Peripheral Intravenous Cannulation

Improving Quality Outcomes for Peripheral Intravenous Cannulation

  • Aim: Improve patient quality outcomes and reduce complications associated with peripheral intravenous cannulation (IVC).
  • Statistics: Up to 90% of peripheral cannulas removed prematurely before therapy completion due to complications.
  • Focus: Clinicians must adhere to best practice techniques throughout the lifespan of the peripheral IVC device for:
    • Reducing complications
    • Ensuring patency
    • Achieving positive patient outcomes
  • Course Purpose: Provide a structured approach to best practice peripheral intravenous cannulation for enhanced outcomes in both patients and healthcare professionals.

Learning Outcomes of the Course

  1. Understanding indications for peripheral intravenous cannula insertion:
    • Recognize common clinical indications and considerations for safe IVC insertion.
  2. Preparing for the insertion procedure:
    • Describe the steps required prior to conducting a peripheral IVC procedure.
  3. Conducting the cannulation procedure:
    • Understand best practices for safely performing a peripheral IVC procedure.
  4. Applying knowledge in practice:
    • Apply learned knowledge during the peripheral IVC procedure.
  5. Post-procedure responsibilities:
    • Describe key responsibilities immediately following IVC insertion.
  6. Complications and troubleshooting:
    • Recognize, assess, and discuss common complications and troubleshoot strategies related to cannulation.

Course Units Overview

  • Unit 1: Introduction
  • Unit 2: Overview of Peripheral IV Cannulation
  • Unit 3: Procedure Preparation
  • Unit 4: The Peripheral IV Cannulation Procedure
  • Unit 5: Post-Procedure Responsibilities
  • Unit 6: Troubleshooting and Complications
  • Unit 7: Conclusion

Definition and Importance of Peripheral Intravenous Cannulation

  • Definition: Peripheral intravenous cannulation is the process of inserting a thin plastic tube through the guide of a needle to administer:
    • Fluids
    • Blood products
    • Medications
  • Notable Fact: One of the most frequent invasive procedures in hospital settings with approximately 1 billion lines used annually worldwide.
  • Requirements for Clinicians: Only trained clinicians may perform peripheral IVC insertion, typically requiring:
    • Attendance at educational sessions
    • Successful insertion practice assessed by a proficient clinician.

Gauge Selection Considerations

  • Gauge Definition: Refers to size or diameter of the cannula; the larger the gauge, the smaller the size of the cannula.
  • Flow Rates: Different gauges affect maximum flow rates for:
    • Blood
    • IV therapy
    • Medications
  • Relevant Factors for gauge selection include:
    • Patient Age: Larger gauges avoided in young children.
    • Vein Condition: Varied quality of veins among individuals require assessment.
    • Cardiovascular Stability: Ability of gauge to tolerate high flow rates for rapid transfusions.
    • Medical/Surgical Interventions: Specific interventions may dictate required gauge and site.
    • Purpose of Cannulation: Determining the reason for cannulation influences gauge choice.

Cannula Sizes and Applications

  • 14 Gauge: Largest size; recommended for severely unwell patients requiring rapid blood transfusion.
  • 16 Gauge and 18 Gauge: Used for patients needing rapid transfusions of significant blood volume.
  • 20 Gauge: Most commonly used in clinical practice; suitable for patients needing approximately 2-3 liters of fluid daily or for IV contrast in imaging.
  • 22 Gauge: Suitable for IV medications and fluids in children or those with smaller veins.
  • 24 Gauge: Reserved for children, neonates, or patients with poor vein conditions (e.g., chemotherapy patients).

Initial Considerations Prior to Insertion

  • Indications: Is the cannula clinically necessary? Consider alternative routes (e.g. oral, subcut).
  • Vein Appropriateness for Gauges: If veins are inadequate, consider alternate access methods such as a central venous access device.
  • Statistics: About a third of peripheral IV cannulas might remain unused, risking patient safety.
    • Importance of thorough assessment of veins.

Factors to Consider for Selecting the Vein for Peripheral Cannulation

  • Existing Cannulas: Avoid re-cannulating areas with recent cannula removal due to scar tissue risks.
  • Medication Effects: Some medications may damage veins; rotate sites accordingly.
  • Patient Preference: Engage patients in site selection for successful outcomes.
    • Common preference: Non-dominant arm.
  • Anatomical Deformities: Consider any limitations due to conditions such as amputations or arthritis.
  • Avoidance Areas:
    • Sites of mastectomy, lymph node clearance, or lymphoedema due to infection risks.
    • Proximity to AV fistulas/grafts and sites of previous IV drug use.
    • Avoid flexion sites to prevent dislodgement, especially for high-risk medications (e.g., chemotherapy).

Vein Anatomy and Characteristics

  • Venous System Function: Transports blood from periphery back to the heart.
  • Layers of a Vein:
    • Tunica Externa: Outer layer providing structural support.
    • Tunica Media: Middle layer containing smooth muscle to adjust vein size.
    • Tunica Intima: Inner layer with endothelial cells ensuring smooth blood flow.
  • Preferred Vein Types: Cephalic, basilic, median cubital veins; forearm preferred access site, although antecubital fossa can be used if necessary.
    • The dorsal venous network on hand as an alternative if other veins are unsuitable.
  • Qualities of an Appropriate Vein:
    • Soft and bouncy texture
    • Refills when depressed
    • Accessible straight length for cannula insertion.

Finding Difficult Veins and Tips

  • Positioning the vein below heart level to increase hydrostatic pressure for visibility.
  • Clenching fist to promote vasodilation.
  • Encouraging fluid intake to enhance blood volume when possible.
  • Properly anchoring the vein for stabilization when inserting the needle.
  • Palpating for veins, verifying position during anchoring, and not relying solely on visual confirmation.
  • Promoting venous dilation using warmth, tapping, or slow insertion techniques to find stubborn veins.

Preparing for Peripheral IVC Insertion

  • Clinical Indication Check: Verify necessity for the cannula, documentation alignment with organization policies.
  • Patient Identification: Confirm identity using full name, date of birth, and unit record number.
  • Patient Allergies: Identify any allergies (e.g., to tape or chlorhexidine).
  • Consent: Explain procedures thoroughly and obtain verbal consent directly or via legal authority if the patient cannot consent.
  • Comfort Considerations: Respect patient privacy and comfort, especially for anxious patients.

Required Equipment for Peripheral IVC Procedure

  1. Clean dressing trolley or IV trolley with sharps container and waste bag.
  2. Personal Protective Equipment (PPE): goggles, gown, gloves.
  3. Single-use tourniquet.
  4. Sterile dressing/cannulation pack containing a cannula of appropriate gauge.
  5. 10 mL of 0.9% sodium chloride.
  6. 10 mL syringe, drawing-up needle, J-loop/bung.
  7. 2% chlorhexidine gluconate and 70% isopropyl alcohol.
  8. Medical tape, considering latex allergies.
  9. Sterile occlusive transparent dressing and a label.
  10. Patient positioning aids, ensuring suitable height for procedure.
  11. Appropriate sharps handling policies for clinician safety.

Aseptic Technique in Peripheral IVC Insertion

  • Definition: Aseptic technique prevents microbial contamination using removal, exclusion, or destruction of microorganisms.
  • Maintained with standard Aseptic Non Touch Technique (ANTT). Key components include avoiding direct contact with:
    • Cannula hub
    • Needleless connector
    • Syringe hub
    • Cannulation site
  • Ensure correct hand hygiene, especially at key contact points.

Step-by-Step Guide to Peripheral IVC Insertion (Overview)

  • Confirm patient identity and provide education about the procedure.
  • Ensure patient comfort and privacy.
  • Gather and check all sterile equipment.
  • Prepare the insertion area with a tourniquet.
  • Identify an appropriate vein and perform hand hygiene.
  • Establish an aseptic field, open dressing packs, and cleanse with chlorhexidine solution.
  • Assess and prepare the cannula, anchoring the vein before insertion at a correct angle.
  • Verify correct placement with flashback, decrease angle, and secure the cannula into the vein.
  • Release pressure on the tourniquet, apply pressure above the cannula tip, and dispose of sharps properly.
  • Connect the J-loop/bung, flush for patency and dressing application post procedure.

Post-Procedure Responsibilities

  • Dispose of sharps and clinical waste appropriately.
  • Label blood samples and ensure they are sent off to the laboratory immediately following insertion if required.
  • Reminder: Blood sampling via cannula should occur as soon after insertion, with recommended initial discard of 2-3 mL before actual sampling.
  • Document insertion details including time, date, gauge, location, and attempts in clinical notes.

Monitoring and Assessment of IV Cannula

  • Regular visual assessment of cannula required to identify phlebitis using the phlebitis scoring system:
    • Score System:
    • 0: No signs of phlebitis (healthy site).
    • 1: Possible phlebitis signs, such as slight pain/redness (monitor).
    • 2: Early signs (pain/redness/swelling)—remove/recite.
    • 3: Mid-stage (pain/redness/induration)—requires removal.
    • 4: Advanced phlebitis (pain/redness/induration/palpable venous cord) necessitating further action.
    • 5: Severe cases (including pyrexia)—requires urgent intervention.

Complications Associated with Peripheral IVC

  • Phlebitis: Inflammation of the vein with signs like erythema, pain, and swelling.
    • Types include:
    • Chemical (from infusates)
    • Mechanical (due to vein movement)
    • Bacterial (from infection)
    • Post-infusion (after removal)
  • Extravasation: Leakage of vesicant substances causing tissue damage; non-vesicants can also have damaging effects but are less severe.
  • Infection: Can vary from localized site to systemic complications (e.g., sepsis) and commonly caused by Staphylococcus aureus.
  • Statistics: Hospital-acquired bloodstream infections can lead to increased mortality and longer hospital stays. 17-29% mortality rate observed in bloodstream infection cases.

Summary Points for Best Practices in Peripheral IVC

  • Clinical indications and considerations are crucial before insertion.
  • Strict adherence to aseptic technique is required when handling devices.
  • Ongoing responsibility lies with the clinician for safe, effective peripheral IV cannulation and management to prevent complications.