SAFE

IV
CANNULATION
 CONTENTS
 Introduction

 Indications of IV cannulation

 Technique of IV cannulation

 Local anaesthesia

 Patient care

 Complications of IV cannulation

 Summary
 INTRODUCTION
 Asmany as one in three hospital patients have
an IV catheter in situ at any given time

 What is IV cannulation?
 Intravenous cannulation is a procedure
whereby a device, such as a cannula with a
flexible tube containing a needle, is inserted into
a small peripheral vein for the purpose of
administering fluids and/or medications or the
obtaining of blood samples.

• Nursing times. 2012;108(34-35):12-4.

• Insertion & Removal of a Peripheral Intravenous Cannula. Clinical SOP no. 20, version 1.0. Scottish diabetes research network.
 Indications
 These mainly include administration
of:
 IV fluids
 Drugs
 Blood and blood products
 Dyes and contrast media

• Nursing times. 2012;108(34-35):12-4.

 Factors to be considered when
selecting a site for IV cannulation
 The general condition of the veins
 Avoidance of points of flexion
 The type of drug to be administered
(determined by the osmolality or pH)
 Speed of drug delivery
 Duration of intended therapy
 The size of the cannula versus the size of the
vein

• Nursing times. 2012;108(34-35):12-4.

 Characteristics of different gauge
cannulae

Update in Anaesthesia. 2011;27(22):6.

 PRACTICAL TECHNIQUE FOR
CANNULA INSERTION
 Prepare your patient –
 explain what will happen and gain verbal
consent.
 Consider using local anaesthesia

 Select your site –

 the default position is usually the dorsal hand,
forearm or antecubital fossa.
 Apply a tourniquet proximally and encourage fist
clenching to engorge the veins.
 Look for a straight, wide, ‘spongy’ vein, with no
evidence of valves.
Update in Anaesthesia. 2011;27(22):6.
  Prepare the site with locally approved
antiseptic
 wipe for 30 seconds and leave to dry before
cannulation

 Warn the patient that you are starting the

procedure.
 Be honest - ‘a small scratch’ is not accurate, ‘a
sharp sting’ may be better.

Update in Anaesthesia. 2011;27(22):6.

  Insert cannula with dominant hand, using other
hand to slightly stretch the skin over the target
vein.
 With the bevel facing up, slide the cannula through
the skin into vein until first ‘flashback’ is seen (Fig. a).
 This indicates that the needle tip has penetrated
the vein.

Update in Anaesthesia. 2011;27(22):6.

  The cannula should then be angled about 5-10
degrees to the skin.
 Advance the cannula a few millimetres further to
ensure the catheter as well as needle tip enters
the vein (Figure b).

Update in Anaesthesia. 2011;27(22):6.

  Withdraw the needle until a second flashback is
seen in the catheter itself (Figure c). (indicates that
the catheter alone is in the vein)

Update in Anaesthesia. 2011;27(22):6.

  Keeping the needle still, advance the catheter to
the hilt.
 Apply digital pressure over the catheter tip and
remove the needle. Attach the giving set or bung.
 Flush your cannula with 0.9% saline to confirm
placement, watching for extravasation of fluid.

 Place a locally approved dressing over the

cannula.

Update in Anaesthesia. 2011;27(22):6.

 TROUBLESHOOTING
A) ‘I can’t find a vein’
 the most common problem in IV cannulation
 There are two ways to solve this problem.

1) Look for alternative sites

 Many longterm patients and IV drug abusers will
be able to tell you where their best veins are.
 Otherwise think about insertion in:
 The ventral forearm or wrist – this area is often
overlooked and usually has some wide flat veins.
 Feet –sometimes suitable veins are found over the
third, fourth and fifth metatarsals.

Update in Anaesthesia. 2011;27(22):6.

  Long saphenous vein at the ankle. This vein is found
just anterior to the medial malleolus.
 Neck – often the external jugular vein is prominent

 in patients with peripheral oedema, the oedema

can be compressed for a minute, driving the
interstitial fluid elsewhere, and veins will come into
view.

Update in Anaesthesia. 2011;27(22):6.

 2) Optimise the veins you can see
 Ifpatient has no veins suitable for cannulation → further
engorge the veins you can see using a combination of
the following techniques
 Fist clenching and unclenching with tourniquet applied →
increases venous return from intrinsic hand muscles
 Tapping veins → dilates the vein
 Warm the hand → encourages venodilation

Update in Anaesthesia. 2011;27(22):6.

 B) ‘The catheter won’t advance’
 Usually because the catheter is not in the vein
 If there’s first flashback but no second flashback
in the catheter → the catheter is usually in one of
two places:
 It has passed through the vein and out of the other
side
 pull the needle a centimetre or so out of the
catheter
 very slowly withdraw the whole cannula, as you
look for a second flashback of blood in catheter
 Once this is present, the catheter is in the vein and
it is possible to advance it

Update in Anaesthesia. 2011;27(22):6.

  It is superficial to the vein – i.e. only the needle tip
has entered the vein, not the catheter itself
 This happens if cannula is not advanced 1-2mm after
the first flashback as in step (b) in the technique
described earlier.
 If needle is already withdrawn → this is
unsalvageable as it is not good practice to reinsert
the needle into the cannula

Update in Anaesthesia. 2011;27(22):6.

 C) ‘A haematoma or bruise is forming at the site of
cannulation’
 It means needle has gone through vein to the
other side, with extravasation of blood into the
surrounding tissues.
 Withdraw the whole cannula and needle again,
looking for a second flashback.
 Once this is present, the catheter can be
advanced into the vein
 It’s particularly important to flush the cannula to
be sure it is truly in the vein

Update in Anaesthesia. 2011;27(22):6.

 D) ‘This vein is very mobile’
 Subcutaneous connective tissue degrades in elderly

 Allows veins to be relatively mobile under the skin

1. Tethering the skin with your other hand can help to

immobilise the vein
2. A speedy approach will pierce the vein before it
has time to move away

Update in Anaesthesia. 2011;27(22):6.

 E) ‘I’ve hit a valve’
 Catheter that was advancing well within the vein
stops before it is in place

 You may have hit a valve within the vein

 flush the catheter with 0.9% saline while advancing
 Hydrostaticpressure opens the vein or
 Dislodges any clot allowing catheter to slide further

 If this is impossible, and catheter is stuck but still

flushing well → secure it well and use as normal
 Bear in mind
 flow rates through a ‘half-in’ catheter will be less
 very prone to being dislodged

Update in Anaesthesia. 2011;27(22):6.

 LOCAL ANAESTHESIA FOR VENOUS
CANNULATION – WHAT TO USE AND WHEN?
 Helps allay patient anxiety and reduce pain
 Cannulation increases mean arterial BP by 10-
15% - abolished by i. d. injection of local
anaesthesia (LA)

 There are two methods:

 Application of cream containing local anaesthetic
or
 Direct i. d. injection of local anaesthetic at the
venupuncture site

• British Journal of Anaesthesia 1993. 70: 519-21.

 Advantages and disadvantages of different
techniques of LA for IV cannulation
Advantages Disadvantages
Intradermal - Works quickly - Requires a second skin
injection puncture
- Good analgesia
- Increases chance of
needlestick injury

- Pain on injection

- Can make cannulation

more difficult by
obscuring the target
vessel (no evidence to
support)
Cream No needles required Takes an hour to work
reliably
• European Journal of Anaesthesiology, 2004 21: 214-6 .
• Anaesthesia & Intensive Care 1999 27: 257-9.
• British Journal of Anaesthesia 1993. 70: 519-21.
 A comparison of i. d. injection and LA cream
found them to be equally effective in relieving
venepuncture pain

 Ideal i. d. anaesthetic:
 Cheap
 Fast acting
 Effective
 Causes minimal pain on injection

• Anesthesiology 1988. 68: 804-6.

 Comparison of etidocaine, bupivacaine,
mepivacaine, chloroprocaine and lidocaine
found that latter two were least painful
 Lidocaine - the fastest acting and the cheapest of
the available local anaesthetic agents

 Other methods of analgesia have been tried:

 Entonox
 Capsaicin cream
 There is no evidence that any are superior to i. d.
lidocaine
• Anesthesia & Analgesia 1987, 66: 1180.
• Peck TE, et al. Pharmacology for Anaesthesia and Intensive Care. 3rd ed. Cambridge: Cambridge University Press; 2008.
• Joint Formulary Committee. British National Formulary. 60th ed. London: British Medical Association and Royal
Pharmaceutical Society; 2010.
• Emergency Medicine Australasia 2007. 19: 427-32.
 Patient care
 Observation and monitoring of the IV cannulation
site and localised tissue are essential to:

 Ensure any significant changes are identified and

responded to appropriately
 To reduce the risk of complications
 If signs of phlebitis are present or if the cannulation
site is not functioning, it should be removed
immediately
 Resited only if the clinical need for a PVC remains

• Nursing times. 2012;108(34-35):12-4.

  Clinicalrequirement should be considered at
least daily
 Should be removed as soon as it is deemed
unnecessary

 Various national guidelines state that removal

should be considered if the IV cannula has been
in situ for longer than
 72 hrs(HPS, 2012) or
 72-96 hrs(Department of Health, 2011)
 as the risk of complications increases with time
(Dougherty and Lister, 2008).
 IV cannula inserted in emergency situations
should be removed within 24 hours (RCN, 2010)

• Nursing times. 2012;108(34-35):12-4.

 CHECKING THE IV CANNULATION SITE

 It is recommend that IV cannulation sites are

checked at least on a daily basis.

 The site should also be assessed:

 during injection of drugs

 when IV fluid bags are changed or
 when drip flow rates are checked (RCN, 2010).

• Nursing times. 2012;108(34-35):12-4.

  To facilitate checking of cannulation site:

 The IV cannula should be dressed with a

transparent dressing to allow the site to be seen
 The dressing should be sterile and semi-permeable;
 Correct application of adhesive dressing keeps the
site secure and ↓ the risk of phlebitis
 If the dressing becomes damp or loose it must be
changed

• Nursing times. 2012;108(34-35):12-4.

 COMPLICATIONS OF IV CANNULATION
 Catheter-related bloodstream infection
 Microorganisms introduced into the bloodstream
via the cannula cause bacteraemia
 Extravasation
 Vesicant solution administered into surrounding
tissue
 Haemorrhage
 Bleeding occurs at puncture site
 Infiltration
 Non-vesicant solution administered into surrounding
tissue
 Phlebitis
 The tunica intima is inflamed
• Nursing times. 2012;108(34-35):12-4.
 SUMMARY
 IV cannulation is commonly used in hospitals to
deliver intravenous therapy

 It’s important to consider the essential factors for

selecting the right site followed by correct
technique of cannulation

 IV site has to be routinely monitored for

complications as well as its further need

 Quality of care can be significantly influenced by

adopting principles of safe management and care
of patients