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 catheter sepsis.

Clinical Infectious Diseases.  16(6):778-84, 1993 Jun.

5.    Ammari LK.  Puck JM.  McGowan KL. Catheter-related Fusarium solani fungemia and pulmonary infection in a patient with leukemia in remission. Clinical Infectious Diseases.  16(1):148-50, 1993 Jan.

6.    Collignon PJ. Intravascular catheter associated sepsis: a common problem. The Australian Study on Intravascular Catheter Associated Sepsis. Medical Journal of Australia.  161(6):374-8, 1994 Sep 19.

7.    Bjornson HS. Pathogenesis, prevention, and management of catheter-associated infections. New Horizons.  1(2):271-8, 1993 May.

8.    Salzman MB.  Rubin LG. Intravenous catheter-related infections.  Advances in Pediatric Infectious Diseases.  10:337-68, 1995.

9.    Bohony J. (1993) 9 Common IV complications and what to do about them. American Journal of Nursing. 93(10):45-9.

10.  Garrison RN.  Wilson MA. Intravenous and central catheter infections.  Surgical Clinics of North America.  74(3):557-70, 1994 Jun.

11.  Perucca R. Micek J. (1993), Treatment of infusion related phlebitis: review and nursing protocol, Journal of Intravenous Nursing, 16(5):282-6.

12.  Freiberg DB.  Barnes DJ.  Fatal sepsis following peripheral intravenous cannula embolus.

Chest.  101(3):865-6, 1992 Mar.

13.  Rapp SE.  Pavlin DJ.  Nessly ML.  Keyes H. Effect of patient position on the incidence of vasovagal response to venous cannulation.  Archives of Internal Medicine.  153(14):1698-704, 1993 Jul 26.

14.  Langham BT.  Harrison DA.  Local anaesthetic: does it really reduce the pain of insertion of all  sizes of venous cannula?   Anaesthesia.  47(10):890-1, 1992 Oct.

15.  Yucha CB. Haistings-Tolsma M. Szeverenyi NM. (1993), Differences among intravenous extravasations using different solutions, Journal of Intravenous Nursing, 16(5):277-81

16.  MacCara ME, (1983), Extravasation: A hazard of intravenous therapy. Drug Intelligence and Clinical Pharmacy. 17(10):713-7.

17.  Leung PS.  Halpern GM.  Gershwin ME.   Evaluation of possible histamine release from human peripheral blood cells using an enzyme immunoassay (HRT) with components of intravenous catheters.  Allergie et Immunologie.  25(8):346-53, 1993 Oct.

18.  Veikko AK. Philip F. (1978).  Is skin preparation necessary before insulin injection?  The Lancet, 1072-1073, 20th May.

19.  Dann TC.  (1969)  Routine skin preparation before injection, An Unnecessary Procedure.  The Lancet, 96-98. July 12th.

20.  Singleton RJ.  Webb RK.  Ludbrook GL.  Fox MA. The Australian Incident Monitoring Study. Problems associated with  vascular access: an analysis of 2000 incident reports. Anaesthesia & Intensive Care.  21(5):664-9, 1993 Oct.

21. UKCC, (1992) Scope of Professional Practice.

22. UKCC. (1992) Code of Professional Conduct.

 

 

 

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