Year 5 MBChB

Clinical Skills Session

Peripheral Venous Cannulation

Authors:

The Clinical Skills Lecturer Team (2020)

Reviewed & ratified by:

Year of review

Learning objectives

To understand reasons for undertaking cannulation

To understand hazards of cannulation including needle stick guidelines

To understand the principles of ANTT (Aseptic non touch technique) and management of a cannula

To be able to carry out cannulation safely and within Trust guidelines

Definition:

Peripheral venous cannulation is where a small flexible tube (cannula) containing a needle stylet is inserted into

a peripheral vein. This then provides intravenous access to allow administration of medicines intravenously etc.

(Dougherty 2008).

Vascular anatomy left anterior forearm;

Images of Shoulder girdle and arm; Standring, Susan, MBE, PhD, DSc, FKC, Hon FAS, Hon FRCS, Gray's Anatomy, Chapter 48, 797-836.e1

By File:Vein.svg: Kelvinsongderivative work: Begoon - This file was derived from: Vein.svg:, CC BY-SA 3.0,

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

The tunica externa contains nerves and is thicker in veins than arteries, the tunica media is predominantly

smooth muscle, but is partially regulated by the vasomotor nerves of the sympathetic nervous system.

Contraction of the smooth muscles results in vasoconstriction and conversely relaxation results in vasodilation.

The tunica intima has valves formed from the folds of the intima and there are many in the peripheries to

promote the upwards flow of blood. (Marieb & Hoehn 2007).

Legal Implications

NHS trust have two forms of liability:

o Direct liability – the Trust itself is at fault

o Vicarious or indirect liability – the Trust is responsible for the faults of others.

When you perform peripheral cannulation you will be measured by the same standard as other health

professionals that have this skill, you have a duty of care and cases of negligence can be brought if you fall

below the standard of care. Ensure that you are supervised at all times and that you are aware of the Trust

policies when you are in clinical practice.

Indications for peripheral venous cannulation:

The common indication for peripheral cannulation is predominantly therapeutic.

For example;

o Administration of medications, fluids, nutritional products, blood products or anaesthesia. This could be

routine or urgent.

Further training is required before you do;

o Blood transfusion (currently in 5th year)

Considerations prior to cannulation;

Consider your safety and patient safety at all times.

o Skin Microorganisms such as Staphylococcus epidermis can be found on a patient’s skin as part of their

natural skin flora, these microorganisms can become pathogenic if they enter the blood stream. You

therefore have the responsibility to ensure the patient’s skin is cleaned and not recontaminated prior to

insertion of the cannula. (Loveday et al 2014)

o Tunica Intima, can be damaged if the cannula is too large for the vein, so choose an appropriate

cannula

o Tunica Media, if a patient is anxious, they may have a sympathetic reaction and the veins could spasm

or contract, making cannulation difficult, (Josephson 2004). Try to reassure your patient and stop if it

isn’t working.

o Damage to valves in the vein, avoid bifurcations of the veins and palpate the vein as you can normally

feel the valves, and try to avoid, these could be damaged permanently.

o Needlestick, ensure needle safe devices are used and see below on needle stick injuries.

o Phobia, check for patient phobias and support patient to lie down if appropriate.

o Infection, this is a big problem for patients ensure ANTT followed.

Needle stick injury

Care should be taken at all times to prevent needle stick injuries. If you come across unsafe practice, you

should inform your supervisor.

What happens if you sustain a needle stick?

There will be a policy in the Trust that you are working in and the School of Medicine has a Health and Safety

code of practice available on the School’s Intranet.

However there are some vital first steps:

o Squeeze it, make it bleed

o Wash it under running water

o Dry it

o Apply a dressing

Then report it and document it thoroughly.

This needs to be reported on the ward / area that you are working, an incident report will be filed and you

may be sent to Occupational Health or Accident and Emergency for further tests. You must report it to the

Nurse in Charge and / or your supervisor.

You will then need to complete an incident report form from the University’s School of Medicine;

Contact Departmental Safety Coordinator: Dr Emma Beddoes, email: ebeddoes@liv.ac.uk

If you need any further support please contact the Wellbeing team at the school.

Sharps

Sharps disposal goes into a sharps box, there are various coloured lids. The lids dictate what can go into the

bin:

o Orange - for sharps with no medication contamination

o Yellow - for sharps including medication contamination

o Purple - for sharps and cytotoxic drugs, eg; chemotherapy

The sharps bins are for:

o Needles and syringes (do not disconnect - dispose as one)

o Suture needles

o Scalpel blades

o Glass vials if no option otherwise

o Cannulas

o some trusts request that ChloraPrep ® and removed cannulas always go into sharps- follow your

Trust’s policy.

In order to reduce sharps injury, be aware of HSE regulations (2013) and:

o NEVER attempt to re-sheath a needle

o Always ensure that lid is fitted correctly and the sharps bin is signed, stating the date it was put

together

o Activate needle safe devices prior to disposal, and never try to adapt equipment.

o Do not overfill the boxes past the fill line, as this is a safety hazard. Image below is from the Learning

Zone with artificial blood…..

o Close the bin lid firmly when full, and sign the label on the front to

confirm you have locked it.

o Irrespective how full the box is, change it every 3 months

o DO NOT DISPOSE OF SHARPS in clinical waste bags!

Incorrect disposal of sharps may cause injury or death

Rice et al (2015) found that sharps injuries increased by 67% over a 10 year period prior to the latest

regulations.

Patient Safety Considerations

Cannulation is an invasive and sometimes uncomfortable routine procedure, occasionally a patient may have

developed a needle phobia due to previous experiences, and you should discuss this when gaining consent,

assist the patient into the most comfortable position. If the patient does not give informed consent then you

should not be practicing venepuncture, always consult your supervisor.

Many clinical practices have different equipment, depending on training and organisational decisions,

therefore you need to know how to use the cannulation system that your clinical placement uses. If you don’t

know how to use it - DON’T USE IT.

Complications

Some other complications are listed below;

o Infection, if ANTT is not applied or if the patient has an underlying infection

o Phlebitis, this is acute inflammation of the tunica intima and can potentially lead to septicaemia

o Allergy, check that the patient is not allergic to the skin cleanser (normally Chlorhexidine Gluconate or

CHG) and reactions to tape or dressings are common

o Mental health – phobia, consider administering topical anaesthetic prior to sampling.

o Medical device failure, this would need reporting, please do not alter any equipment prior to use as

this would affect the way it is licensed to be used.

o Skin damage (often from tourniquet if skin is fragile)

o Thrombus

o Bruising, increased risk if patient is on anticoagulants or the needle goes through the vein.

o Pain, consider topical anaesthetic

o Chemical Peripheral vein irritation, hypertonic solutions (eg: 10% Dextrose) can often irritate

peripheral veins, you should know the osmolarity of anything being infused into the vein.

o Mechanical Peripheral vein irritation, avoid siting a cannula over a joint and again choose an

appropriate sized cannula for the vein.

o Infection, if ANTT is not adhered to.

o Emboli, if a large volume of air enters the patient’s blood stream normally through IV infusion sets.

o Infiltration or extravasation, these will be discussed later in this study guide.

o Venepuncture hazards,

o Accidental arterial puncture, apply pressure and document.

o Damage to a nerve ligament or tendon, remove immediately if signs of pain, loss of sensation

etc and document incident.

o Haematoma, apply pressure on the haematoma site, this is worse if the patient is on anti-

coagulants.

o Chemical Peripheral vein irritation, hypertonic solutions (eg: 10% Dextrose) can often irritate

peripheral veins, you should know the osmolarity of anything being infused into the vein.

o Mechanical Peripheral vein irritation, avoid siting a cannula over a joint and again choose an

appropriate sized cannula for the vein.

o Infection, if ANTT is not adhered to.

Ensure any complications are documented clearly in the patient’s notes and that complications are reported to

your supervisor immediately.

ANTT

Cannulation should utilise an Aseptic non touch technique (ANTT) approach, ANTT minimises the transmission

of virulent pathogenic organisms in sterile or aseptic procedures. Understanding and adhering to the concept of

ANTT is paramount in patient and staff safety. The aim of ANTT is asepsis, which is done by “protecting Key-

Parts and Key –Sites from microorganisms” carried by the person doing the procedure. (ANTT Clinical Practice

Framework, Principle 2, 2018)

The increase of antibiotic resistant bacteria requires clinicians to prevent the spread of infection and practicing

ANTT with good hand hygiene can contribute to this.

ANTT is practiced when:

o Carrying out invasive clinical procedures, such as taking blood,

o Maintaining indwelling medical devices, such as a peripheral venous cannula,

o When handling equipment and carrying out procedures involving key parts and key sites,

(Loveday et al, 2014)

“Key parts are the critical parts of procedure equipment, that if contaminated are most likely to cause

infection.” (ANTT Clinical Practice Framework, Safeguard 2, 2018)

Some key parts:

o Syringe tip, needles, tip of a cannula, patient’s skin, catheter tip, wounds, rubber seals on IV lines, drug

bottles, etc.

(ANTT, 2018)

Contamination of key parts

Below are some images of contaminated key parts:

Differences in Clinical Practice

Differences may be due to clinician preference, trust policies and clinical context (e.g. patient on ward, separate

from equipment area).

You need to understand the concepts of the technique so that once on placement, you can be flexible with the

procedure in any given circumstance, and comply with local trust policy.

Putting an unsheathed needle in a tray or touching the part that goes into the patient

Cannulation equipment and policy varies from Trust to Trust. Ensure that you are familiar with local policy and

equipment before carrying out the procedure on a patient.

Phlebitis and Infection

Phlebitis is the inflammation of a vein, or more specifically its inner lining, the tunica intima (RCN, 2010)

Clinical Signs of Phlebitis:

o Redness

o Pain

o Heat and or swelling

o Palpable Venous Cord

Types and causes of phlebitis

o Chemical phlebitis - the drugs or fluids being administered can cause irritation to vein.

o Mechanical phlebitis - too big a cannula in too small a vein, movement of the device once sited, eg; over

a joint.

o Infective phlebitis - poor aseptic technique on insertion, contamination of the infusion line.

Visual Infusion Phlebitis Score (VIP).

Many NHS Trusts have now adopted the VIP scoring system developed by Jackson (1998), as recommended by

NICE and epic3 Guidance (NICE 2012 and Loveday et al 2014). Various charts are used for scoring and most are

based on Jacksons’s recommendations as published in the Nursing Times 2011(Higginson).

Permission for use of image kindly given by:

BMJ Publishing Group Ltd. BMJ Case Reports

Phlebitis as a consequence of peripheral intravenous

administration of cisatracurium besylate in critically ill patients

Annelijn M Meeder,Marijke S van der Steen,Annemieke

Rozendaal,Arthur R H van Zanten

Oct 3, 2016

Copyright © 2016, Copyright © 2020 BMJ Publishing Group Ltd.

All rights reserved.

Procedure/ examination

Patient Safety

Featured in Higginson (2011)

On first meeting a patient introduce yourself, confirm that you have the correct patient with the name and

date of birth, if available please check this with the name band and written documentation such as the NHS/

hospital number/ first line of address.

Check the patient’s allergy status, especially conscious of Chlorhexidine Gluconate (CHG 2%). Ensure the

procedure is explained to the patient in terms that they understand, gain informed consent and ensure that you

are supervised, with a chaperone available as appropriate. Allow the patient to ask any questions that they may

have and discuss any past problems (e.g. fainting/ bleeding/ anti-coagulant medication history). Assist patient

into a comfortable position, as appropriate to the procedure. If the patient has a history of fainting, they may be

positioned better on a trolley, ask the relatives if they have any problems with needles. Also consider the

patient’s own personal preference (e.g. choice of arm) or issues preventing the use of 1 arm, eg; lymphoedema.

Your explanation of the procedure to the patient should include why they are being cannulated. Don personal

protective equipment as you are coming into contact with bodily fluids (Loveday 2014) and use sharps in

accordance with HSE (2013).

Be aware of hand hygiene and preventing the spread of disease, WHO (2009) https://www.who.int/infection-

prevention/tools/hand-hygiene/en/

As with any invasive procedure, please ensure all steps are checked with your supervisor.

Site Selection

Common insertion sites

Cephalic vein – readily accommodates a large-gauge cannula and, by virtue of its position on the forearm

provides a natural splint (Weinstein and Plumer 2007), does not restrict patients movements as avoids area of

joint flexion

Basilic – awkward position (see above) and has a tendency to have many valves (Dougherty 2008, Hadaway

2000), patient may easily knock cannula on furniture

Dorsal venous network - allows for cannulation proximally along the veins when resiting the device

(Weinstein and Plumer 2007), reduces patient mobility and is more painful on insertion

Median cubital – Close to brachial artery and radial nerve, avoid unless experienced. Greatly reduces patient

mobility.

The superficial veins of the lower limbs -may also be cannulated, but these tend to be avoided as they are

associated with a higher risk of infection and embolism (RCN, 2010).

Several factors must be considered when selecting a site for peripheral venous cannulation.

The risk of infection or phlebitis can be reduced if the following is considered:

o The general condition of the veins

o Avoiding points of flexion on insertion

o The type of drug to be administered (determined by the osmolality or pH)

o Speed of drug delivery

o Duration of intended therapy

o The size of the cannula versus the size of the vein.

Sites to avoid if possible

o Thrombosed, fibrosed or sclerosed veins

o Inflamed, bruised or painful areas

o Areas of thin or fragile skin

o Near bony prominences and joints

o Near sites of infection or oedema including a history of lymphadenopathy

o Renal fistula

o Areas near to a recent cannulation

o Dominant arm

o Moles or skin lesions

o Limbs with weakness following CVA

Difficulty accessing Vein

There are patients where you will struggle to find a vein, whilst you are practicing this skill, it is recommended

that you only attempt venepuncture when you feel happy that you can access the vein. You should be

supervised at all times and do not attempt venepuncture more than twice on a patient who has given informed

consent.

You may also come across ultrasound guided vascular access, this is often used in hospital to access vessels that

are difficult to find for a variety of reasons, and you should have the opportunity to see this used during your

clinical placements. Short video available to show pulsation of artery on the website.

Cannulation equipment

o Equipment may all be in a cannula sterile pack (including or excluding cannula, flush and cleaning

solution)

o Cannula (Appropriate size)

o Cleaning solution e.g. swabs or Chloraprep®

o Sterile gauze

o Cannula dressing

o Tourniquet

o Gloves (sterile/ non sterile dependent on Trust

policy)

o Apron

o Extension set

o Saline for flushing cannula (most are pre- filled)

o Optional dressing towel to put under arm or create a sterile field

o Procedure tray

o Sharps bin

o Pen for documentation

Example of a cannula pack

Some equipment that you may see

Tourniquets

Only one tourniquet is used the photo is purely to

compare fastenings

Using a Tourniquet

A tourniquet must not be left on for more than 60 seconds (NHS Clinical Evaluation Team 2018)

A tourniquet is used to assist in finding potential veins suitable for cannulation, it can be applied twice once to

find a suitable vein, it must then be released whilst the skin is cleaned, and reapplied prior to the procedure.

The tourniquet used should be capable of being released with one hand. Most trusts use disposable ‘single use’

tourniquets to reduce the spread of infection- these should be used.

The tourniquet is applied approximately 8cm above the chosen site. This will usually mean it is applied to the

upper arm. The tourniquet should not be so tight as to cause pain or impede arterial blood flow (check pulse is

present if unsure). Please be aware if a patient has delicate skin that could bruise or tear and exercise extreme

caution.

Occasionally patients have very large veins that are easy to palpate, you do not need to use the tourniquet to

identify veins in this instance, and you may not require it for cannulation.

Fist clenching as a means of emphasising location of veins is not recommended as this can cause pseudo

hyperkalaemia, especially in conjunction with tourniquet use. (Bailey and Thurlow, 2008; Garza, D. and Becan-

McBride, K, 2010)

If a tourniquet is left in situ for too long, it can also affect the clotting around the insertion site and increase the

risk of phlebitis.

If the veins are not prominent, then consider:

o Positioning the arm below heart level helps dilate the vein

o Light tapping or rubbing may be useful but NEVER slap the vein

o The use of a warm pack helps encourage vasodilation and venous filling (Brooks, 2014).

Commonest type of device currently used in North West Trusts

Safety Device activated

Non-ported Cannula

Cannula gauges, flow rate and applications

Practical procedure

Sequence of events, this can vary between Trust sites, please follow Trust policy:

o Understand the need for cannulation

o Do patient safety checks and gain informed consent

o Gather equipment, checking expiry dates

o Wash tray/ trolley

o Wash hands using Ayeliffe technique

o Prepare equipment, protecting all key parts, ie:

o Prepare Normal Saline flush

o Prime extension set, you may leave syringe attached so that key parts are protected

o Open dressing and all other equipment

Colour Size Flow Rate

Crystalloid

Common Applications

14G 350 ml/min

Used in theatres or emergency for rapid transfusion of blood or

viscous fluids

16G 215 ml/min

Used in theatres or emergency for rapid transfusion of blood or

viscous fluids

18G 104 ml/min

Transfusion of blood products, parenteral nutrition and large

volume infusions.

20G 62 ml/min Infusions 2 – 3 l per days and intermittent bolus injections.

22G 35 ml/min Poor access.

24G 24 ml/min Paediatric patients or very poor access.

o Don an apron (can be done any time prior to procedure)

o Use tourniquet to identify vein and release tourniquet.

o Clean skin with Trust recommended solution (usually Chlorhexidine Gluconate2% in 70% alcohol)

product needs 30 seconds of cleaning to activate, and allow at least 30 seconds for product to dry

(Loveday et al 2014). CONFIRM THAT THE PATIENT IS NOT ALLERGIC TO THE CLEANING SOLUTION

BEFORE USE!

o While skin is drying reapply tourniquet

o Wash hands using Ayeliffe technique

o Don gloves

o Insert cannula and release tourniquet

o Dispose of needle stylet immediately into a sharps bin

o Secure cannula and flush

o Apply dressing

o Document date on dressing and document the procedure.

Equipment;

Approximately 5ml (Trust dependent) of 0.9% Normal Saline Flush should be used to “flush” a cannula. Most

Trusts in the region have a pre- drawn flush available, normally Posi-Flush®. If you are at a trust that doesn’t,

you will have to draw up Normal Saline as you would when drawing up a drug for injection, maintaining ANTT.

– On insertion cannulas should be flushed immediately

– During intermittent therapy they should be flushed after each use

– 0.9% Sodium chloride is acceptable (Goode et al 1991)

Some of the pre-filled syringes are completely sterile, others are only sterile on the inside of the syringe like

the ones pictured above, so ensure that you know your device and know how to handle it, reducing any

contamination.

Prime extension set

Extension sets, can be single or multiple lumens they have a clamp that must be clamped off between each

use, the key parts must be protected at all times.

By protecting the key parts, this also means that prior to administration of fluid or drug the bung must be

cleaned with a wipe (follow Trust policy) for 30 seconds and allowed to dry.

Priming the extension set

You need to ensure that before you attach this to the patient the line of the extension set is primed to reduce

air emboli. You can leave the flush attached until the cannula is flushed and leave the cap on the extension set.

This procedure can be done wearing gloves or with clean hands and can also be done with the extension set

inside of its sterile pack (follow Trust policy) but always maintain key parts.

Flush Technique

The method adopted is called the “push/pause” technique:

by pulsating the delivery of the fluid a turbulent flow is created, removing debris from cannula lumen

(Cummings-Winfield & Mushani Kanji 2008, Goodwin & Carlson 2010, Philips 2005)

When flushing the cannula, warn the patient that they may feel a cold sensation in their arm, if they complain

of pain or you see bulging of the skin when administering the flush, stop immediately and remove cannula and

document incident. Secure the extension set after use follow Trust guidance.

Clean skin

Crack ChloraPrep ®

Clean skin for 30 seconds, using a cross hatch motion and leave to dry

Do not re palpate skin, unless wearing sterile gloves.

Insert cannula

After reapplying tourniquet, washing hands and donning gloves, anchor the vein below the insertion point.

Unsheath needle open the wings on the cannula.

Students should have no more than 2 attempts at cannulation, if unsuccessful seek advice.

Stabilise the vein by applying traction below the insertion site

(Dougherty 2008)

Angle cannula at ~30 degrees

Puncture skin and watch for flash back (blood) in the clear chamber

as the tip enters the vein, once flash back is visible, you can release

the tourniquet.

Reduce the Insertion angle of the cannula to prevent puncturing

the posterior wall of the vein (Perucca 2010) and introduce the

cannula a little more (flash back should be seen in the lumen of the

cannula).

Hold the needle introducer and advance the cannula off it and into

the vein, under no circumstances re-insert the introducer.

Apply pressure to the vein, distal to the tip of the cannula, if it is a

cannula that doesn’t have a valve in to prevent blood leakage. You

may consider having sterile gauze to mop up any leakage.

Safely remove the needle stylet or introducerimmediately into the

sharps bin.

Apply extension set without letting go of the cannula and either secure or flush. Apply the rest of the dressing.

The dressing.

NICE accredited epic3 guidelines (Loveday et al, 2014) recommend that staff should use a sterile, transparent,

semipermeable polyurethane dressing to cover the intravascular insertion site.

Dressings may differ from Trust to Trust but they should:

o Provide an effective barrier to bacteria

o Securely fix the cannula

o Be sterile

o Be waterproof

o Adhere well

o Be comfortable for the patient (Finlay 1997)

The dressing should be assessed every shift and changed if dirty using 2% chlorhexidine gluconate (CHG) in

70% isopropyl iodine (Loveday et al 2014).

Apply pressure for approximately 1 minute. Discourage the patient from bending their arm (Ernst 2000).

Applying the dressing

Remove the back with strips on, this can be done when

setting up the equipement, as long as you do not

contaminate the side strips.

Do not let go of the cannula until at least one side is taped down.

Ensure that you do not touch or cover the insertion point.

Apply dressing ensuring insertion point visible and

completely covered.

Remove the outer part.

Write the date on the dressing

Place the date on the hand away from the insertion

point.

When removing the dressing or cannula

The dressing MUST be removed using the stretch and release method.

-This avoids unnecessary movement of the indwelling cannula

-Prevents damage to the skin

Sterile gauze, semi- permeable dressing must be applied to the site of cannula removal and left on for 24

hours. Some trusts require the insertion site to be cleaned with ChloraPrep® or CHG 2% following removal

The date of removal must be documented

Documentation

Document the insertion of cannula. Examples of documentation is available on the next page, this varies from

Trust to Trust, and is now often electronic but the peripheral venous cannula should be monitored every 8

hours and removed if there is a problem or if it is not required.

Documentation often required:

o Phlebitis score

o Insertion point

o Attempts at insertion

o Skin Preparation

o Dressing used

o Lot number of cannula

o Amount of Flush used

o Use of personal protective equipment

Further Complications

Bleeding can occur especially if the cannula is removed accidentally, a haematoma can occur for many

reasons, but especially if the needle on insertion went through the vein.

Infiltration is where the cannula is poorly positioned or moves

into tissues (tissued) if the cannula for example went through

the vein. If fluid is infused the arm would become oedematous

and would be cold to the touch and can result in blisters,

remove the cannula immediately and report injury.

Extravasation of drugs that may cause

necrosis of the site and potential death. The

patient will feel pain and the skin will be

warm to the touch, Remove cannula and

report injury. Further reading listed below in

the references, Upton et al (1979)

Extravasation injury of balanced simulates the clinical condition of necrotizing fasciitis: A case report

Journal of Pediatric Surgery Case Reports. D'Acunto, Carmine; Neri, Iria; Purpura, Valeria; Orlandi, Catuscia; Melandri, Davide..

Published October 1, 2015. The extensive edema with large blisters on the dorsum of the right hand and wrist of the 2-month-old male

patient after extravasation of balanced electrolyte solution Copyright © 2019 Copyright © 2019 by Elsevier, Inc. All rights reserved.

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Meeder, A. M., van der Steen, Marijke S, Rozendaal, A., & van Zanten, A. R. (2016). Phlebitis as a

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