INTRAVENOUS PERIPHERALCANNULATION

Midwifery Practice 2

INTRODUCTIONWhat do you already know?What experiences have you had with iv cannulation?

What are your thoughts on this midwifery role?

What do you expect to gain from this session?

AIM OF THE SESSION

To introduce the procedure of peripheral intravenous cannulation

LEARNING OUTCOMES

Understand the purpose and indications of iv cannulation

Gain an overview of the techniqueFamiliarise yourselves with equipment and procedure

Gain some practiceUnderstand common complications and how to solve them.

PURPOSE OF IV CANNULATION

To have quick and easy access to the patient’s

blood stream for rapid or more effective

administration of a required or potentially

needed treatment

INDICATIONSFluid administration or replacement

(epidural, PPH..)Drug administration

◦ in an emergency◦ in cases where it is required that a drug is absorbed and metabolised more effectively than it would be by any other route (ie.IV antibiotics, Syntocinon..)

Administration of whole blood or blood products

In preparation for a potential complication (multiparity, multiple births)

ANATOMY & PHYSIOLOGY REVISION

Veins return _______ blood to the _____ against the flow of gravity.

This occurs under ____ pressure, therefore veins do not require ____ ______ walls like arteries. To maintain the direction of flow, veins are equipped with ___-___ valves.

Veins tend to be located more ______ than arteries and do not _______ on palpation.

CHOICE OF VEINPalpate using fingers (not thumb)

Feels like elastic tube filled full

Does not have a pulse!Ideally in the lower half of the arm or back of the hand

Locate the straightest portion of the vein

STRUCTURES TO AVOID

Dominant armJointsFlexure of the elbowAreas with compromised circulation, oedema or fracture

Valves in the veins (seen as bulges)

Arteries

POINTS TO CONSIDER Evidence of altered anatomy or physiology? Burns, scars…

Anticoagulant therapy, bleeding/clotting disorder (HELPP, liver disease…)?

Vascular or circulatory problems, or vascular or lymphatic surgery?

One arm or particular site being easier than any other?

MATERIALS / EQUIPMENT

TorniqueteSterile glovesAlcohol and/or clorhexidine wipesIV cannula (and sharps bin!!)IV dressingSwabs? LidocaineProtective cloth / pad for the bed

DEVICES

-Butterfly - mainly in neonates - administration of small amounts of drugs - drawing up blood

DEVICES

- “Over the needle” cannula:

- It’s the most commonly used device- Mounted over the needle:once device is pushed off of the needle into the vein, the stylet is removed- Drug, blood and fluid administration

Colour Gauge

Flow/Rate mls/min

Type of infusion

Orange 14 343 -Rapid blood transfusion-Emergencies

Grey 16 196 -Rapid blood transfusion-Emergencies

Green 18 90 Blood products, medicines, fluids

Pink 20 61 General crystalloid use

Blue 22 36 Paediatrics, oncology

Yellow 24 22 Paediatrics, oncology, neonatology, elderly

TOURNIQUET

- Know how to use it before approaching patient!- 5 cm above site (3 finger breadths)- 2 fingered gap- Apply tourniquet to the upper arm ensuring it does not obstruct arterial flow- Check patient is comfortable

A LATEX GLOVE MUST NEVER BE USED

THE CEPHALIC VEIN It readily accommodates a large-gauge

cannula and, by its position on the forearm, provides a natural splint.

However, its position at a joint may increase complications such as mechanical phlebitis and even general discomfort.

The tendons controlling the thumb obscure the vein during insertion and care must be taken not to touch the radial nerve.

THE BASILIC VEINThe basilic vein is a large vessel, which is often overlooked due to its inconspicuous position on the ulnar border of the hand and forearm.

Cannulation can be awkward due to its position, its tendency to have many valves and to roll easily.

METACARPAL VEINS

Ideal position for IV; primary choice in pregnancy although veins are thin with inadequate tissue and muscle support in the elderly

Dorsal venous network

Not very stable:Usually easily visualized and palpated but can only accommodate smaller gauge catheters

Last resort for short-term therapy

CONSIDERATIONS-Appropriate preparation of environment –

including consent and adequate lighting / client comfort.

-Use equipment designed for the specific purpose /task e.g. a proper tourniquet, skin prep, small sharps bin

-Awareness of woman’s history

-Good technique – including assessment of vessel and woman throughout, and insertion of cannula along the line of the vein NOT across.

-Adequate infection control/skin cleansing and wearing of gloves. Beware of sharps!!

TECHNIQUEIntroduce yourself and explain procedure

Wash handsApply tourniquetAsk the woman to clench her fist

Identify veinPut on glovesClean the skin

CANNULA INSERTIONHold catheter in dominant hand“Anchor” veinBevel up, quick, short, jabbing motion to enter skin (at about a 20-30 degree angle in the direction of the vein)

As you enter the vein, you will see flashback

Advance catheter whilst simultaneously withdrawing needle to enter vein until 2nd flashback is seen along cannula

ONCE INSIDE THE VEINAdvance plastic catheterShould slide easily: do not force it

Release tourniquet, ask the woman to bend arm and apply pressure at the distal end on the catheter.

Withdraw needle ensuring the catheter stays in vein

Never insert a needle into the catheter while it is in the woman’s arm

YOU HAVE DONE IT!!Dispose of needle in sharps containerSecure the cannula as per hospital

policyDraw bloods if you need to or connect

purged giving setWrite date and time of insertion of

cannula on dressingDocument: location of insertion, type

and gauge, date and time, bloods taken, number and location of attempts, adverse events.

TROUBLESHOOTING If you don’t get flashback, do not remove

cannulaSlowly withdraw while watching for flashbackIf not in vein, change direction of the needle

slighltlyIf still unsuccessful, do not panic: we all have

failed at some point!Release tourniquet, place gauze over puncture,

remove catheter, tape down gauze?Try on another arm / ?Ask another team

memberIf you hit an artery, remove catheter and apply firm pressure for at least 5

minutes

PRINCIPLES OF CARETo prevent morbidity -

infection and trauma.To maintain a ‘closed’ IV

system with few connections to reduce the risk of contamination.

To maintain a patent device.To prevent damage to the

device and associated equipment

CANNULA CAREChange catheter site every 48-72 hrs

Inspection and documentation of status of cannula and area on each shift

? Flush device prior to administering a drug or connecting fluids

RISKS & COMPLICATIONS

- - Damage to nerves and local tissue caused by poor technique

- - Fibrosis of vessels caused by intima layer of vessel becoming roughened by scarring with the cannula.

- - Haematoma – caused by ‘overshooting’ the vessel.

- - Alcohol must be allowed to dry to avoid irritation to tissues

COMPLICATIONS- Extravasation: inadvertent administration of a vesicant solution or drug into the tissues

- Phlebitis caused by inadequate cleansing or poor infection control technique allowing entry of bacteria or micro-organisms

COMPLICATIONS: PhlebitisSIGNS & SYMPTOMS:

◦Redness or tenderness at tip of catheter or along infusion site

◦Puffy tissue over vein◦Elevated temperatureWHAT TO DO:

- Stop infusion- Remove catheter- Call for help- Document

COMPLICATIONS:Cellulitis/infection

SINGS & SYMPTOMS◦Warm/hot◦Swelling◦Possibly febrile◦MalaiseWHAT TO DO:- Stop infusion- Remove catheter- Call for help- Document

BIBLIOGRAPHY

http://www.youtube.com/watch?v=E8MDwv5YId0&feature=related

http://www.youtube.com/watch?v=Vrg69FlHi6g