peripheral iv cannulation

PERIPHERAL PERIPHERAL INTRA-VENOUS (I.V.)INTRA-VENOUS (I.V.)

CANNULATIONCANNULATIONhttp://www.nationwidechildrens.org/GD/DocumentManagement

IntroductionIntroduction

I.V. equipment and therapies have become more complex

The number of patients in hospitals receiving I.V therapy (includes medication administration for acute incidents eg. I.V. Morphine, for pain relief), is 80% plus.

It is important to understand the legal aspects/implications of practicing I.V. procedures/therapy.

Your ResponsibilitiesYour Responsibilities

You are responsible for obtaining and adhering to organisational guidelines. (Includes scope of practice guidelines)

You need to:Have appropriate theory and skill

preparation.Maintain your individual accreditation in

compliance with institutional or hospital guidelines.

Liability and LitigationLiability and Litigation

Litigation is usually undertaken in the case of:

Infiltration/Extravasation

Phlebitis

Air embolism

Breakage of I.V./C.V.C. in situ

Haematomas causing compression injury.

PreventionPrevention

In the case of infiltration, there would be no case for litigation if the following standard practices were followed:

I.V. site was observed immediately after starting the infusion/or whilst administering the medication.

Infiltration was notedInfusion/medication administration was stopped

immediately and I.V. was removed.Incident was documented.

Prevention cont.Prevention cont.

If infiltration was allowed to develop into oedema of the arm or wrist, there is a strong case of litigation as lawyers can use equations to determine how long the infusion was left unmonitored.

To allow infiltration to develop to this stage indicates a failure to observe standard practices.


Preventing complications for the patient and nurse:

Know your organisations policy on I.V. therapy.

Check and inspect the I.V. Site regularly.

Ask the patient how the I.V. site feels.

Document

Troubleshoot and report any problems.


Ensure your practice is up to standard.

The nurse who inserted the I.V. needs to be able to explain:

Vein selection and what criteria was used.

Criteria for the selection of I.V. gauge.

Method used to check if the device was working.

Venous anatomy and physiology.


The nurse looking after a patient with an I.V. infusion, needs to explain:

The standard operating procedure for the infusion pump being used.

Type of solution or medication being infused. It’s side effects and interventions.

DocumentationDocumentation

The following must be documented when practicing I.V. therapy:Time and dateName of vein accessedGauge and length of I.V. cannulaSolution being administered and rate of flow.Use of pump or gravity I.V. set.Assessment of I.V. site.Patient responseAny interventions taken to resolve an I.V. problem.Notification of Doctor.

Anatomy and Physiology of the Anatomy and Physiology of the Forearm and HandForearm and Hand

Muscles and tendons

Nerves

Arteries

Veins

Muscles and Tendons of the Forearm Muscles and Tendons of the Forearm and Handand Hand

Biceps Brachii – Large conspicuous muscle lies anterior to the humerous. It is inserted by the biceps brachii tendon at the tuberosity of the radius.

The biceps brachii tendon is deep in the ante cubital fossa and lies to the side and beneath the radial artery.

The broad flat part of this tendon is called the Bicipital Aponeurosis that descends across the brachial artery and fuses with the fascia of the forearm flexor muscles.

The biceps brachii flexes and supinates the forearm

Muscles and tendons cont.Muscles and tendons cont.

Brachioradialis muscle:

Origin is at the anterior distal surface of the humerous.

It runs along the radial (thumb) aspect of the forearm.

It forms a long tendon that inserts at the styloid process of the radius.

It flexes the forearm

Muscles and Tendons cont.Muscles and Tendons cont.

Superficial flexor muscles include:Palmaris LongusFlexor Carpi RadialisFlexor carpi UlnarisFlexor Digitorum SuperficialisThis group of muscles is attached proximally to the humerous.They end more than halfway down to the wrist, in long tendons (which

take the names of the muscles of origin)These tendons tunnel under the flexor retinaculum, into the palm and

insert into the bases of the metacarpal bones.Responsible for flexion, abduction, adduction of the palm.

Muscles and Tendons cont.Muscles and Tendons cont.

Superficial extensor muscles include:Extensor Carpi UlnarisExtensor DigitorumExtensor Carpi Radialis BrevisExtensor Digiti MinimiThese muscles descend down the posterior medial aspect of

the forearm and above the wrist they divide into tendons.The tendons of the extensor digitorum divide into four and

tunnel under the extensor retinaculum, they diverge on the dorsum of the hand, one tendon to each finger.

Muscles of the forearmMuscles of the forearm

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Nerves of the Forearm and HandNerves of the Forearm and Hand

Supplied by four main nerves:

Musculocutaneous nerve

Median nerve

Radial nerve

Ulna nerve

These nerves originate from the brachial plexus in the shoulder.

Nerves cont.Nerves cont.

Musculocutaneous nerveSupplies motor fibres to biceps brachiiSupplies sensory fibres to the lateral forearmLocated between the biceps and brachialis muscles. At the

elbow it continues as the Lateral Cutaneous nerve of the forearm. It passes beneath the Cephalic Vein and runs adjacent to it.

It divides to form the posterior and anterior branch of the Lateral Cutaneous nerve, which descend along the radial border of the forearm to the wrist.


Median nerveSupplies motor fibres to flexor muscles in the anterior aspect of

the arm.Supplies sensory fibres to the radial half of the palm.Located in the upper arm adjacent to the biceps brachiiCrosses in front of the radial artery deep into the forearm.Descends down the medial aspect of the forearm.Emerges between the tendons of the flexor muscles to supply

the hand.


Injury to the Median Nerve results in:

Inability to pronate the forearm

Inability to flex the wrist properly

Second phalanges of index and middle finger cannot be flexed.

Thumb cannot be flexed or abducted resulting in the inability to pick up small objects.


Ulnar Nerve

Supplies motor fibres to the anteromedial flexor muscles and skin in the ulnar aspect of the arm.

It is deep and protected by the flexor carpi ulnaris muscle.

Runs along the anterior aspect of the forearm, emerges approximately 5cm below the wrist, divides into branches supplying the hand.


Injury to the Ulnar Nerve results in:

Impaired flexion and adduction of the wrist.

Difficulty in spreading fingers, hand can become clawed.


Radial NerveSupplies motor fibres to the muscles on the posterior aspect of

the arm, forearm and hand.Supplies sensory fibres to the skin in the same area.Located under the triceps brachii muscleIn the upper arm.Descends down the posterior aspect of the arm where it forms

several branches, located under the posterior extensor muscle.

Two main branches of the Radial Nerve- deep and superficial terminal branch.


Radial nerve cont.

The superficial terminal branch descend behind the brachii radial muscle, lateral to the radial artery. It curves around the side of the radius (approximately 7cm from the wrist) over the top of the wrist where it divides into five dorsal digital nerves.


Injury to the Radial Nerve results in:

Inability to extend the hand at the wrist – wrist drop.

Loss of sensation to the skin of the radial aspect of the hand.

Nerves of the forearmNerves of the forearm

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Blood VesselsBlood Vessels

Peripheral Veins

Take oxygenated blood back to the heart.

It is a low pressure system (veins can collapse).

The walls of the vessels are small and thin but muscular and are able to contract and expand.

Veins contain valves which aid in maintaining blood flow in one direction.

Veins are generally more superficial.

Arterial Supply to the forearmArterial Supply to the forearm

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Blood Vessels cont.Blood Vessels cont.

Peripheral Arteries

Transport oxygenated blood from the heart to tissues.

They have thick muscular walls.

They do not require valves due to pulsation and high pressures, they do not collapse.

They are deep and protected.

Blood Vessels cont.Blood Vessels cont.

Blood vessel structure:Tunica InternaInner layerElastic endothelial liningBasement membraneTunica MediaMiddle layerContains nerve fibres and smooth muscle liningTunica ExternaOuter layerContains fiberous connective tissue, gives strength to arterial

wall, will resist rupture due to thickness.

Arteries cont.Arteries cont.

Brachial Artery continues down from the axilliary artery, ends approximately 1cm distal to the elbow joint.

It then divides into the radial and ulnar arteries.

The brachial artery is superficial, covered only by skin and fascia of the Bicipital Aponeurosis.

The median nerve runs along side it.


Radial artery is a more direct continuation of the brachial artery.Smaller than the ulnar arteryBegins approximately 1cm below the bend of the elbow.Descends along the lateral side of the forearm to the wristThe radial pulse is felt on the radial aspect of the wrist (thumb side),

where the artery passes in front of the radius bone.As the radial artery passes over the wrist it bifricates into the superficial

palmar branch.The radial artery also passes under the carpal bones of the thumb to

form the deep palmar archDigital arteries branch from both arches to supply the fingers.


Ulnar artery is the larger terminal branch of the brachial artery.

Begins below the bend of the elbow and courses down the medial aspect of the forearm and wrist.

It crosses the palmar surface of the hand where it forms the main component of the superficial palmar arch.

Arteries on the dorsum of the hand are mostly deep and protected by the overlying tendons and faciae.

Venous Supply to the ForearmVenous Supply to the Forearm

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Blood Vessels - VeinsBlood Vessels - Veins

Divided into two groups Superficial and Deep

Superficial veins show considerable individual variation.

They are subcutaneous in the fasciae and are easily palpable.

Superficial Veins cont.Superficial Veins cont.

Cephalic Vein begins in the dorsal venous network on the posterior dorsum of the hand (radial aspect).

Ascends along the lateral border of the forearmForms the median cubital vein in front of the ante cubital

fossa. The median cubital vein can sometimes be large and transfer most of the blood from the cephalic vein to the upper bascilic vein. The proximal cephalic vein may be absent or diminished.

Accessory cephalic vein ascends from the wrist, moves medially up the posterior forearm and turns over to the ante cubital fossa.


Basilic Vein begins in the dorsal venous network and ascends along the posterior ulnar side of the wrist.

In the forearm it inclines around the medial anterior surface.

It forms one of the large veins of the ante cubital fossa as it ascends into the upper arm to join the right axillary vein


Median Vein drains the palmar venous arch.

Ascends anterior in the forearm to join the median cubital vein or the basilic vein.

May divide below the elbow and join both the above veins.

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Veins cont.Veins cont.

Deep veinsAccompany arteries.Usually in pairs on either side of the artery and are

connected by short crosslinks.The deep veins are relatively small.Most of the blood in the fore arm is returned by the

superficial veins.They are not advised for use for routine I.V. access

due to their close proximity to arteries and nerves.

Deep veins cont.Deep veins cont.

Radial veins drain the dorsal metacarpal veins and run alongside the radial artery.

Ulnar veins drain the palmar venus arch and run alongside the ulnar artery.

These veins join up to form the deep brachial vein in the elbow. A large venous branch can also connect them to the median cubital vein.

Complications of I.V. TherapyComplications of I.V. Therapy

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Complications cont.Complications cont.

5% of all nosocomial infections result from I.V. therapy.

80-85% of hospital patients receive I.V. therapy.

There is an estimated 40-60% incidence of complications from I.V. therapy.

Infiltration/ExtravasationInfiltration/Extravasation

Definition:Diffusion or accumulation of injected fluid into the

subcutaneous space.Cause:Cannula displaced out of the vein wall.S&S:Swelling and painSlowing of the infusionCoolness of the skin

Infiltration/Extravasation cont.Infiltration/Extravasation cont.

Prevention:Appropriate selection of site and cannulaProper stabilisation of the cannulation and tubingFrequent checking of the insertion site.Intervention:Remove I.V. cannula immediatelyApply ice (early) or warm compress (late) to aid

absorption.Use recommended antidote or treatment for

specific drug extravasations.

HaematomaHaematoma

Definition:Localised collection of extravasated blood, usually clotted, in an organ

or tissue.Cause:Blood leaking out of the vein into the tissue due to puncture or trauma.S&SSwelling, tenderness and discolouration.PreventionProper device insertionPressure over site on removalInterventionApply appropriate pressure bandage, monitor.

PhlebitisPhlebitis

Definition:Inflammation of the veinCause:Poor aseptic techniqueHigh osmolarity I.V. infusions or drugsTrauma to the vein during insertion/incorrect

cannula gaugeProlonged use of the same site

Phlebitis cont.Phlebitis cont.

Symptoms:Tenderness, redness, heat and oedemaAdvanced-induration, palpable venous cord.Prevention:Smooth insertionAseptic techniqueStabilisation and secure taping of all tubingRotation of the siteReplace loose and contaminated dressingsDilution of drugsFrequent observation of site

Phlebitis cont.Phlebitis cont.

Intervention:

Remove cannula and apply warm compresses.

Observe for signs of infection

If phlebitis is advanced antibiotics may be required.

ThrombophlebitisThrombophlebitis

Definition:Formation of a thrombus and inflammation in

the vein, usually occurs after phlebitis.Cause:Injury to the veinInfectionChemical irritationProlonged use of the same vein

Thrombophlebitis cont.Thrombophlebitis cont.

S&S:Tenderness/rednessHeat/oedemaCordlike appearance of the veinSlowing of the I.V. infusionPrevention:Smooth insertionAsepsisStabilisation of I.V. cannula and tubingCorrect administration of drugsChange cannula frequently (72hrs)Intervention:Remove I.V. cannulaObserve for signs of infection

VenespasmVenespasm

Definition: spasm of the vein wall.Cause:AnxietyCold I.V. fluidsDrug irritationTrauma to the vein during cannula insertionS&S:PainSlowing of the I.V. infusionBlanching at the insertion siteVein difficult to palpate

Venespasm cont.Venespasm cont.

Prevention:

Warm arm bath prior to cannula insertion

Reassurance

Allow infusions to come to room temperature.

Interventions:

Warm compresses

Slow infusion rate

Reassurance

OcclusionOcclusion

Definition: slowing or cessation of fluid infusion due to:Fibrin formation in or around the tip of the cannulaMechanical occlusion (kink) of the cannulaCause:Cannula not flushedKinking of the cannulaBack flow or interrupted flowS&S:I.V. not runningBlood in the lineDiscomfort

Occlusion cont.Occlusion cont.

Prevention:Check I.V. site regularlyFlushing of cannula frequentlyAvoid increased venous pressure proximally to the

cannula (BP cuff)Intervention:Check for kinks in cannulaRaise I.V. flask higherRemove cannula

InfectionInfection

Definition: Pathogen in the surrounding tissue of the I.V. site.

Cause:Lack of asepsisProlonged use of the same siteS&S:Tenderness and swellingErythema/purulent drainage

Infection cont.Infection cont.

Prevention:

Frequent checking of the site

Intervention:

Remove cannula

Antibiotics may be required

Documentation

Other complicationsOther complications

Fluid overload

Electrolyte imbalance

Transfusion reactions

Air embolus

Resources and ReferencesResources and References

Journal of intravenous nursing, Vol 18 (2), 1998“Reducing the risks of complications in I.V. therapy”

Dougherty, RN. Nursing Standard, Oct 22 (12), 1997

Principles of anatomy and physiology, Gerard J. Tortora, Nicholas P. Anagnostakos. Fifth Edition

The Joanna Briggs Institute, Best Practice Management of Peripheral Intravenous Devices 11/02/2008 http://www.joannabriggs.edu.au/best_practice/bp3.php

I.V. Cannulation TechniqueI.V. Cannulation Technique

Identification & selection of a suitable vein:

Patients medical history

Age, body size and general condition

Type of blood sample required for I.V. fluid/medication to be infused

Expected duration of I.V. therapy

Your skill at venepuncture or cannulation

Technique cont.Technique cont.

For I.V therapy that is to continue for several days, start with the most distal location available and move up as necessary.

For an obese patient the hand veins may be the only accessible site.

The cephalic vein can offer a comfortable site in a thin patient, if placed to avoid interfering with flexion.


Proficiency is achieved by:Practicing on real patients and all types of arm

sites.Observe the procedure several times, then try

yourself under supervision.Ask for feedbackDo not be discouraged by failures, you may have a

fewCARDINAL RULE : Do not persist after two (2)

unsuccessful attempts on the same patient. Get a more experienced member of staff to help.


Choosing the site: Adult patientVeins in the hands may be a good first choice. Allows for

availability of more proximal sites. (Dorsal & Metacarpal Veins)

Lower arm veins are good for shorter term I.V. therapy. Leaves the patient’s hands free, larger arm veins do not become phlebetic as quickly. (Cephalic & Basilic Veins)

The antecubital fossa provides good veins for blood sampling as they are very prominent. They are not recommended for long term I.V. therapy as placement interferes with flexion.

Upper arm veins should only be used as a third choice, when all other sites have been used.


Veins used as a last resort:The inner aspect of the arm: painful site, prone to

bruising, phlebitis and infiltration.Antecubital fossa: suitable for blood sampling and

short term infusion due to position.Legs, feet and ankles: requires medical approval as

mobility is reduced and circulation can be compromised.

The dorsum of the foot and the saphenous vein of the ankle are the best sites to try if necessary.

I.V. sitesI.V. sites

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Sites to avoid:Veins below previous I.V. infiltration or phlebetic

sites.Sclerosed or thrombosed veins.Areas of skin inflammation, bruising or breakdown.An arm affected lymphedema, node dissection after

mastectomy, thrombosis, cellulitis or infection.Arm with an arteriovenous shunt or fistula.

Cannulation DevicesCannulation Devices

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Vein IdentificationVein Identification

Dorsal Metacarpal Veins – usually prominent and visible, lie flat on the hand, easy to feel, easily accessible.

Hand provides a flat surface for stability.Phlebitis and infiltration occur more easily due to small vein size

and hand movement.Haematomas form rapidly.May not be appropriate for elderly patient’s due to diminished

skin turgor and subcutaneous tissue.Limited hand movement particularly for patients using crutches

and frames.22gauge or smaller/1 inch or shorter.

Vein Identification cont.Vein Identification cont.

Cephalic Veins begin in the dorsal venous network on the thumb side of the hand and ascends along the lateral border of the forearm.

Excellent route for I.V. infusions.Larger vein, providing haemodilution for hypertonic or irritating

solutions.Arm bones act as a natural splint.May be accessed from the wrist to the upper arm. Access in the wrist

can result in phlebitis and infiltration due to hand movement.Vein tends to roll during insertion of cannula device.Use the smallest and shortest cannula to accommodate therapy.22-18 gauge


Basillic Vein begins in the dorsal venous network on the little finger side of the hand and ascends along the medial side of the forearm.

Straighter in the upper arm than the Cephalic vein, large and prominent vein.

Inconspicous positioning on the medial side of the forearm, results in this site often not being considered.

May be accessed anywhere along it’s course, vein tends to roll and may be awkward to access due to it’s position.

Can accommodate a larger cannula.22-18 gauge


Antecubital Veins located in the inner aspect of the elbow and are comprised of the Median Cubital, Accessory Cephalic and Basilic Veins

Often used for short term or emergency access, generally blood sampling only.

Last resort site for I.V. therapy or PICC line or midline catheter.

Painful site due to numerous nerve endings in this area.

All gauge sizes are suitable.

Locating a suitable veinLocating a suitable vein

Inspect and palpate

Vein should feel FIRM, ROUND, ELASTIC and ENGORGED.

Do not use if vein feels KNOTTY, HARD or SMALL.

AVOID ARTERIES – when cannulating in the antecubital fossa, palpate for arterial pulsation.

Assess both arms before making final selection, ask patient about past experiences.

Cannula SelectionCannula Selection

Use the smallest cannula that will achieve the desired outcome –

24 gauge can infuse 3 litres in 24hrs. 22 gauge can complete a 3 unit blood transfusion.Cannula must be smaller than the vein to increase

haemodilution, thereby reduce irritation and prevent mechanical phlebitis.

Solutions containing medications and Hypertonic solutions requuire larger veins to be cannulated to dilute the fluid and prevent mechanical phlebitis.

I.V. Therapy EquipmentI.V. Therapy Equipment

Cannula & Needles:Mostly made from teflon or

Polyurethane. Completely

retractable stylets to prevent

Needle stick injury, are recent

Advancements.

Recessed needles and cannula

will replace exposed needles

eventually.

I.V. Equipment cont.I.V. Equipment cont.

I.V. administration sets (giving set)Moving to a needless system

where a blunt cannula can be

used in the Y port (Interlink ®).

Tubing is being developed that

will not absorb drugs or ‘leech’

plastic particles into the solution.

Non PVC tubing will be less toxic

when disposed of.

I.V. Equipment cont.I.V. Equipment cont.

I.V. Drugs & SolutionsMany solutions and antibiotics

now come pre-mixed in “add-a-

Line’ giving bags.

Computerised delivery systems

will replace infusion pumps.

These systems will be multi-

channel and deliver drugs and

fluids according to I.V. protocols

That are preprogrammed.

Equipment required for CannulationEquipment required for Cannulation

TorniquetDressing packAbsorbant pad “bluey”GlovesSelected I.V. cannulaSkin cleansing prep.5 or 10ml syringes ( for saline flush and/or blood sampling)3 way tap or bungI.V. fluids and primed giving set.Occlusive dressing ‘Opsite” or ‘Tegaderm’.TapeBlood tubes if blood sampling performed.Aseptic Handwash for 1 min. required prior to donning gloves.

Preparation for the procedurePreparation for the procedure

Gather equipment and prime I.V. tubing before approaching the patient.

Explain the procedure, gain consent, reassure.Position the patient to allow easy access to the desired site,

ensure patient and yourself are comfortable.Position the arm below heart level to encourage capillary filling.Rub the arm (gently) to warm the skin and inspect the area of

intended insertion.If necessary cover the arm with warm packs to promote

vasodilatation.Be confident, but know your limitations.

1. Applying the torniquet1. Applying the torniquet

Apply 5-7cm below the antecubital fossa, if cannulating the hand or lower arm.Tourniquet should be tight enough to trap venous blood in the veins without cutting off arterial flow.Remove if veins are not filling up well. Allow vessels to refill then reapply the tourniquet. Veins may “rebound” and fill better.In elderly patients, lift the tourniquet up, stretch the skin, and underlying tissues away from the venipuncture site. Gently lower the tourniquet.Ask the patient to clench their fist several times to encourage the veins to become turgid and more rounded.

2. Pre-Cannulation2. Pre-Cannulation

Identify desirable veinEncourage vein to enlarge by lightly flicking to stimulate mechanical reflex dilation.Palpate the vein, should feel elastic and resilient.Shave or clip hair if necessary.Cleanse site with skin prep. In a circular motion from inside out.Allow to dry. Much of the solution’s germicidal action takes place during the drying period (+/- 1 min.)

3. Vein stabilisation3. Vein stabilisation

Immobilise vein: prevent rolling by maintaining vein in a taut, distended, stable position.Hand vein: - Grasp patient’s hand with your non-dominant hand. - Place your fingers under the palm and fingers with your thumb on top of the patient’s hand. - Pull hand downward to flex wrist and create an arch. - Elbow remains supported on the bed. - Stretch skin down over the knuckles with your thumb to stabilise vein. - Keep a firm grip during insertion.

Vein stabilisation cont.Vein stabilisation cont.

Cephalic Vein:

Ask patient to clench their fist.

Pull fist down laterally.

Lower arm Vein:

Anchor vein below site of insertion with thumb and pull skin taut.

4. Inserting the cannula4. Inserting the cannula

Venepuncture:Hold the needle (with syringe) bevel side up over the vein.

Enter the vein – in a smooth deft motion – at a 25-30 degree angle.

Observe for blood in the coloured hub of the needle.

Holding the syringe steady, remove your anchor ‘hand’ and use it to gently withdraw the syringe plunger until sufficient blood is obtained.

Collect cotton ball/gauze in your free hand, remove needle from the vein in a quick motion, immediately place the cotton ball/gauze over the puncture site and tape securely.

Maintain firm direct pressure over area for a few minutes (patient can be asked to do this), to stop the bleeding.

Inserting the cannulaInserting the cannula

Cannulation:

Hold the flashback chamber of the cannula, not the coloured “hub”.

Hold the cannula over the vein, bevel side up and pointing in the direction of blood flow.

Use an approach angle of 15 degrees for superficial veins and 25-30 degrees for deeper veins.

5. Inserting the cannula5. Inserting the cannula

Insert the cannula through the skin with a smooth assertive motion.

Observe for “flask back” of blood into the flash chamber. This indicates that the vein has been penetrated successfully.

Lower the cannula angle and continue to advance the cannula 2-3mm further into the vein.

Inserting the cannula cont.Inserting the cannula cont.

With one hand, hold the stylet in place and use the other hand to advance the catheter over the stylet into the vein.Release the tourniquet.Remove the stylet whilst holding the cannula hub, minimise blood leakage by applying pressure to vein beyond cannula tip with finger.NEVER reintroduce the stylet if the cannula does not feed into the chosen vein.The cannula can shear off and enter the patient’s circulation

Post-CannulationPost-Cannulation

Flushing with 5ml of normal saline checks patency of the vein.Connect I.V. giving set, or tap to the cannula.Cover with sterile transparent dressing, allows for observation of the insertion site, allowing for early detection of complications.Label dressing with date and time of insertion and cannula size.Stabilise tubing independently of the cannula, splint arm if necessary.Commence I.V. infusion as required.Reassure patient, dispose of equipment correctly, wash hands, document.

TroubleshootingTroubleshooting

Back flow stops when stylet is removed:Opposite wall of the vein may have been pierced.Retract cannula slightly without removing

tourniquet, until “flash back” appears again. This indicates the tip of cannula is back in the lumen, quickly advance the cannula into the vein.

Release tourniquet.Stop procedure if haematoma develops or if there

is leakage from the insertion site. May occur in elderly patient’s due to fragile veins.

Troubleshooting cont.Troubleshooting cont.

Venospasm can prevent cannula insertion, usually common in anxious patients. Reassure patient and allow them to rest for a short period. Warm arm bath can assist in correcting this problem.

Improper torniquet placement – too high, low, tight or loose, can cause insufficient engorgement of vein.

Failure to release torniquet promptly may cause bleeding outside the vein.

A tentative stop start approach can injure the vein.

Inadequate vein stretching which allows the cannula to push the vein to the side instead of entering.

Troubleshooting cont.Troubleshooting cont.

Stopping to soon after insertion so that only the stylet, not the cannula has entered the lumen. Blood “flash back” disappears when the stylet is removed. Discontinue and restart procedure.

Failure to penetrate vein wall due to improper insertion angle causing the cannula to ride on top of, or below, the vein. Discontinue and restart the prodedure.

Resources and ReferencesResources and References

Journal of intravenous nursing, Vol 18 (2), 1998“Reducing the risks of complications in I.V. therapy” Dougherty,

RN. Nursing Standard, Oct 22 (12), 1997Principles of anatomy and physiology, Gerard J. Tortora,

Nicholas P. Anagnostakos. Fifth EditionThe Joanna Briggs Institute, Best Practice Management of

Peripheral Intravenous Devices 11/02/2008 http://www.joannabriggs.edu.au/best_practice/bp3.php

All pictures for cannulation procedure:http://www.qub.ac.uk/cskills/iv_cannulation/iv_cannulation.htm

peripheral iv cannulation

Health & Medicine

forearm flexor muscles

hand muscles

muscles of origin

lateral forearm

forearm http

group of muscles

brachialis muscles

long tendons