Download Cannulation

Venepuncture and Cannulation
Sharron Oulds
IV Specialist Practitioner
Aims of the session:
• To use existing knowledge to examine and demonstrate
procedure for:
-Cannulation
-Venepuncture
-Blood cultures
• To discuss aspects surrounding the procedures.
• To discuss the importance of documentation in terms of
monitoring and audit.
Introduction
• Products- Equipment used for each procedure, tips and
hints to enable efficient and practical use.
• Place- Vein selection for each procedure, discussion of
how to reduce complications.
• Paperwork- Discussion of essential documentation and
monitoring of national standards through audit.
Cannulation- Products
• Epic2 Guidelines (Pratt et al 2007)
• Disposable tourniquet
• Skin prep 70% alcohol
Asepsis- Why?
• MRSA and MSSA Bacteraemia
Cannula insertedPoor hand hygiene
Poor skin preparation
Extended time insitu
Initial signs of
phlebitis
Sepsis- further
treatment
Further investigations
Extended hospital stay
Further implications
Sepsis- further
treatment
Further intervention
Extended hospital stay
or Death
Clinical risk management committee.
HANDS NOT WASHED
COMPLICATIONS
TIME
INAPPROPRIATE
ANTIBIOTICS
VENFLON LEFT
IN SITU- NOT BEING
USED
MRSA INFECTION
C. DIFFICILE
PATIENT
DECEASED
Saving Lives!
• Epic Guidelines (2001), Epic 2 (2007),
Saving Lives- High impact interventions
(2007)
MRSA Bacteraemia Comparative Chart by Year
(post 48 hours from admission)
35
30
No of Bacteraemia
post 48 hours
25
Target
20
15
10
5
0
2008 / 09
2009 / 10
2010 / 11
Year
2011 / 12
Cannulation- Place
• Flow rates- Haemodilution, cannula size
Cannula gauge
size and
colour
Flow rate
(ml/min)
Flow rate
(ml/hr)
Applicable use
Preferred site
Used in
14G Orange
265-343
16 Litres20 Litres/hr
Rapid transfusion of
whole blood,
viscous fluids
Emergency
situations
16G Grey
170-196
10 Litres11Litres/hr
Rapid transfusion of
whole blood,
viscous fluids
18G
90-96
5.5 Litres6 Litres/hr
Blood infusions,
parental nutrition,
stem cell harvest,
large volumes of
fluids
20G Pink
55-60
3 Litres3.5 Litres/hr
22G Blue
25-35
1.5 Litres –
2 Litres/hr
18-22
1 Litre1.5 Litres /hr
Accessory cephalic
Basilic (ulnar
aspect of lower arm
along ulnar bone)
Metacarpal (on
dorsum of hand)
Metacarpal (on
dorsum of hand)
Accessory cephalic
Basilic (ulnar
aspect of lower arm
)
Any situation
24G Yellow
Routine infusions,
blood components,
large volumes of
fluids, (2-3) litres
per day, patients
on long term
medication
Slow blood
transfusions,
elderly& paediatric
patients , fragile
small veins, most
medications &fluids
Elderly & paediatric
patients, fragile
veins, medications,
short term
infusions
ACF, Median
cephalic (radial
side) Median Basilic
(ulnar side) Median
cubital (in front of
elbow joint)
ACF, Median
cephalic (radial
side) Median Basilic
(ulnar side) Median
cubital (in front of
elbow joint)
Median
cubital(radial
aspect of forearm)
Median basilica
(ulnar aspect of
forearm) Median
antebrachial
Accessory cephalic
Basilic (ulnar
aspect of lower arm
along ulnar bone)
Metacarpal (on
dorsum of hand)
Green
Emergency
situations
Any situation
Any situation
Elderly or
peadiactrics
Cannulation- Place
Vein selection- Position of cannula
can pose risk of complications.
Phlebitis
Mechanical, Chemical,
Bacterial.
Infiltration
Extravasation
Cannulation- Paperwork
Department of Health (2007) Saving lives- High Impact
Interventions
Care Bundle 2- Peripheral venous cannulation
• Cannula Pathway- Essential documentation.
• Insertion date and time
• Position and gauge
• Fragility
Cannulation- Audit
Cannula >
A
B
C
D
E
F
G
H
I
J
Phlebitis score 1 or below
1
1
0
0
1
1
0
1
1
1
dressing dated
1
1
1
1
1
0
1
1
1
1
Cannula in situ less than 72 hours
0
1
1
1
1
0
1
1
1
1
Clinically indicated
1
0
0
0
1
0
1
1
0
1
Point of entry visible for inspection
1
0
1
1
1
1
1
1
0
1
correct dressing type
1
1
1
1
0
1
1
1
0
1
lines in use less than 72 hours
1
1
1
1
1
1
1
1
1
1
Lines discarded when not in use (none visible)
1
1
1
1
1
1
0
1
1
1
minimal connections
1
1
1
1
1
1
1
1
1
0
Insertion documented
1
1
0
1
1
0
1
1
0
1
ongoing care documented
0
1
0
1
1
0
1
1
0
1
Removals documented
1
1
1
1
1
1
1
1
1
1
10
10
8
10
11
7
10
12
7
11
Total score
PREVENTING THE SPREAD OF INFECTION
79%
MAINTAINING A CLOSED SYSTEM
90%
EFFECTIVE RECORD KEEPING
77%
%AGE FULL COMPLIANCE
10%
0
Venepuncture- Product
Venepuncture- Place
Vein selection- Risk of Complications
• Haematoma
• Vasovagal
• Arterial puncture
Order of Draw
Inversion of samples
Blood cultures-Product
Department of Health (2007)
Saving Lives High Impact
Intervention- Best Practice in
taking Blood Cultures
Contamination
• Contamination of blood cultures occurs frequently.
• From where?
• Implications
-Extended Hospital stay
-Unnecessary treatment
-Possibilities of resistance or sensitivity reactions
-Cost to both patient and trust
Blood cultures
Decontaminate 2%
chlorhexidine 70%
alcohol
Aerobic bottle first
Anaerobic bottle
second
Points for practice
• Aseptic Non-Touch Technique- think key parts
• Hand decontamination
• Skin preparation
• Do Not re-palpate after cleaning site
• Documentation is essential
Thank you