenance infusions

YellowYellow 2424 1313 Bolus medications. Short term Bolus medications. Short term infusions. Neonatesinfusions. Neonates

PurplePurple 2626 NeonatesNeonates

VENESECTIONVENESECTION

DEVICE SELECTIONDEVICE SELECTION

VACUTAINERVACUTAINER

• Quicker collection than other methodsQuicker collection than other methods

• Closed systemClosed system

• Exact amount of blood obtainedExact amount of blood obtained

• Reduces the risk of haemolysis of the Reduces the risk of haemolysis of the samplesample

• Reduces the risk of needlestick injuryReduces the risk of needlestick injury

BOTTLES & BLOOD BOTTLES & BLOOD FORMSFORMS• E-QUEST SYSTEM E-QUEST SYSTEM for blood requests & for blood requests &

results within SUHTresults within SUHT

• ALWAYS ALWAYS ensure that the ensure that the GROUP &GROUP & SAVESAVE or or CROSSMATCHCROSSMATCH request has request has been correctly completed & signed for been correctly completed & signed for by the requesting by the requesting MEDICAL MEDICAL PRACTIONERPRACTIONER

Serum

AB Levels

Coagulation INR / APTR

Lithium Heparin, PST, U&E’s, Bone & Liver

E.D.T.A.

FBC & ESR

Cross Match Group & Save

Glucose

Trace Elements

ORDER OF DRAWORDER OF DRAW

• No AdditivesNo Additives ( ( GreenGreen, , Red, Red, Dark BlueDark Blue))

• Coagulation ScreenCoagulation Screen ( (Light BlueLight Blue))

• Other AdditivesOther Additives ( (GoldGold, , GreyGrey, , LavenderLavender & & PinkPink))

EXCEPTION: EXCEPTION: Blood Cultures always FILL FIRSTBlood Cultures always FILL FIRST

Risks and Risks and Complications of Complications of

Cannulation & Cannulation & VenesectionVenesection

Risks - During InsertionRisks - During Insertion

• InfectionInfection

• HaemorrhageHaemorrhage

• HaematomaHaematoma

• Vaso-vagal episodeVaso-vagal episode

• Needle phobiasNeedle phobias

• AllergiesAllergies

• TransfixationTransfixation

• PainPain

• Nerve damageNerve damage

• Arterial punctureArterial puncture

• Needlestick injuryNeedlestick injury

TransfixationTransfixation

SkinSkin

Vein wallVein wall

Vein wallVein wall

Haematoma/BruisingHaematoma/Bruising

• TransfixationTransfixation

• Tourniquet too tight / Tourniquet too tight / too long / use of too long / use of RUBBER GLOVE!RUBBER GLOVE!

• Arterial punctureArterial puncture

• Repeated insertion Repeated insertion sitessites

Future Complications of Future Complications of CannulationCannulation• Phlebitis — septic / mechanical / chemical Phlebitis — septic / mechanical / chemical

• InfiltrationInfiltration

• ExtravasationExtravasation

• Thrombosis / Embolism Thrombosis / Embolism

• Speed shock / Fluid overloadSpeed shock / Fluid overload

PhlebitisPhlebitis

•TYPES OF:TYPES OF:

InfiltrationInfiltration

• ““The inadvertent The inadvertent administration of administration of non-non-vesicantvesicant solution/medication solution/medication into surrounding into surrounding tissues."tissues."

(Royal Marsden (Royal Marsden Manual, 2004)Manual, 2004)

• The cannula may still The cannula may still appear to be patent, appear to be patent, so early recognition is so early recognition is vital to avoid tissue vital to avoid tissue damage.damage.

ExtravasationExtravasation

• ““the inadvertent the inadvertent administration of administration of a a vesicant vesicant substancesubstance into into the tissues the tissues surrounding a surrounding a vein.”vein.”

(Royal Marsden (Royal Marsden Manual, Manual, 2004)2004)

Site preparationSite preparation• As cannulation / venesection is As cannulation / venesection is performed using an performed using an

aseptic non-touch techniqueaseptic non-touch technique it is imperative it is imperative that the vein is cleaned that the vein is cleaned PRIORPRIOR TO THETO THE PROCEDURE, wearing clean non-latex glovesPROCEDURE, wearing clean non-latex gloves

• CleanClean the the veinvein for for 30 seconds30 seconds with 2% with 2% chlorhexidine in 70% alcohol solution, cleaning the chlorhexidine in 70% alcohol solution, cleaning the vein in a criss-cross motion vein in a criss-cross motion

• Allow Allow veinvein to to air dryair dry

• DO NOTDO NOT re-touchre-touch or or palpatepalpate the the veinvein once once cleanedcleaned

• Consider hair clipping if appropriateConsider hair clipping if appropriate

DOCUMENTATIONDOCUMENTATION• SEE CANNULA CARE PLAN includes:SEE CANNULA CARE PLAN includes:• Time & date of blood sample / cannula Time & date of blood sample / cannula

insertioninsertion• Site of insertionSite of insertion• Gauge and batch number of the cannulaGauge and batch number of the cannula• What blood samples have been takenWhat blood samples have been taken• Number of attempts Number of attempts ((MAX 2MAX 2 per person) per person)• Any complications noted (e.g. haematoma)Any complications noted (e.g. haematoma)• Print & sign your namePrint & sign your name• Evidence verbal consent has been Evidence verbal consent has been

obtained obtained