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PERIPHERAL VENOUS CANNULATION GUIDELINES Reference 1271 Date approved July 2013 Approving Body Matron’s Forum Supporting Policy/ Working in Working in New Ways Package for New Ways (WINW) Package Venepuncture and cannulation Implementation date July 2013 Supersedes Version 1 Consultation undertaken Nursing Practice Guidelines Group, Ward Sisters/Charge Nurses, Practice Development Matrons (PDMs), Clinical Leads, Matrons. Target audience Document derivation / evidence base: Registered Nurses and Midwives Department of Health (2007) Saving L reducing infection, delivering clean safe (revised edition), London, Crown Copyright DH Saving Lives High Impact Interventions: Peripheral intravenous cannula care bundle Review Date Lead Executive Author/Lead Manager Further Guidance/Information Distribution: July 2018 Director of Nursing Diane Ryan, Stuart Thompson-Mchale Ward Sisters/Charge Nurses, PDMs, Clinical Leads, Matrons, Nursing Practice Guidelines Group (includes University of Nottingham representative), Clinical Quality, Risk and Safety Manager, Trust Intranet. This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using the guidelines after the review date. 1 CONTENTS Page SUMMARY OF APPLICATION INTRODUCTION 3 4 INFECTION CONTROL INDICATIONS CONTRAINDICATIONS 4 5 5 OTHER COMPLICATIONS 6 FACTORS AFFECTING THE SUCCESS OF CANULATION 7 SELECTING A SITE FOR CANNULATION DEVICE INFORMATION AND CHOICE OF CANNULA EQUIPMENT LIST THE PRINCIPLE AND RATIONALLE OF CANNULA INSERTION REFERRENCES BIBLIOGRAPHY 7 9 9 10 14 15 2 Summary of Venous Cannulation Nursing actions Ensure there are no contraindications for the insertion of the cannula. Inform the patient of the procedure and obtain consent. Inform the patient of possible complications that can occur as a result of having a cannula in-situ. . Preparation and site selection Select a site where the vein is long straight and accessible ensuring not on the ante-cubital fossa or near a bony prominence. Wash hands and prepare the equipment needed. Extend the limb and apply a tourniquet. Palpate the selected vein and thoroughly clean the site with an alcohol swab. Principles of the procedure Put on disposable gloves. Remove the cannula cover and loosen the introducer from the cannula. Anchor the vein by holding the surrounding skin taut using your non-dominant hand. Insert the cannual at an angle of between 5-10 degrees. Observe flashback of blood in the cannula chamber. Level off the cannula and advance a few millimetres into the vein. Withdraw introducer approximately 5mm. Advance the cannula further into the vein, observing for continued flashback of blood along the cannula. Release the tourniquet. Apply firm pressure over the vein at the distal end of the cannual and then withdraw. Attach an extension set or sterile bung to the end of the cannula Flush the cannula with 5mls of sterile saline and then apply a sterile transparent dressing. Additional instructions There should be no more than 2 unsuccessful attempts by the same practitioner on the same patient. 3 NURSING PRACTICE GUIDELINES PERIPHERAL VENOUS CANNULATION GUIDELINES INTRODUCTION Peripheral venous cannulation is the insertion of a Vascular Access Device (VAD) into a peripheral vein (RCN, 2010). A cannula is a flexible tube containing an introducer which may be inserted into a blood vessel (Anderson & Anderson 1995; Phillips 2005) and are usually placed in the peripheral veins of the lower arms. There are occasions when they may be inserted into the veins of the foot, but they should not be used routinely due to the increased risk of thrombophlebitis (RCN, 2010; Weinstein 2007). If veins of the feet are used, the cannula should be re-sited as soon as possible (Phillips, Collins and Dougherty 2011). It is thought that approximately 70% of all patients will have a cannula inserted during their admission (Rivera, Strauss, Van Zundert et.al., 2007). Although there is a wide range of VAD’s available to allow for the type of therapy being given, and for the patients quality of life needs, the principles of care for the device remain the same: To prevent infection To maintain a ‘closed’ intravenous system with few connections to reduce the risk of contamination To maintain a patent device To prevent damage to the device & associated intravenous equipment (Dougherty & Lister, 2011) The cannulation procedure may be performed by a practitioner who can demonstrate relevant theoretical knowledge & who has been assessed as competent using a cannulation package as part of the ‘Working in New Ways’ initiative (Nottingham University Hospitals NHS Trust, 2011a). In addition, the practitioner must be satisfied that the cannula needs to be inserted and that the patient consents to the procedure (NUH, 2010). INFECTION CONTROL Insertion of a cannula must be performed using an aseptic non-touch technique (Department of Health, 2003). Thorough hand cleaning according to the Hand Hygiene Policy (NUH 2011b) must be performed to reduce the risk of cross-infection to the patient. Gloves should be worn in line with standard precautions and the NUH Glove selection Guideline (2011c). 4 All disposable equipment must be sterile and single use only, and should be disposed of in accordance with local policy. (RCN 2010; NUH 2011d) Visibly dirty skin should be washed with soap & water (Perucca, 2001). The following procedure is then applied: Clean and prepare the skin with 2% chlorhexidine gluconate in 70%alcohol solution using a swab, cloth or other applicator. Apply ensuring the skin is wet for 30-60 seconds (rub for 5-10 seconds and then lay swab over the skin for the rest of the time). This should be allowed to air dry for up to 1 minute (Weinstein, 2007). Following cleaning, the skin should not be touched or re-palpated, as the cleaning regimen will have to be repeated (Dougherty and Lister, 2011). The need to remove hair by shaving has not been substantiated (Weinstein 2007). Shaving the skin prior to cannulation is not recommended as it can cause micro abrasions which can become a focus for infection. If excessive hair needs to be removed it should be clipped (RCN, 2010d). The cannula should be secured & covered with a sterile dressing which should be transparent, easy to apply and remove, waterproof, semipermeable and comfortable for the patient (McGovern 2010; Dougherty and Lister 2011). INDICATIONS The main indications for the insertion of a peripheral venous cannula are: administration of intravenous medicines. transfusions of blood or blood components. maintenance or correction of hydration levels if unable to tolerate oral fluids. potential venous access. CONTRA-INDICATIONS The advantages of using a peripheral cannula are that they are usually easy to insert and have few associated complications. However, they are known to increase phlebitis and when necessary need re-siting (Dougherty and Lister, 2011). In addition, some patients may not be able to tolerate the presence of a cannula. In such cases an alternative may be required such as a peripherally inserted central venous catheters (PiCC), or a central line. The selection of a site for cannulation may be contra-indicated by: The presence of injury or damage (e.g. fracture, cerebrovascular accident, oedema, lymphadenopathy, thrombosis caused by multiple attempts of cannulation or venepuncture). The presence of infection as suggested by inflammation, phlebitis, cellulitis. Veins which are mobile or tortuous, or sited near a bony prominence. If intravenous therapy is predicted to be long-term. Continuous infusions or therapies which are vesicant or have a pH of <5 or >9 (Hadaway, 2010). 5 OTHER COMPLICATIONS Accidental Damage A nerve, tendon or artery may be inadvertently punctured causing pain, damage or haemorrhage as well as loss of confidence for the nurse. The nurse may also lose confidence in undertaking the procedure Phlebitis This is characterised by pain and discomfort resulting from inflammation of the intima of the vein. The three main types are: Mechanical - damage/irritation by a cannula that is too large for the vein, or inadequate securement of the cannula which allows for movement. Chemical – drugs which cause irritation (ph <5 or >9 or extreme osmolarity or vesicant. Vesicant drugs can cause blistering and necrosis if they leak into the surrounding tissues (Scales, 2008). Bacterial - poor hygiene or aseptic techniques leading to infection (Dougherty and Lister, 2011). Haematoma Haematoma may form if the cannula pierces the front and/or back wall of a vein. This can occur during insertion or removal of the cannula and may render the vein unsuitable for further cannulation (Perucca, 2010). In the event of a haematoma occurring, firm pressure should be applied for 3-5 minutes. The risk of this occurring can be reduced through good vein and device selection and competent technique. Extravasation This is the leakage of vesicant fluids or drugs into surrounding tissues which can cause local necrosis (East Midlands Cancer Network, 2012). Prolonged Bleeding Time This may be due to a medical condition or drug therapy. It increases the risk of bruising/haematoma formation, and worsens the consequences of inadvertent arterial puncture. Blood Spillage See local infection control guidelines (NUH, 2010d) Needle or Blood Phobia Patients may experience mild to severe needle/blood phobias due to past experiences (Dougherty and Lister, 2011). It is advisable to establish if the patient is known to have any concerns or anxieties before commencing cannulation as this may adversely affect the practitioner’s success and further compound the patient’s fears (Weinstein, 2007). Anxiety can cause constriction of peripheral veins thereby making the procedure more difficult (Dougherty and Lister, 2011). A careful explanation and a confident manner is essential. 6 Vasovagal Faint/Syncope This is due to enervation of the autonomic nervous system. It is important to ensure that the patient is sitting/lying in a chair/bed whilst undertaking the procedure (Phillips, Collins and Dougherty 2011). However, if the patient begins to feel faint or appears pale and sweaty, the procedure should be stopped immediately. FACTORS AFFECTING THE SUCCESS OF CANNULATION The success of cannulation can be affected by factors influencing venous dilation. The tunica media is composed of muscle fibres that constrict or dilate in response to stimuli from the vasomotor centre in the medulla, via sympathetic nerve transmission. Factors which impede venous dilation include: patient anxiety. patient temperature. mechanical or chemical irritants e.g. introduction of needle into vein, drugs. clinical state of patient e.g. dehydrated, vasoconstricted (Mallett and Bailey, 1996). Other factors affecting the success of cannulation include: thrombosed or hardened veins; choice of cannula size; patient co-operation, previous experiences and preferences; skill of the person performing the cannulation. SELECTING A SITE FOR CANNULATION Preference should be given to a site where the veins are accessible, unused, easily detected by palpation and/or visual inspection and appear healthy and patent. Such veins feel soft and bouncy to the touch and refill quickly following compression (Weinstein, 2007). Long, straight veins with a large lumen are ideal (Dougherty and Lister, 2011). However, there are many patients who do not have ‘ideal’ veins and practitioners will need to rely on their knowledge of the anatomy and experience of the procedure in general to determine the best site for cannulation in such situations. The most common veins used are the basilic or cephalic veins of the forearm, which allow the placement of a variety of different sized cannulae in an area which is easily immobilised and does not cause too much restriction in patient activity. The ante-cubical fossa should only be used as a last resort as the effects of extravasation are more devastating, it is difficult to immobilise, uncomfortable for the patient and may hamper other procedures such as venepuncture and blood pressure recording (Weinstein 2007). 7 There are many factors that influence choice of site but if the patient is able to carry out normal activities while a cannula is in situ, and it is secured and dressed appropriately then the patient will receive their intravenous therapy with few interruptions avoiding unnecessary delays (Doherty and Lister, 2011). The use of the patient’s dominant arm should be avoided, whenever possible. Best Practice When inserting a cannula, the introducer should never be reinserted as this may cause the distal part of the sheath of the cannula to shear off and enter the circulation system. In addition, a cannula, following an abortive attempt, should never be re-inserted as this increases the risk of sepsis. (Philips, Collins and Doherty, 2011.) 8 DEVICE INFORMATION AND CHOICE OF CANNULA A number of different types of peripheral cannula are available. It has been shown that the incidence of vascular complications increases as the ratio of cannula external diameter to vessel lumen increases (Dougherty & Lister, 2011). Therefore, the smallest, shortest gauge cannula should be used in any given situation (RCN, 2010). Some of the factors which influence choice of cannula are: the purpose of the cannulation; proposed drug administration; the expected duration of cannula placement; the size of the vein to be cannulated. Each cannula has the volume of fluid that can be infused on the external package. This will also inform the practitioner of an appropriate size. For the administration of viscous fluids/drugs, larger gauge needles may be required. In addition, larger gauge needles are used routinely in emergency situations Best Practice The smallest, shortest gauge cannula should be used in any given situation (RCN, 2010) EQUIPMENT LIST Sharps container Procedure tray Cannulation Pack which includes; 1 small drape 1 Clinell wipe 2 dry Swabs 1 IV cannula dressing 1 Customised cannulation label 1 needle free extension set Gloves – in accordance with risk assessment and local policies Appropriate cannula for the purpose and length of infusion 5mls sterile saline and syringe Disposable tourniquet Prepared infusion or needle free bung Alcohol hand rub VIPS chart (NUH01290S) 9 The Principle and Rationale of Cannula Insertion PRINCIPLE Explain and discuss the procedure to the patient and gain verbal consent. RATIONALE To ensure the patient understands the procedure and gives their informed consent. Document consent. Where doubt exists over the patient’s ability to consent to the procedure follow the guidance in ‘Consent to Examination or Treatment Policy’ (NUH, 2012). Where possible involve patient in To reduce anxiety, understand selection of cannulation site, taking patients’ previous IV History, and into account factors discussed in the obtain consent. previous introduction, indications, contraindications and hazards Avoid using unsuitable limbs with sections. limited venous return or access. Also ensure that, if the patient is seated on a bed/chair, he/she has To reduce the risk if injury from falling back support. backwards if the patient has a vasovagal attack during the procedure. The use of a local anaesthetic To reduce patient discomfort injection (which needs to be administered a few minutes before cannulation) or anaesthetic cream (e.g.Emla Cream/Ametrop gel, cryogesic spray) should be considered. Cream needs to be applied according to manufacturer’s instructions (i.e. between 15-60 minutes prior to procedure) in order to take effect. Cryogesic spray if used acts immediately CONSIDERATIONS Clean hands as per Hand Hygiene policy ( NUH, 2011b) Collect equipment identified in equipment list. Where possible, establish if the patient is known to be at risk, due to prolonged bleeding time. Ascertain if the patient has any known allergies to the dressing which is to be used. Use an alternative dressing if necessary. RATIONALE So procedure has no unnecessary interruptions. To promote safety for patient and staff. To prevent an allergic reaction 10 Prepare equipment on the procedure tray using an aseptic non-touch technique (see Aseptic Non Touch Technique guidelines, NUH 2012b). Clean hands before and after palpating skin Extend the limb and support on a pillow Apply tourniquet to the chosen limb. To minimise transmission of infection (DoH, 2007) Use the following methods to encourage venous access: ask the patient to clench and unclench his/her fist; lower the extremity below the level of the heart; stroke veins with fingertips; apply heat pad (under supervision) or immerse hand/arm in warm water. Lightly palpate selected vein and assess its suitability for cannulation. To assess availability and suitability of veins and to promote blood flow and venous engorgement/ distension. Thoroughly clean the site with alcohol swab and then allow to air dry for at least 1 minute. To reduce the risk of infection. Put on disposable gloves according to the ‘Glove Selection Guideline’ (NUH 2011c). To reduce the risk of cross infection Check expiry date of cannula. Remove the cannula cover and inspect for signs of damage. Loosen the introducer from the cannula. Do not completely remove introducer To reduce the risk of cross infection and to prevent accidental injury to the skin or vein. Anchor the vein by holding the surrounding skin taut using your nondominant hand. To help immobilise the vein and facilitate entry To maintain asepsis. To increase accessibility and patient comfort. To cause venous dilation and aid cannula insertion. Allows the limb to be restrained whilst also having more flexibility and control on the amount of pressure applied Palpation helps reduce the risk of accidental puncture of artery, nerve or tendon. 11 Insert the cannula, bevel up, in line with the vein and at an angle of between 5°-10°. To facilitate entry into the vein and minimise trauma. Observe flashback of blood in the cannula chamber. To ensure the cannula tip is in the vein. Level off the cannula and advance a few millimetres further into the vein. To ensure cannula is in the vein. Withdraw introducer approximately 5mm To avoid exiting through the posterior wall of the vein. Advance the cannula further into the vein, observing for continued flashback of blood along the cannula. To ensure cannula is inserted completely into the vein. Release tourniquet To reduce venous engorgement Apply gentle but firm pressure over the vein at distal end of cannula and then withdraw the introducer and place it directly into the sharps container. Attach an extension set plus either a sterile bung , needle-free extension set or prepared infusion set to the end of the cannula. Flush the cannula with 5mls of 0.9% sodium chloride. Observe for signs of swelling or discomfort. To reduce the risk of blood spillage and needle stick injury Apply a sterile transparent dressing using an aseptic technique, ensuring that the entry site is visible and the date label is completed and attached to the dressing. If an infusion set is being used, ensure this is secured in a double loop on the patient’s arm using hypo-allergenic adhesive tape. Dispose of clinical waste as per local policy To reduce the risk of the cannula being dislodged and trauma to the vein wall. To close the system and prepare for use. Ensures the cannula is secure even when lines are being changed To check patency and position and prevent occlusion by blood. To allow inspection of the insertion site and reduce the risk of infection (Wilson, 2001). To reduce the risk of cross infection. 12 Document date, time, position and size of cannula in the relevant documentation as per local policy. Ensure the insertion site is inspected regularly for signs of infection/phlebitis (DoH, 2003). Sites must be inspected prior to administration of medication, four hourly if an infusion is in progress or if the patient complains of pain or discomfort around the site. This should be documented on the VIP chart. When the cannula is removed, this must be recorded in the relevant documentation as per local policy (DoH, 2003). Best Practice To allow replacement at 72 hours irrespective of the presence of infection (DoH, 2003) and to maintain an accurate record. Note that writing the date and time of insertion on the dressing does not replace the need to record the insertion in the patient’s notes.( VIP chart) To ensure site remains patent and, if infection or phlebitis is noted, the cannula can be removed. To maintain accurate records. Attempts at cannulation There should be no more than 2 unsuccessful attempts by the same practitioner on one patient at any given time. If the attempts are unsuccessful, the patient must be reassured and another (more experienced practitioner) should undertake subsequent cannulation (Weinstein 2007.) 13 References Anderson KN & Anderson LE (Eds) (1995) Mosby’s Pocket Dictionary of Nursing, Medicine and Professionals Allied to Medicine. London:Mosby. Department of Health (2007a) Saving Lives: reducing infection, delivering clean safe care (revised edition), London, Crown Copyright Department of Health (2007b) Saving Lives High Impact Interventions: Peripheral intravenous cannula care bundle. London: HMSO. Department of Health (2003) Winning Ways: Working together to reduce healthcare associated infection in England. London: HMSO. Dougherty, L. and Lister, S. (Eds.) (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8th ed. Oxford: Blackwell Publishing. East Midlands Cancer Network (2011) Guidelines on the Management of Extravasation Hadaway, L. (2000) Peripheral IV therapy in adults Self-study Workbook. Georgia, USA: Hadaway Associates Mallett J and Bailey C (1996) Manual of Clinical Nursing Procedures 4th ed. Oxford: Blackwell Science McGovern, D. (2010). Peripheral IV cannulation in chemotherapy administration. British journal of Nursing 9(14):pp 878 Nottingham University Hospitals NHS Trust (2012a) Consent to examination or treatment policy. Nottingham University Hospitals NHS Trust (2012b) Aseptic non touch technique (ANTT) policy. Nottingham University Hospitals NHS Trust (2011a) Working In New Ways – Expanding the Scope of Professional Practice. Nottingham University Hospitals NHS Trust (2011b) Hand Hygiene Policy. Nottingham University Hospitals NHS Trust (2011c) Glove Selection Guideline: Examination and Surgical Gloves. Nottingham University Hospitals NHS Trust (2011d) Infection Prevention and Control Cleaning and Decontamination Policy Nottingham University Hospitals NHS Trust (2010) Guide to intravenous Therapy 14 Perucca R (2001) Obtaining vascular access Infusion Therapy in Clinical Practice 2nd edition (Eds. J Hankin et al Philadelphia, USA: W B Saunders. Phillips, L. (2005) Manual of IV therapeutics. 4th ed. FA Davis, Philadelphia Phillips S, Collins M, and Dougherty L (eds) (2011) Venepuncture and cannulation. London:Wiley Blackwell. Rivera, A.M, Strauss, K.W., Van Zundert, A.A.J. and Mortier, E.P. (2007) Matching the peripheral intravenous catheter to the individual patient. Acta Anaesth. Belg. 58(1): pp. 19-25. RCN (2010) Standards for Infusion Therapy 3rd. Edition. Royal College of Nursing, London. Scales, K. (2008) Intravenous therapy: a guide to good practice. British Journal of Nursing. 17(19): pp S4-S12 Weinstein, S (2007) Plumer’s Principles and practice of Intravenous therapy 8th ed. London: Lippincott, Williams and Wilkins. Bibliography Hudek K (1986) Compliance in Intravenous Therapy CINA 2(3): pp 7-8 Infection Nurses Society (INS) (2000) Standards for Infusion Therapy Massachusetts, USA: INS Infection Control Nurses Association (ICNA) (2001) Guidelines for Preventing Intravascular Catheter Related Infection London: ICNA Nottingham Acute Trusts (2009) Venepuncture and Cannulation: An Educational Self-Directed Package Nottingham: NAT Authors: NPGG Link: modified by Diane Ryan Stuart Thompson-Mchale For Review: 2018 15