nuffield health cannulation training virtual e - learn 2021

Nuffield Health

Cannulation Training

Virtual E - Learn 2021

Session NotesVersion - January 2021

Copyright The Training & Development Consultancy Ltd.

THE TRAINING & DEVELOPMENTCONSULTANCY LTD.

NUFFIELD HEALTH VIRTUAL E-LEARN 2021CANNULATION PROGRAMME

SESSION NOTES

Learning Outcomes

T o describe the anatomy and physiology of veins and associated structures.

To recognise the infection prevention and control aspects.

To discuss the professional and legal aspects.

To describe peripheral venous access devices (cannulae).

To demonstrate the procedure of cannulation.

To recognise potential complications.

Copyright The Training & Development Consultancy Ltd. rev January 2021

Page 1


Tunica Adventitia

Tunica Media

Tunica Intima


SESSION NOTES

Anatomy and Physiology

The wall of a vein has three layers.

1. The tunica intima. The innermost layer made up of endothelium, which is in contact with venous blood. The lining is smooth with the exception of one - way valves which prevent backflow of blood and pooling of blood in vessels affected by gravity. Valves can sometimes be detected as small bulges in veins and can often be felt on palpation. It is preferable to choose a stretch of vein without valves to enable easy advancement of the cannula. Damage to this lining can result is platelet adherence and thrombus formation.

2. The tunica media. The middle layer in a vein wall, made up of elastic tissue, nerve and muscle fibres. There is less elastic tissue and fewer muscle fibres than seen in arterial walls, making veins more prone to collapse. The nerves in this layer are sensitive to temperature changes and chemical or mechanical irritation which can cause spasm of the vein.

3. The tunica adventitia. The outer layer of a vein wall, made up of collagen, nerves and connective tissue.

(cont.)


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Cephalic vein

Basilic vein

Median cubital vein

Brachial artery

Radial artery

Ulnar artery


SESSION NOTES


Patients taking steroids may have more delicate skin which is prone to damage and those taking anti - coagulants or have a coagulopathy may be more prone to bruising and haematoma.

With age, there is a reduction in subcutaneous fat and collagen, with the epidermis becoming thinner and less elastic. Consequently, the veins may be easier to visualise but can be more mobile (therefore can ‘roll’ more easily), be more fragile and thrombosed. The skin is more fragile making it more prone to tearing and bruising, which needs to be considered when applying counter - traction. The increased mobility of the veins coupled with a less elastic skin may require a greater degree of counter - traction and vein anchoring

Older veins have an increased peripheral resistance due to calcium deposits and a reduction in elastin. Therefore the lumen of the veins may be reduced possibly requiring a smaller gauge of cannula and it may be necessary to reduce the insertion angle.

Thinning of the subcutaneous fat layer increases the risk of hypothermia, and the cold can affect the tunica media (muscle) layer of the vein causing venous spasm.

Key Veins and Arteries of the Arm


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Radial nerve

Median nerve

Ulnar nerve

Cephalic veinBasilic vein

Cephalic vein


SESSION NOTES


Key Nerves of the Arm

Key Veins of the Hand


Page 4



SESSION NOTES


Commonly the metacarpal veins on the dorsum of the hand are used for cannulation. This area provides a natural splint. It is recommended to cannulate the distal ends of veins first and if necessary to move up the vein towards the antecubital fossa (ACF).

The veins of the antecubital fossa are:

The basilic vein – is often the more prominent vein but as it is not well supported by subcutaneous tissue can ‘roll’ more easily. This vein can run in close proximity to the median nerve and the brachial artery.

The cephalic vein – travels along the radial aspect of the forearm into the ACF where is crosses to become the median cubital vein. As it crosses the ACF it also crosses the brachial artery and it is in close proximity to the radial nerve.

The median cubital vein is another vein of choice in the ACF.

Veins in the feet are not recommended for cannulation particularly in diabetic Patients as there may be an increased risk of tissue necrosis. In adult Patients there is a risk of embolism and thrombophlebitis.

The main arteries that travel the arm are the brachial, ulnar and radial.

The main nerves that travel the arm are the median, ulnar and radial.


Page 5



SESSION NOTES

Choosing a Vein

A suitable vein should;- Be soft, bouncy (not thrombosed) and straight- Refill quickly after pressure has been applied and then released- Be well supported (can apply pressure on the vein without it rolling away)- Be palpable

(Not all veins will be visible and the practitioner may have to be guided by palpation)

Veins to be avoided;- If the surrounding area is affected by cellulitis, dermatitis, lymphoedema, bruising, fracture or a cerebrovascular accident- If the Patient has had a mastectomy on that side- If it is thrombosed- If there is an AV fistula or vascular graft- Veins that are over a flexion point- Veins on the dominant side (except for short procedures)

Palpation of a vein - key points;- Palpation should distinguish between veins and arteries / tendons, identify any local valves and assess the condition and location of veins- Two fingers should be used- Fingers on the non - dominant side may be more sensitive- Thumbs should not be used as they have a pulse and could lead to confusion in deciding whether a vessel is a vein or an artery- Ensure good lighting and a position that does not cast shadows across the proposed site(cont.)


Page 6



SESSION NOTES

Choosing a Vein

Where it is difficult to visualise and / or palpate a vein the following techniques can be used;- Gravity- Gentle tapping- Application of warmth- Application of a tourniquet (which should be removed after a vein has been identified)

In dehydrated Patients it may be easier to locate and access a vein after rehydration.

Note: when taking blood the tourniquet should be tight enough to prevent venous blood leaving the arm and so distending the veins, but not so tight that arterial blood is prevented from entering the arm. The tourniquet should be disposable, placed approximately 6 to 7 cm above the proposed cannulation site and not be left in place for more than one or two minutes to avoid haemolysis or pooling of blood.


Page 7



SESSION NOTES

Infection Control

Cannulation breaches the intact barrier of the skin and involves direct access into the blood stream with a risk of blood - borne infection. Sources of infection can be extrinsic (contamination of sterile items) or intrinsic (poor technique, poor skin disinfection or ineffective operator hand washing).

There are some Patients who may be at a greater risk of infection;- Immunocompromised or immunosuppressed- Older Patients (the rate of epidermal cell replacement in the older patient can be reduced by more than 50%, resulting in a decreased rate of healing and a compromised skin barrier. The immune system also becomes less responsive with age)- Presence of chronic diseases such as diabetes, vascular insufficiency or cancer- Malnourishment- Presence of invasive devices- Length of stay in hospital

An aseptic non - touch technique (ANTT) must be used where key parts and non - key parts are identified. Key parts should only be in contact with sterile surfaces, Non - key parts can be touched by non - sterile surfaces.

Additional infection prevention and control aspects;- Non - sterile gloves- Plastic apron- Hand hygiene prior to palpation and again before putting on gloves for the procedure- Environment - clean, free from sources of contamination. If possible should not be undertaken during periods of domestic cleaning or high activity (mealtimes)- Sterile equipment should be checked for tamper / integrity prior to use- Patient skin disinfection - if the Patient’s skin is visibly dirty it should be first washed with soap and water. The skin should then be cleaned with 2% chlorhexidine / 70% alcohol using a ‘cross-hatch’ method for a minimum of 30 seconds and allowed to air dry for at least the same amount of time.(cont.)


Page 8



SESSION NOTES

Infection Control

Common faults in ANTT during venepuncture can include;- Poor hand hygiene- Ineffective skin disinfection- Using re - usable tourniquets- Blowing or fanning the skin to help evaporation after skin disinfection- Touching the insertion site after skin disinfection- Inadvertently touching a ‘key part’

Disposal of Sharps

The sharps container should be kept in close proximity to where the procedure is being undertaken and the operator should dispose of their own sharps as soon as possible after the procedure. Needles should not be re sheathed, bent or broken prior to disposal. Safety engineered devices should be used.

Professional and Legal Considerations

Before undertaking cannulation, practitioners must have received training and have subsequently been assessed a competent, and that competency is maintained.

Practitioners should ensure that the procedure is in the best interests of the Patient and practice within the boundaries of accountability and duty of care.

Informed consent must be gained before undertaking cannulation. This means providing the Patient with sufficient information to enable them to make a decision to have the procedure or not. In the older Patient, deficits in hearing or sight can affect how that Patient understands procedures and information may need to repeated or reinforced. Practitioners also need to ensure that the Patient has capacity to give informed consent.


Page 9



SESSION NOTES

Peripheral Vascular Access Devices (Cannulae)

Peripheral cannulae are short plastic devices that can be used for the administration of medications and / or fluids. The cannula itself is not rigid and therefore a stylet (located inside the cannula) is used to gain access through the skin and into the vein. The complete length of the stylet is not introduced into the vein, just enough to provide a conduit over which the cannula can be passed.

The size of cannula chosen should be the smallest one to meet the clinical requirements.

Guide to cannulae sizes.

Gauge 14 (brown) Rapid infusions (350 ml / hr)Gauge 16 (grey) Rapid infusions (215 ml / hr)Gauge 18 (green) Blood/larger fluid volumes (104 ml / hr) Gauge 20 (pink) Maintenance fluids - medications (62 ml / hr)Gauge 22 (blue) Medications / slow infusion rates (35 ml / hr)Gauge 24 (yellow) Children / older Patients with friable veins (24 ml / hr)

With the clinical requirements of the cannula in mind and when gathering equipment together prior to the procedure, ensure that the requirements can be carried out without breaking the closed system. This may require an extension set and needle free injection ports should be used. The top port of the cannula should not be used for the administration of medications. Once the cannula has been inserted, it should be flushed with 0.9% sodium chloride. Local policies should be followed in terms of the prescribing of 0.9% sodium chloride, remembering that it is a prescription only medicine (POM).


Page 10



SESSION NOTES

Steps in A Cannulation Procedure

Deep breathing, relaxation and distraction can be useful strategies for many anxious Patients. The environment is which the procedure is to be undertaken should afford the Patient privacy, dignity and comfort.

Gain informed consent (and document).Assemble equipment (prime any equipment as appropriate).Ensure the Patient is comfortable and place the arm on a pillow.Wash hands and identify and palpate a suitable vein.Wash hands and put on gloves.Clean the skin and allow to dry.Apply the tourniquet.Remove the cannula from its packaging, slightly loosen the white cap, inspect for integrity.Apply traction to the skin below the proposed cannulation site, do not touch the area that has been cleaned or have your fingers above the proposed cannulation site.Ensure the bevel of the needle is upwards and insert into the skin at an angle of approximately 300 (or less in older Patient).Once in the vein (look for flashback) reduce the angle slightly and advance the needle a further 1 - 2 mm.Release traction on the skin.Keeping the stylet steady, advance the cannula into the vein.Release the tourniquet.Apply pressure to the vein distal to the cannula tip (being careful not to contaminate the puncture site) and remove the needle (the safety device should be activated during this process) and dispose in the sharps container.Attach chosen (primed) equipment and flush the cannula with 0.9% sodium chloride (pulsatile method ending in a positive pressure).Secure the cannula with a high vapour transmission rate dressing (date and time if dressing allows).Ensure the Patient feels well and that the cannula is comfortable.Dispose of equipment.Document the procedure (time, date, vein, size of cannula, number of attempts, any complications and the name of the practitioner).Commence a Visual Infusion Phlebitis (VIP) score.


Page 11



SESSION NOTES

Potential Complications

Pain - by hitting an artery. Remove the tourniquet, then the needle, elevate the arm and apply pressure for at least 5 minutes or until bleeding has ceased. Apply a dressing and do not re - attempt or take a blood pressure on the same arm. Request a medical review.

Pain - by hitting a nerve. As for hitting an artery.

Pain can also be caused by poor technique, large bore devices, insufficient counter traction or skin puncture before the alcohol has evaporated.

Haematoma and bruising can be caused by too steep an angle when entering the vein or over - advancement once in the vein. Other causes may be the use of a large bore device, not releasing the tourniquet early enough or fragile veins.

Vasovagal attack (faint). Discontinue the procedure and lie the Patient down. If the Patient has a history of fainting during cannulation it is advisable to perform the procedure with the Patient lying down


Page 12


IV site appears healthy 0 - No signs of phlebitis- Observe cannula

One of the following is present : pain near IV site, erythema, swelling

1 - Possible early signs of phlebitis- Observe cannula

Two of the following are present : pain near IV site, erythema, swelling

2 - Early signs of phlebitis- Re-site cannula

All of the following are present : pain along path of cannula, erythema, induration

3 - Medium stage of phlebitis- Re-site cannula- Consider treatment

All of the following are present and extensive : pain along path of cannula, erythema, induration, palpable venous cord

4 - Advanced stage of phlebitis or start of thrombophlebitis. - Re-site cannula- Consider treatment

All of the following are present and extensive : pain along path of cannula, erythema, induration, palpable venous cord, pyrexia

5 - Advanced stage of thrombophlebitis.- Initiate treatment- Re-site cannula


SESSION NOTES

On Going Cannula Management

A VIP score should be documented at least once per shift (or at least before the cannula is removed after a procedure). Phlebitis can be due to infection, due to mechanical forces (large bore cannula, inadequate securement of the cannula or using the top port of the cannula to administer medications) or due to chemical irritants (hypertonic solutions).

Example of a Visual Infusion Phlebitis (VIP) score

The Patient should be provided with information regarding hand washing (if the cannula is in the back of the hand) and movement.

The high vapour transmission rate dressing should be changed if the site requires cleaning, if it is not providing a water - proof barrier or if it is not keeping the cannula stable. If the site requires cleaning, 2% chlorhexidine / 70% alcohol should be used and the site allowed to air dry prior to a new dressing being applied.

(cont.)


Page 13



SESSION NOTES

On Going Cannula Management

If an intravenous infusion is not in progress or the Patient is not receiving intravenous bolus medications on a regular basis, the cannula should be flushed. The flush solution should be 0.9% sodium chloride and the method should be pulsatile finishing on a positive pressure. The frequency of flushing should reflect local policy.

The most recent evidence recommends that a peripheral cannula can stay in situ until removal is indicated as a result of a problem or complication. Many hospitals policies may suggest removal at either 72 or 96 hours. Removal is an aseptic non - touch technique with a sterile dressing being placed on the puncture site after removal.

Tips for Gaining Competency

Arrange for your supervised cannulations as soon as possible after this training session.

Initially choose Patients who are not overly anxious about the procedure.

Initially choose Patients with ‘good’ veins and who are not elderly or on medications that could affect the veins, skin or coagulation.


Page 14


CPD Method - Course Attendance Participatory

Date(s) - .................... Number of hours - ....................

Description of the topic(s), key points of the learning activity, how it links to my practice, what I have learnt and how I will apply it to my practice. (Retain certificate of attendance, session notes with learning outcomes as evidence.) -

To which part(s) of the NMC code the CPD related. (Prioritise people, Practise effectively, Preserve safety, Promote professionalism and trust.) -


CPD LOG AND RECORD OF TRAINING ATTENDANCE


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nuffield health cannulation training virtual e - learn 2021

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