Peripheral
venous cannulation
An open
learning pack for registered nurses and midwives
Intravenous cannulation
This article
examines the procedure of establishing peripheral venous access by cannulation,
it considers potential complications to the patient, potential risks to the
practitioner and the practical aspects of the procedure.
Potential
complications to the patient
As in all
nursing procedures a sound understanding of possible complications means that
these can be anticipated and so avoided.
Infection
Responsible
micro-organisms
Vascular
catheter-related infection is an important cause of mortality and morbidity in
hospitalised patients(1). Studies have found the most common
responsible organisms to be Staphylococcus aureus and Staphylococcus
epidermidis,(2, 3).Other implicated organisms include
Candida, Pseudomonas aeruginosa and infections with multiple pathogens. The
most severe complications are usually caused by S. aureus(4).
Catheter-related fungal infections have also been reported in
immuno-compromised patients,(5)
Scope of the
problem
A major
Australian study found systemic sepsis with peripheral vein catheters occurred
in 0.36 of every 1000 catheters. However with central vein catheters it was 23
episodes per 1000 catheters(6). These figures extrapolate to at
least 3000 cases of intravascular sepsis per year in Australia. Almost 4000
cases of line-associated bacteraemia were reported from England and Wales in
1991(1).
Major
infective complications documented in the literature include septic shock,
sustained sepsis, suppurative thrombophlebitis, metastatic infection,
endocarditis, and arteritis(4). Clearly in addition to the human
cost of such complications, hospital stays may be lengthened and financial
costs incurred.
Nursing
observations and interventions
In the case
of frank local peripheral phlebitis or
cellulitis the diagnosis is usually obvious. Local features include pain, a
collection of exudate, oedema, warm skin, and erythema. However
catheter-related bloodstream infections are often difficult to recognise
because there are frequently no signs of inflammation around the catheter(7). Bloodstream
infection from a cannula is often only presumed because a common skin
micro-organism is isolated from the blood when clinical manifestations of
infection are present and there is no other apparent source of infection.(8) A high index of suspicion for these
infections is therefore needed in the assessment of a patient who has a febrile
illness. Features of systemic infection include pyrexia, (typically 38.0 -
39`C) and Leucocytosis. Less common features are lack of response to broad
spectrum antibiotics, and endocarditis,(9). Infections associated with venous
catheters often respond well to the glycopeptides - Vancomycin and Teicoplanin,(9). Clearly the
earlier an infection can be detected the better, so the maintenance of basic
nursing observations remains very important.
Most
catheter-related infections occurring shortly after catheter insertion probably
gain access to the bloodstream by extraluminal migration. Central lines may
also rarely become contaminated by haematogenous systemic translocation of
organisms probably from the gut,(3). It must
always be remembered that the entry site is an open wound, and should therefore
be dressed appropriately. Transparent dressing will prevent bacterial access
while still allowing visual inspection. When catheters are in place for
extended periods the inside of the catheter hub probably plays a major role in
micro-organisms gaining access endoluminally,(8) (fig. 1).
This is one reason why blood samples should not be routinely removed from an
indwelling line. However it is common practice to remove a blood sample from
the catheter when first inserted. This seems reasonable as there is back flow
of blood into the catheter hub anyway during insertion.
If infection
is identified in peripheral or central venous catheters they should be removed.
Generally any infection will resolve after the infective focus is eliminated.
However systemic antibiotic therapy,
based on specific bacterial culture results, is indicated in any patient whose
systemic signs of infection do not resolve promptly. Any suspect catheter tips
should be sent for culture and sensitivity testing. When removing a potentially
infected catheter for culture, care should be taken not to contaminate the tip
with skin surface bacteria. Repeated examination of all insertion sites is
indicated until the fever resolves.(10)
Prevention of
infection is clearly preferable to treatment of established infective cases.
The strict application of appropriate aseptic techniques and subsequent care of
the catheter are the most important
factor in reducing the incidence of sepsis(1,9). Care must be
taken not to contaminate the catheter during insertion. Full aseptic technique
must be applied during catheter insertion. Hands should be washed in soap and
water as this will reduce the number of bacteria on the practitioners skin.
Cleaning the hands with 70% ethanol is even more bactericidal. Another factor
predisposing to infection is poor insertion technique resulting in local
trauma. There should be as little collateral tissue damage as possible. The
longer a device is in place the more likely it is to become infected and the
current thinking is that peripheral catheters should be removed after 48 hours
to reduce infection risk, (3).
Another
possible port of micro-organism entry into the body is via the lumen of a
catheter. This means that all intravenous systems must be kept closed. For
example male connectors on fluid administration sets should not be left open to
the air. Full aseptic technique must naturally be employed when preparing any
intravenous infusion or bolus.
Phlebitis and
thrombophlebitis
Inflammation
of a vein may occur due to infection or as a result of direct chemical
irritation from an infusion,(11). Typically
there is redness, tenderness and swelling around the site and the vein often
feels hard on palpation. There may also be evidence of "tracking" ie.
red lines running up the arm from spreading venous or lymphatic inflammation. If phlebitis occurs the cannula should be
re-sited. The inflamed area should be made as comfortable as possible and a
medical opinion taken regarding possible antibiotic therapy,(9). In
thrombophlebitis the inflammation is associated with thrombus formation.
Emboli
One potential
source of emboli is the material of the catheter itself. During insertion of
the catheter the needle, (ie. the metal introducer) must not be partly
withdrawn from the plastic catheter and reinserted. This may result in the
trocar cutting through the catheter, (plate 1) the cut part of the catheter may
then be carried away in the venous return to the heart. As this is a foreign
body it is likely to become a focus for infection, possibly lodged in the
pulmonary arterial system. The resulting multiple septic complications have
been clearly reported as a cause of mortality secondary to peripheral
intravenous cannulation,(12). It is a frequent observation in hospitals that the
needle is withdrawn to see if the catheter fills up with blood, thereby
indicating successful venous penetration. This is bad practice. The flashback
of blood into the hub of the catheter should be used to indicate entry into the
lumen of the vein.
Thrombosis and
air are two other possible sources of emboli. No air must enter the circulatory
system. Signs of air emboli include a rapid drop in blood pressure with
tachycardia, which is potentially fatal. Air introduction should be prevented
by careful priming of all administration equipment and ensuring any connectors
are air tight.
Vasovagal
response
A study
carried out in Washington found that a vasovagal reaction occurred in 12.6%
of patients cannulated while sitting up,
however this figure drooped to 2.1% of recumbent patients. Two sitting patients,
(1.3%), experienced frank syncope. In the vasovagal reactions observed there
were significant falls in both heart rate and blood pressure. Individuals
experiencing a drop in blood pressure were 4.7 times more likely than
asymptomatic patients to have a history of fainting. Clearly patients should be
asked if they have a history of syncope and the default position for catheter
insertion should be lying down (13).
Pain
The amount of
pain complained of during cannulation seems to vary considerably. In children
local anaesthetic creams eg. Emla, may be applied one hour before the procedure
is carried out if time allows. It has been clearly demonstrated that a
subcutaneous injection of 1% lignocaine
is significantly less painful than the insertion of a 22-gauge venous cannula,(14). This means
that if pain is considered a problem in can be significantly reduced by
subcutaneous infiltration with local anaesthetic before cannulation.
Haematoma/haemorrhage
The cannula
should be inserted immediately over the chosen peripheral vein to minimise
damage to non-venous tissue. The cannula should be introduced into the vein in
a smooth action and not manipulated under the skin as this will damage tissues
and lead to bleeding. Once the cannular is in the vein, after the flashback is
seen, the tourniquet should be removed. Also before needle removal an assistant
may apply proximal pressure to the cannulated vein to prevent haemorrhage. No
pressure should be applied to the vein over the position of the catheter as
this will damage the intima of the vein. If the practitioner is working alone
haemorrhage via the catheter lumen may be prevented by holding the cannulated
limb up. If during the procedure haematoma formation is noted the tourniquet
should be released to reduce venous pressure and the cannula removed. Direct
pressure should then be applied for at least three minutes.
System
disconnection
If the luer
lock is not securely tightened or falls off there may be significant back flow
of blood out from the now open end of the cannular. This may also occur if an
attached intravenous infusion becomes disconnected. These complications may be
prevented by securing all connections and checking them routinely.
Extravasation
The infusion
of fluids or drugs into the tissues instead of the venous circulation is termed
extravasation, (or tissueing). This occurs when a cannula is dislodged from a
vein or there is leakage between the cannula and the wall of the vein,(15). A study of 16,380 patients revealed some
extravasation in 22.8% of those receiving intravenous infusions, of these 0.24%
resulted in significant tissue damage,(16). The commonly
presenting features of such tissueing are localised swelling and pain. The risk
of extravasation going undetected are greater in patients who cannot
communicate with their carers eg. children, the elderly and patients with
reduced states of consciousness. It is interesting to note that extravasation
occurs more frequently at night than during the day,(16).
Fluids which
are acid, alkaline, vasoconstricting, cytotoxic or hypertonic may be
particularly irritating to tissues and may cause local necrosis. Such fluids
are termed vesicant and should be monitored particularly carefully. If
extravasation occurs the infusion should be stopped and medical advice taken.
The limb may be elevated to encourage lymphatic drainage and checks made for
tissue damage, impaired circulation and nerve damage. An important aspect in
the prevention of extravasation is good visualisation of the entry site. This
precludes dressings which prevent visualisation so transparent dressings are
ideal. Any localised blistering may indicate tissueing. If the integrity of a
cannular is in doubt it may be tested with a small volume of injectable saline
as this is non-vesicating.
Unintended
arterial cannulation
If the vessel
to be cannulated is palpated before insertion arterial puncture should never
occur as the typical arterial pulsation will have been felt. If an artery were
cannulated, bright red blood would be seen in the flashback. The catheter
should be removed and firm direct pressure applied for at least five minutes to
the entry site and haemostasis ensured.
Allergy
There has been
some anecdotal discussion relating to allergic reactions to indwelling
catheters including possible anaphylaxis. These accounts are almost certainly
untrue.
A study in
California found that none of the blood samples they tested released
significant amounts of histamine when challenged with extracts from aquavene or
silicone catheters. This means that catheters based on these compounds are most
unlikely to cause histamine-associated
reactions(17). Clearly there
are the usual risks of adverse reactions to any drugs given intravenously.
Damage to
peripheral veins
While is it
clearly important not to cause any unnecessary damage to anyones veins, it is a
vital point in renal patients. An arterovenous fistula must never be cannulated
for routine venous access. Indeed any patient with what might be described as
pre-renal failure should not be cannulated between the wrist and the elbow to
preserve the arm veins. A functional definition of pre-renal disease might be
any patient with a serum creatanine of over 200 mmls with progressive renal
disease. Such patients may however may be cannulated on the back of the hand
Potential
complications to the practitioner
Needle stick
injuries from used needles are perhaps the greatest danger to the practitioner.
These can result in the inoculation of dangerous viruses. It is therefore vital
to prevent such injuries occurring. In clinical practice nurses have
accidentally stabbed themselves and others. As soon as the needle is removed
from the catheter it may be placed into a puncture resistant sharps container
which is already conveniently positioned. Containers should not be overfilled or people may injure
themselves putting in further used sharps.
If
unfortunately an inoculation injury does occur the offending needle should be quickly
removed. The wound is then encouraged to bleed as much as possible. This will
wash out some of the micro-organisms which may have been introduced. Bleeding
may be encouraged by firm squeezing and running under a flow of warm water. The
wound may then be soaked in iodine which has good antibacterial and viral
properties. Such incidents must be officially reported as accidents and advice
taken from the occupational health department.
The risk of
injury is increased if the patient moves suddenly or unexpectedly. The
procedure must first be explained to the patient to gain his or her full
co-operation. The current psychological profile of the patient should also be
considered in an attempt to predict poor co-operation. If for any reason there
is contact with the patients blood there is a theoretical risk of nosocomial
infection. The risk is far greater if the practitioner has any open wounds or
sores on his or her hands. This risk may be significantly reduced by wearing
latex seamless gloves. With good technique there should be no blood loss during
the procedure, however the principle of applying universal precautions should
be encouraged.
When a
catheter is removed there is a risk that a drop of blood maybe flicked up into
near by eyes. A gauze swab should be placed over the entry site before the
catheter is removed. This will also allow the immediate application of direct
pressure to achieve haemostasis.
The scope of
professional practice
"The
practice of nursing, midwifery and health visiting requires the application of
knowledge and the simultaneous exercise of judgement and skill" (21). The scope of
professional practice document goes on to discuss the need for practice to be
responsive to the needs of the individual patient. The author suggests this may
form the basis of a question to be asked by the practitioner before extending
their scope of practice, "will this area of practice benefit the totality
of holistic patient care"? If the answer to this question is yes, then
extending the scope of an individuals practice is probably desirable. Nurses
must act in a way which promotes and safeguards the interests and well-being of
patients, and often to do this specific skills are required.
It must be
remembered that the onus of responsibility for practice lies with the
individual practitioner from initial registration onwards. "As a
registered nurse ..... you are personally accountable for your practice......"(22). In addition
to these conditions for extension of role, adjustment to the scope of personal
professional practice must not compromise or fragment existing aspects of
patient care. In practice this means that nurses need to make managers aware of
the various demands on their time including areas where they have extended
their scope.
Training
implications
Education and
training are the basis of nursing decision making and practice, so clearly
these are vital if the scope of practice is to be extended. Cannulation is not part of the basic
pre-registration preparation of nurses, it is an area of theory and skill which
may be learned after qualification. In common with all nursing procedures the
practitioner should be conversant with relevant theory and research
underpinning the practical aspects of the procedure. In most hospital areas
teaching sessions are arranged to cover the theoretical and practical aspects
of the procedure as an introduction to the topic. After this there is a period
of supervised clinical practice under the mentorship of a competent
practitioner who may hold a nursing or medical qualification. As the practical
aspect of cannulation is a skill the learning practitioner will improve
technique with time and practice. After a period of supervision the
practitioner will be able to practice independently of his or her mentor, often
after some locally arranged assessment of competence. No specific number of
supervised practices can be given as different practitioners will feel competent
after different amounts of practice, however ten supervised practices may be taken by some.
Individuals
should keep a record of their educational activities for portfolio development
and for PREP. However in addition, evidence of further training and education
in new areas of practice can be used to illustrate an individuals claim to
competence. In practical terms this means a nurse learning cannulation should
keep evidence of having attended one or more preparatory sessions together with
evidence of their supervised clinical practice. Supervised practice is usually
recorded on a card which the mentors signs to say they have supervised the
cannulation. Practitioners should also be completely clear that their managers
know the areas of practice they are involved in.
Once trained
in any area of practice the individual must also ensure that they are up to
date. Nurses must maintain and improve their professional knowledge and
competence. This means that learning the skill of cannulation is not a once
only activity, but an area of on-going updating and development. If a practitioner feels out of date or
"rusty" they should arrange update preparation before carrying out
the procedure. It is always important nurses recognise their limitations and
know when to refer a situation to an individual with greater expertise.
Theoretical
aspects
Indications
In order to
practice intelligently the nurse should be aware of the indications for
cannulation in the case of each patient. The usual reasons are to
establish venous access for drug or
fluid administration. For example a cannula will clearly need to be in situ if
a patient is prescribed regular intravenous medication or a blood transfusion.
A cannula will also clearly be required to deliver crystalline or colloidal
intravenous fluids.
Anticipation
of an indication
In addition to
the indications above, a cannula is often inserted if intravenous drugs or
fluids may be required in the future. For example every patient with severe
unexplained chest pain should have a cannula in situ. This means that in the
event of a cardiac arrest secondary to myocardial infarction emergency drugs
may be administered without delay. The same is true if there is the possibility
that emergency fluid replacement may be
needed. In cases of trauma where shock is a possibility a cannula should be
inserted early as delay may result in circulatory collapse. In shocked patients
cannulation is much more difficult and a central vein may have to be used to
gain venous access. In addition the fluids given via the catheter may overt the
onset of shock if sufficient fluids are replaced.
Asepsis
Careful
attention must be paid to asepsis throughout the procedure. An important part
of the development of safe technique is ensuring this is always maintained.
This will involve ensuring the equipment is sterile when removed from the manufactures packaging and that it is not
subsequently contaminated. Contamination could occur from the hands of the
practitioner, from contact with other objects such as bed clothes or indeed
from the patients own skin. Bacteria entering the bloodstream can lead to
bacteraemia.
Practical
considerations
An appropriate
explanation of the procedure should be given to the patient and the likelihood
of their co-operation assessed. If it is suspected the patient may move around
during the procedure a colleague may be employed to support the patients arm.
This may be a problem in confused patients for example. The patient should be
seated or lying in a comfortable position.
Cannula
selection
The cannula
chosen should be the smallest to meet the clinical need. The commonly used sizes are 22, 20, 18, and
16 Gauge. Blue (22 gauge) are used in paediatrics and adults with small veins,
flow rate is about 31 mls per minute. Pink (20 gauge) are used for giving long
term medication and will allow the administration of 2-3 litres of fluid per
day. Green (18 gauge) may be used for blood transfusions and giving larger
volumes, up to 80 mls per minute. Grey (16 gauge) allow rapid infusion of blood
and fluids at a rate of about 170 mls per minute. Clearly the larger the lumen
of the catheter the faster the flow rate. Flow through a cannular is determined
by the square of cannula diameter. This means that if the diameter of the
catheter is doubled the flow rate is increased sixteenfold. The indication for
cannulation should be considered and the cannula gauge chosen accordingly. For
example emergency colloid or blood replacement after a post partum haemorrhage
will require a grey cannula whereas a line for intermittent intravenous bolus
injections of antibiotics could be green or pink.
Vein selection
The
non-dominant arm is used whenever possible. If a larger cannula is to be used a
larger vein must be selected. Large cannulas will not fit into small veins. A
tourniquet is applied proximal to the desired site of insertion and the veins
allowed to fill up. The tourniquet will not prevent arterial perfusion of the
arm, however it will significantly reduce venous drainage, so blood will
accumulate in the arm, filling the veins. Possible veins may then be palpated.
Ideally the chosen vein should be splinted by a long bone so the catheter is
not bent by movement in a joint. In addition, a straight length of vein will
allow the catheter to lie in the vein without any bends in it. Ideally the most
distal suitable vein should be selected. This means that if re-siting is later
required fluids given will not leak out of the original puncture site as the
next site chosen may be more proximal. Commonly chosen sites include veins in
the back of the hand and over the lateral distal surface of the radius. In an
emergency any available peripheral vein may be used such as the usually
accessible median cubital vein in the anti-cubital fossa. If the cannula has to
be positioned over a joint a splint may be required to ensure continuing
satisfactory flow.
The vein
selected should feel full and bouncy, indicating that there is a volume of
blood into which to insert the cannula. Palpation is a more accurate guide to
vein selection than visualisation. Perhaps the most common reason the vein is
missed in a cannulation attempt is failure to take time to learn the position
of the vein at the venous palpation stage of the procedure. If difficulties are
experienced flicking or tapping the vein may overcome sympathetic tone and
cause vasodilation, however the area should not be slapped. Warming the area
may also cause peripheral vasodilation.
Skin
preparation
There have
been several well reported studies which indicate skin cleaning is of no
benefit before parental procedures, (18,19). However
current bacteriological opinion is firmly in favour of cleaning the site of
insertion. The skin should be cleaned to remove blood, mucus and other organic
debris with a preparation such as isopropyl alcohol or 1% iodine in ethanol
70%.). If the area is swabbed back and forward the sebum and bacteria will also
be moved back and forward. The area should be swabbed in one direction, lifting
the swab away from the skin after each stroke. The bactericidal effect of the
alcohol in a swab will be limited due to the short contact time. However the
solvent effect of the alcohol on the sebum will remove this greasy material
from the skin surface as a result of the unidirectional swabbing. Bacteria on
the skin surface will therefore be moved away from the insertion site along
with the sebum. This will help to move material and bacteria away from the
entry site, (fig 2After swabbing the site should then be allowed to dry,
usually for about 30 - 60 seconds, before insertion of the catheter, (3). Dry shaving of local hair may sometimes be
indicated in hairy individuals. Shaving, if performed, should be carried out immediately before
insertion as abrasions caused by shaving may lead to local skin infection. Once
the site is cleaned ideally the practitioner will not palpate the area again to
minimise the number of bacteria on the skin surface.
In children a
transdermal local anaesthetic cream should be employed whenever time permits.
Alternatively a small dose of subcutaneous 1% lignocaine may be given for
analgesic purposes.
Insertion
The selected
vein should be secured or "anchored", this is often done with the
left thumb of the practitioner located about 2 centimetres lower and to the
side of the insertion site. As the cannula is pushed into the vein enough
opposing force may be applied to maintain the position of the vein. The point of
the cannula should be placed directly over the middle of the vein with the
bevelled surface upwards. A usual angle of entry into the vein is about 25`.
The cannular must be held in such a way as to ensure that the needle is fully
pressed into the catheter, this is to ensure that the plastic of the catheter
is never in front of the cutting surface. If this were to occur then the
plastic could be cut and potentially lead to the sheered end of the catheter
forming an embolus. Keeping the needle fully engaged in the catheter is usually
achieved with opposing force from the finger and thumb.
A flashback of
blood in the flashback chamber is the signal that the cannula has entered the
lumen of the vein. The cannula should be advanced enough to ensure the whole tip
of the cannula is in the lumen. The angle may now be reduced to ensure that the
posterior vein wall is not pierced. At this stage the tourniquet should be
loosened or removed. The needle part of the cannula should now be held still
and the catheter passed over it. If the needle is pulled out too early the
plastic catheter may kink. The metal needle acts as a guide for the plastic
catheter. The catheter is passed until its full length lies in the vein. The
needle must never be advanced back into the catheter, after the catheter has
been slid over the needle. If this is
done there is a risk the needle may cut off the end of the catheter.
Once the
catheter is fully inserted the needle may be removed and carefully disposed
of. Ideally, before needle removal a
colleague applies pressure proximally over the cannulated vein. This will
prevent haemorrhage from the catheter when the needle is fully removed. It is
important that no pressure is applied over the length of vein that the catheter
is lying is as this will damage the tunica intima. Such a damaged area of
venous epithelium may cause platelet aggregation and subsequent thrombus
formation. If the practitioner is alone
the cannulated limb should be elevated before the needle is withdrawn. If the
tourniquet is not fully released blood will leak out of the catheter as the
venous pressure will still be high.
Saline flush
After needle
removal the bung may be secured or a primed infusion directly attached. If an
infusion is not immediately commenced the catheter must be flushed through with
2 mls of injectable saline. This injection is in essence an intravenous bolus
injection so should be carried out according to local protocols for such
injections. As the saline is introduced the nurse should observe for formation
of a local bleb or blister which may indicate extravarsation. In addition if
the patient complains of pain this may indicate the saline is entering the
tissues, and not entering the venous circulation. A suitable dressing is then
applied to secure the catheter to prevent accidental removal.
Removal of a
blood sample
The convention
in most hospitals is that if a blood sample is required during cannulation this
may be taken. However once the cannula is in situ and has been flushed with
saline the first time it should not be used for removal of blood samples again.
The reason blood may be removed on the first occasion is that the cannula fills
up with blood on insertion whether a blood sample is taken or not. However on
subsequent occasions blood would be drawn back into the catheter and a volume
of blood would be left in the catheter after the sample had been withdrawn. As
this blood was flushed back into the vein as the cannula was cleared with
injectable saline, infection from the catheter port may also be flushed into
the blood stream.
Dressings
The nurse must
be able to carry out regular inspections of a peripheral catheter entry site.
In addition the area must be observed during fluid entry to ensure there is no
extravasation. However as the entry site is essentially an open wound it should
be covered with a protective dressing to prevent external bacterial colonisation.
These requirements mean that a transparent dressing is indicated and there are
several brand names available. Ideally the area should be well covered and the
catheter secured with the same dressing.
While the
author is not aware of any national guidelines on inserting and maintaining
peripheral venous cannulars there are often locally prepared procedures and
policies which can be very helpful.
Peripheral venous cannulation
Outline stages
in the procedure
Appropriate
explanation to the patient
Assess degree
of expected patient compliance
Application of
tourniquet
Palpation of
candidate veins
Learn the
position of chosen vein
Clean the skin
with unidirectional swabbing
Allow time for
antiseptic to dry
"Anchor"
the vein
Insert the
cannula about 1-2 cm into the vein
Observe the
flashback for confirmation of entry
Release
tourniquet
Hold the
needle still and completely advance the plastic catheter
Hold arm up or
have pressure applied proximal to the catheter
Remove needle
part
Connect fully
primed giving set or put on the bung
If the bung is
used immediately flush with 2 mls of injectable
isotonic
saline
Dress/secure
The student will be able to;
Demonstrate awareness of the role of
the Nurse in relation to the scope of professional practice document and the
code of ethics.
Give the indications for cannulation
as agreed with local nurse managers
* establishment
of venous access for drug or possible drug administration.
* delivery
of intravenous fluids.
Discuss the types of cannula
available, their sizes and individual indications.
Give reasons for the strict
maintenance of asepsis.
Discuss how asepsis will be maintained
in practice.
Describe possible veins which may be
used for cannulation.
Demonstrate the selection of an
appropriate vein.
Describe the use of the tourniquet
Discuss the appropriate skin
preparation for the procedure
Demonstrate the correct method of
insertion of the cannula
Discuss the prevention of catheter
shearing, (cutting of the catheter by the introducer needle)
Demonstrate appropriate dressing and
securing of the catheter once in situ.
Discuss the continuing care of the in
situ catheter, (including protocols for flushing with injectable saline).
State the signs and symptoms which
occur when a catheter is located in the tissues.
Discuss the removal of the catheter.
Describe local protocols for the
administration of intravenous drugs and fluids.
Discuss the protection of the
practitioner and others from the possibility of nosocomial infection.
State current policy from local
"Guidance on the management of infections" re. wearing of gloves.
Describe how any haemorrhage or
haematoma will be managed.
Discuss first aid and administrative
procedures in the event of needle stick injury.
Discuss possible complications of
cannulation, eg. air embolism, haematoma, infection.
Peripheral
venous access
complication number
of cases
extravascular
extravasation 14
unintended
arterial cannulation 8
disruptions
to intravenous lines 6
problems
with infusion lines,
taps,
pumps and connectors 5
Central
venous access
complication number
of cases
arterial
puncture with haematomas 9
morbidity
and/or prolonged admission 5
catheter
misplacement and pneumo or
hydrothorax
5
problems
arising from operator
inexperience. 4
Table 1. Incidence of complications
associated with access to the vascular system. (65
complications were found in a study of 2000 cases).(20)
References
1.
Elliott TS. Line-associated bacteraemias. Communicable Disease
Report. CDR Review. 3(7):R91-6, 1993
Jun 18.
2.
Fry DE. Fry RV. Borzotta AP. Nosocomial blood-borne infection
secondary to intravascular devices. American Journal of Surgery. 167(2):268-72, 1994 Feb.
3.
Elliott TS. Faroqui MH.
Infections and intravascular devices. British Journal of Hospital Medicine. 48(8):496-7, 500-3, 1992 Oct 21-Nov 3.
4.
Arnow PM. Quimosing EM. Beach M. Consequences of intravascular
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Table 2. Possible learning outcomes
for assessing theoretical competence
Now you have read this information
answer all of the following questions.
You may obtain the required
information from the following sources
* this
pack
* other
reference works, books and journals
* your
own background knowledge
* friends
and colleges, both nursing and medical
It is important you discuss the issues
raised with a variety of people to improve your understanding of the concepts
involved.
What are bacteria?
Which bacteria may cause contamination
of an intravenous cannular?
Why do intravascular devices pose a
particular infection risk?
What complications may arise as a
result of infection in intravascular devices?
State how you would recognise all of
the possible complications you mentioned in the previous question.
What action would you take if you
suspected a catheter was infected?
List the possible routes by which
bacteria may enter a vein via a peripheral cannular and identify these on the
diagram on the next page
Which measures may be taken by you to
ensure asepsis during cannular insertion?
How is skin preparation routinely
carried out on your ward or unit?
Why is skin preparation important?
What is phlebitis and which types of
phlebitis may occur?
What is thrombophlebitis and why is
thrombus formation in the systemic veins a particular hazard?
List the possible sources of emboli
which may arise as a consequence of peripheral venous cannulation.
What is catheter shear?
How will you prevent catheter shear in
practice?
How will you account for the
possibility of a vasovagal response during or shortly after cannulation?
How may any pain associated with
cannulation be reduced in anxious individuals and children?
What is a haematoma?
How will you prevent haemorrhage
during cannulation?
What does extravasation mean?
In which circumstances is
extravasation a particular hazard?
How will you recognise/test for
extravasation?
How will you recognise the unlikely
occurrence of unintentional arterial cannulation?
What action will you take if
unintentional arterial cannulation were to occur?
What is a virus?
Which viruses may present a nosocomial
threat to you during cannulation?
List the possible ways you could be
exposed to blood borne viruses during cannulation and subsequent care of the
catheter.
How will your practice prevent each of
the possible routes of self contamination you have just listed?
What action would you take if you or a
colleague were splashed in the eye with blood?
What action would you take if you or a
colleague were stabbed with a contaminated sharp?
Which types and sizes of cannular are
is stock on your ward or unit?
Give all of the indications for each
gauge of cannular you have listed as used on your ward or unit.
Which factors may influence your
choice of cannular for a particular individual patient?
Which veins may be selected for
cannulation?
Which factors will you take into
account in your selection of a particular venous site for cannulation?
Why is it important to cannulate
patients at risk of shock in the early stages of their management?
How will you hold the cannular as you
insert it?
How will you secure the position of
the vein during insertion?
At what stage will you apply the
tourniquet?
At which stage in the procedure will
you remove the tourniquet?
What is meant by the
"flashback" of blood?
How will you prevent the catheter
kinking during insertion
How will you flush through the
catheter immediately after insertion?
May a sample of blood be removed
immediately after catheter insertion?
Why are subsequent blood samples not
routinely removed via an indwelling catheter?
What are the important properties of
the dressing you will apply over the catheter entry site?
Why are the properties you have just
mentioned important?
How will you secure the catheter to
prevent accidental removal?
Which patients should not be
cannulated between the wrist or the elbow?
How will you prevent accidental
disconnection of the system and the resultant haemorrhage?
Once you have completed this pack you should keen it
safe as part of your PREP portfolio
Lumen of vein
Colonization of distal catheter tip
Haematogenous spread
Intraluminal introduction
Internal hub colonization
Contamination of infusion fluid