Best Practices in IV Cannulation

Date/Location
WHY IV CANNULATION ?

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BASIC ANATOMY

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 VEINS
Tunica Intima

Tunica Adventitia

Valve

Tunica Media

Veins have 03 layers: 4

 TUNICA INTIMA

Inner most layer of the vein

Consists of smooth, elastic endothelial lining

Damage to this lining or presence of foreign material

induces an inflammatory response
Resulting complications - Phlebitis, Thrombus
formation
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 TUNICA MEDIA

The middle layer is made of muscles & elastic tissue

Nerve fibres are present in this area

Stimulation of this layer by cold infusions and

irritating medications can cause Vasospasm
Patients may feel pain during venepuncture, when the
needle penetrates this layer
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 TUNICA ADVENTITIA

The outer layer of the vein consists of connective

tissue
Provides support & protection to the vein

Blood vessels to the vein are also present in this layer

A hematoma may be formed, if one of the vessels is

penetrated
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 VEINS USED FOR
CANNULATION
Basilic
Cephalic

Metacarpal

Median
Cubital

Cephalic

Basilic

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 ARTERIES

Do not have valves

Pressure within the artery keeps blood moving in

appropriate direction
Arterial flow is downward - with gravity

Are much deeper than veins & surrounded by nerve

endings
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 Blood Vessels

Vein Valve

Tunica Intima

Tunica Media

Tunica
Adventitia

Artery

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 Arteries

Brachial
Artery

Radial Artery

Ulnar Artery
Veins, Arteries
& Nerves
Cephalic
Basillic
Radial
Brachial Artery

Radial 1st Intercostal

Artery
Cephalic Vein

Veins Median Cubital

Median
Vein

Arteries Ulnar Ulnar Artery

Nerves Basilic

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 Initiation of Therapy

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INITIATION OF THERAPY

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 Equipment
required

Examination
Tourniquet
gloves Gauze squares Adhesive tape

Surgical
Sterile drapes
scissors Clear, moist permeable Site label (to record time
dressing of insertion)

Antiseptic Swabs
Check integrity of
packaging, solution for
cloudiness & expiry date
of material

I.V. Catheter
 Catheter CATHETER
selection

Ported

Non-Ported

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 CATHETER PARTS

Luer Lock
Plug Needle
grip Injection
port
cap

Cannula Flashback
hub chamber
+ wings

Valve Cannul
a
Bevel

Trim
distanc
Needle
e

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 Best Practices in IV Access – Initiation of therapy

TRIM DISTANCE CONSISTENCY

Indications

Patient assessment

Patient preparation.
Catheter over
Patient identification nccedl bevel Catheter too long
Site selection

Device selection

- Devices

- Cannul selection

- Catheter parts
Correct
- Cannula gauge Correct catheter length
lie distance

Lie distance
Catheter too short
too long
 CATHETER SELECTION

The smallest gauge and shortest

length appropriate for therapy
 CANNULA GAUGE

Gauge corresponds to external diameter of the catheter

• Is governed by ISO 10555

Gauge of the cannula is important

• The smaller the gauge, the less irritating to the vein

Thin-wall concept

• Same external diameter but higher internal diameter

• Better flow rates
• Option to choose a finer gauge
• Minimises complications

Larger gauge catheter:

• Prevents proper haemodilution

• Prohibits adequate blood flow around the cannula
• Can cause trauma to the Tunica intima

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COMMON APPLICATIONS
 Patient
preparation
PATIENT PREPARATION

1
2
3

5
6

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 Site SITE SELECTION
Selection

• Vein selected should accommodate both the gauge & the length of the catheter selected
• IV sites on the extremities should be chosen from most Distal to proximal
• This avoids infusion of medications through a previously traumatised area & preserves veins
for future venipuncture
• Ideal Vein characteristics
• Easily palpable veins with good capillary refill
• Veins in the non-dominant side
• Veins opposite to surgical procedure
• Veins with the largest diameter

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 SITES TO AVOID

• Small visible superficial veins

• Veins in the lower extremities
• Veins irritated from previous use
• (May lead to Deep Vein Thrombosis)
• Sclerosed veins
• Points of flexion
• Limbs affected by clinical condition
• Veins close to arteries
• Infected sites
• Obvious valves
• Broken skin
• Median cubital veins

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 HAND HYGIENE GUIDELINES

When hands are

visibly dirty
• Wash with non
antimicrobial or
antimicrobial soap
and water Multiple use towels
Antispetic soaps as Wearing Gloves
Non antimicrobial are not
next most effective does not replace the
soaps are the least recommended for
after alcohol based need for hand
effective use in healthcare
hand rubs hygiene
settings

It is recommended for all

clinical indications
( except when hands are
visibly soiled )
Antiseptic hand rub
( typically alcohol based)
are most effective
It is also one of the
options for surgical hand
antisepsis

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VEIN DILATATION TECHNIQUE

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 SITE PREPARATION

• Remove excess of hair with

Clippers –
• do not shave!
• Antiseptic apply -
Chlorhexidine or 70%
Isopropyl alcohol
• Apply antiseptic in a circular
motion, starting at the
intended puncture site
working outwards
• Allow antiseptic solution to
dry completely
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CANNULATION TECHNIQUE
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CANNULATION TECHNIQUE

• Apply tourniquet at least

12 - 15 cm above
insertion site
• Tourniquet should be
tight enough to restrict
venous flow but not
arterial flow.
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CANNULATION TECHNIQUE

• Prepare site with appropriate

antiseptic
• Remove needle cover and inspect
catheter for any defects.
• Twist stylet 180° within the catheter
or until a pop is felt.
• Reseat hub on flash chamber
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CANNULATION TECHNIQUE

• Maintain traction on the skin

to anchor the vein.
• Hold the catheter with thumb
(behind the thumb rest) with
the 2nd and the 3rd finger in
front of the side port or
catheter wings
• Ensure cannula is in bevel up
position
• Insert the stylet through the
skin and into the vein at an
angle of 15° to 30 °
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CANNULATION TECHNIQUE

• Entry of the needle tip into

the vein is indicated by
presence of blood in the
flashback chamber
• Upon visualisation of
flashback decrease the
catheter to skin angle
(virtually parallel) to the
skin.
• Advance the entire
catheter another couple of
millimeters.
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CANNULATION TECHNIQUE

• Hold the stylet stationary

and advance the
catheter off the stylet
and into the vein.
(The needle to be
withdrawn only a few
mm as the needle acts
as stabiliser for a
catheter to move in the
vein)
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CANNULATION TECHNIQUE

• Remove tourniquet
• Remove the stylet while
applying digital pressure
to the vein just beyond
the catheter tip (to
prevent excessive
bleeding)
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CANNULATION TECHNIQUE

• Immediately carefully dispose

of the stylet in an
appropriately labelled sharps
disposal unit.
• Connect the pre-primed
I.V.Set - check & adjust flow
rate.
• Alternatively connect the
sterile luer-lok plug
• Flush the catheter through the
injection port
• Document details
 CATHETER FLUSHING

• Syringe size
– PIV – any size syringe
– CVC – 10 mL syringe or
equivalent syringe
diameter
• Technique
– Positive fluid displacement
 CATHETER FLUSHING

• PIV 1-3 mL normal saline

• Volumes and solutions
– Minimum of twice the volume of the catheter
plus anything added to it, such as an extension
tube
– Common locking volumes and solutions
• CVC 3-5 mL heparinized saline (10 u/mL)
• Port 3-5 mL heparinized saline (100 u/mL)
 Fixation Technique

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Vascular Access Device Stabilization

• Vascular access device stabilization shall be used

to:
– Preserve the integrity of the access device
– Minimize catheter movement at the hub
– Prevent catheter dislodgement and loss of access
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OCCLUSIVE DRESSINGS

• A clear waterproof
dressing allows
• Puncture site to be
visible
• Patient can bathe and
shower
• However, it allows
moisture or blood to
accumulate - increasing
chances of infection
 INS STANDARDS ON FLUSHING

• Vascular access devices shall be flushed at

established intervals to
• Promote and maintain patency
• Prevent the mixing of incompatible medications and solutions.
• Positive fluid displacement shall be used according to
administration system requirements.
• Single-use pre filled flushing systems shall be used

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 WHEN TO FLUSH

• Immediately after catheter insertion

• Before and after each dose of intermittent medication
when no fluids are infusing to prevent mixing of
incompatible drugs
• Between doses of multiple intermittent medications
• After the bag has dry out
• When converting from continuous to intermittent
infusion
• Before and after drawing blood samples from a
catheter

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 AFTER CARE OF THE CATHETER

Site inspection
• Site should be inspected at least daily and always before and after any intermittent injection of
drugs
• Look for signs of phlebitis (redness, tenderness, swelling, pain), inflammation or infiltration.
• Resite, if necessary

Dressing change
• Wet or soiled dressings should be changed. Remove carefully to preserve line.

Careful handling
• When handling the catheter & other apparatus associated with it, take care not to contaminate the
equipment. Always use aseptic technique

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 AFTER CARE OF THE CATHETER

Catheter change
• Time of insertion should be recorded & the catheter resited every 48 to 72 hours
• IV administration sets should be changed only when they is clinical indication

Connection check
• All connections should be checked for tightness
• Ensure the injection port cap is closed at all times

Patency maintenance
• Flush to confirm patency pre & post each drug administration, in line with hospital policy

Needlestick
• Avoid using needles, wherever possible. If used, dispose of in a sharps container. Do not resheath
needles.

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REPLACEMENT OF SHORT PERIPHERAL IV
CATHETERS

• Infusion Nursing Standards

– The nurse should consider replacement of the
short peripheral catheter when clinically indicated:
– Emergency situation where aseptic
technique has been compromised
– Replace as soon as possible and
no later than 48 hours
• CDC Guidelines
– Replace peripheral catheters NO MORE
frequently than 72-96 hours to reduce the
incidence of infection and phlebitis in
adults
 Managing Complications
• Phlebitis
• Extravasation/Infiltration
• Infection

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CATHETER OCCLUSION

• Type of Occlusion
– Blood clot
– Precipitate formation
• Causes
– Allowing solutions to run
dry
– Improper flushing
– Incompatible medication
administration
 PHLEBITIS

• Chemical
– Irritation of the intima of the vein
• Mechanical
– Damage to the intima from
the catheter and/or needle
• Bacterial
– Inflammation of the intima
caused by bacteria
 CHEMICAL PHLEBITIS

• Contributing factors
– Chemical properties of solutions outside normal
range
– Inadequate hemodilution
• Pooling of medication within the vein
• A large catheter in a small vein
– Skin antiseptic not allowed to dry before venipuncture
 MECHANICAL PHLEBITIS

• Contributing factors
– Catheter movement
• Manipulation during insertion
• Flexion without proper
immobilization
• Improper catheter stabilization
– Poor skin traction during insertion
– Large catheter in a small vein
 BACTERIAL PHLEBITIS

• Least frequently recognized phlebitis

• Can lead to catheter-related
bloodstream infection
• Contributing factors
– Poor handwashing
– Inadequate cleaning of connectors
– Breaks in aseptic technique
– Improper skin antiseptic
– Nonocclusive dressings
– Migration of bacteria along catheter entry
site
VIP SCORE

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 PHLEBITIS

• Grade 0 • Grade 1
– No clinical symptoms – Redness at the site
with or without pain
 PHLEBITIS

• Grade 2 • Grade 3
– Pain at the site with – Pain at the site
redness and/or swelling with redness
– Streak formation
– Palpable venous cord
 PHLEBITIS

• Grade 4
– Pain at the site with redness and/or
swelling
– Streak formation
– Palpable venous cord > 1 inch in length
– Purulent drainage

Infusion Therapy and Clinical

Training
EXTRAVASATION & INFILTRATION

Extravasation Infiltration
Inadvertent Inadvertent administration
administration of of a non-vesicant
vesicant medication or medication or solution
solution into the into the surrounding
surrounding tissue tissue
May cause tissue necrosis
POTENTIAL AREAS OF CONTAMINATION
INFECTION PREVENTION
MEASURES

• Hand washing
• Wearing gloves
• Adequate cleaning of the insertion site
• Cleaning connectors prior to each entry
• Frequent observation of the insertion site
• Continued evaluation of the need for an IV
catheter
• Single patient use items
– Tourniquets
– Flush syringes
– Start packs
– Tape
– Dressing change kits
 Questions?

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 Thank You

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