Peripheral Venous Cannulation Adults Policy

PERIPHERAL VENOUS CANNULATION (ADULTS) POLICY
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Version 3
Sub-committee approval group Infection Prevention Management Committee
Document Manager (job title) Lead Nurse Infection Prevention
Date ratified 15 October 2020
Date issued 29 March 2021
Review date 14 October 2023
Electronic location Infection Control Policies
Related Procedural Documents Hand hygiene, standard precautions, consent

Peripheral venous cannulation, Cannulation, Cannulae,
Key Words (to aid with searching)
Asepsis, AccuVein, IV site, Phlebitis, IV access
Summary
The purpose of this policy is to inform all practitioners about the requirements and processes for peripheral
venous cannulation and appropriate aftercare and removal. By using this policy, practitioners will act to
reduce the risks to patients and staff associated with peripheral venous cannulation. These include
thrombosis, pain, local or systemic infection; occupational sharps injury and inappropriate cannula insertion.
Version tracking
Date
Version Brief Summary of Changes Author
Ratified
3 15/10/2020 • Minor revision to include healthcare IPT
students and the future nurse standards.
• References updated.
2 16/11/2016 • Minor revision (no impact on process to IPT
be followed)
1 Dec 2014 • Rewrite of Clinical Policy for Peripheral IPT
Venous Cannulation Insertion and
Management

Version 3 Review date: 14/10/23 (unless requirements change) Page 1 of 16
CONTENTS
PROCESS .......................................................................................................................................................3
1. INTRODUCTION ....................................................................................................................................4
2. SCOPE ...................................................................................................................................................4
3. PROCESS ...............................................................................................................................................4
4. TRAINING REQUIREMENTS .................................................................................................................13
5. REFERENCES AND ASSOCIATED DOCUMENTATION ...........................................................................13
6. EQUALITY IMPACT SCREENING ...........................................................................................................14
7. MONITORING COMPLIANCE ...............................................................................................................14
Appendix A: Roles and Responsibilities ......................................................................................................16

PROCESS
For quick reference the guide below is a summary of actions required. Additional details, by exception to cover
any additional notes that supplement the quick reference guide can be found in Section 3 – Process.
1. Peripheral venous cannulation is an aseptic procedure and should only be undertaken when there is
a clear and immediate need for intravenous access, or there is significant risk of haemorrhage.
Cannulation should not be performed as a routine clinical intervention and should only be carried out by
suitably trained practitioners
2. Cannulae should be appropriate for the product to be delivered, the intended speed of delivery, the
duration of intended therapy and the condition and size of the vein
Catheter Flow Rate Time to infuse
Gauge Indication
length (mm) (ml/min) 1L N/S (mins)
24 14 26 38
Neonates / Paediatrics
24 19 22 45
22 25 35 28 Long-term medications / fluid therapy
20 25 65 15
Large fluid volumes/blood or contrast/dyes
20 32 60 17
18 32 105 9.5
Whole blood administration
18 45 100 10
16 50 210 5
Rapid infusion of blood or components
14 50 345 3
3. An upper extremity site is preferable for cannulation. Areas of flexion e.g. antecubital fossa should be
avoided where possible
4. A sterile cannulation pack must be used for all cannulation attempts
5. Skin must be prepared with 2% chlorhexidine gluconate in 70% isopropyl alcohol (2% CHG/70% IPA)
(Sanicloth) and allowed to dry between each and every cannulation attempt
6. During cannulation, never re-introduce the needle into the cannula sheath as this may damage the
sheath which then has the potential to break and lodge inside the vein
7. Peripheral venous cannulae insertion sites must be visually inspected and palpated for tenderness a
minimum of once per shift and a Visual Infusion Phlebitis(VIP) score recorded
8. Peripheral venous cannulae should be electively re-sited if a non-aseptic insertion is suspected (e.g.
emergency situation), if sited in a lower limb or if the cannula is more than 72 hours old

1. INTRODUCTION
Peripheral venous cannulation is the process of inserting a small hollow catheter over a needle into a
peripheral vein. Peripheral venous cannulation is an invasive intervention that should only be carried out
by suitably trained practitioners.
2. SCOPE
All staff (permanent, locum, agency, bank and voluntary staff of the Trust, the Ministry of Defence
Hospital Unit, Joint Hospitals Group South (Portsmouth) and Engie must follow the procedural
documents agreed by the Trust. For staff other than those directly employed by the Trust the
appropriate line management or chain of command will be taken into account. Breaches of adherence
to Trust policy may have potential contractual consequences for the employee.
In the event of an infection outbreak, pandemic or major incident, the Trust recognises that it may not
be possible to adhere to all aspects of this document. In such circumstances, staff should take advice
from their manager and all possible action must be taken to maintain ongoing patient and staff safety.
3. PROCESS
3.1 Peripheral venous cannulation is an aseptic procedure and should only be undertaken when there
is a clear and immediate need for intravenous access, or there is significant risk of haemorrhage.
Cannulation should not be performed as a routine clinical intervention.
Indications for peripheral venous cannulation1:

Peripheral venous cannulation is generally indicated for:
• Short-term administration of intravenous fluid therapy of usually less than 3-4 days
• Administration of intravenous medication or blood and blood products
• Administration of dyes and contrast media
• Vascular access for emergency
Peripheral venous cannulation is not indicated at Portsmouth Hospitals University NHS Trust for:
• The administration of Total Parentral Nutrition (TPN)
• Vesicant and irritant solutions which can cause blistering and tissue necrosis if they leak into
the tissue (sclerosing solutions, some chemotherapeutic agents, and vasopressors)
• Longer term fluid or drug infusions (>3 days) or medications (>5 days) where multiple attempts
are required to establish peripheral venous access
An appropriate vascular device should be inserted to administer these solutions.

3.2 Cannula selection:
The cannula should be appropriate for:
• The type of infusion / medication / contrast to be delivered
• The intended or required speed of delivery
• The duration of intended therapy
• The condition and size of the vein
Non-ported cannulae may be associated with a reduced risk of infection and should be used for the
majority of patients2. Ported cannulae should only be used in main and maternity theatres, where
rapid sequence induction may be necessary.
Always select the smallest cannula necessary for the task.
Catheter Time to
Flow Rate
Gauge length infuse 1L N/S Indication
(ml/min)
(mm) (mins)
24 14 26 38
Neonates / Paediatrics
24 19 22 45
22 25 35 28 Long-term medications / fluid therapy
20 25 65 15
Large fluid volumes/blood or contrast/dyes
20 32 60 17
18 32 105 9.5
Whole blood administration
18 45 100 10
16 50 210 5
Rapid infusion of blood or components
14 50 345 3
3.3 Prevention and management of incidents and adverse events:

Peripheral venous cannulation carries a risk of inoculation injury with contaminated sharps.
The following must be adhered to at all times:

Used cannulae must be discarded immediately at the point of use by the person generating the waste
into a sharps bin that complies to UN 3921 and BS7320
Sharps bins must not be overfilled, and must have the temporary closure mechanism in place when
not in use
Practitioners should not work alone with confused or disoriented patients who may move
unexpectedly, contributing to inoculation injuries
3.4 Consent:
Informed consent must be obtained from all patients who have capacity prior to any cannulation
attempt3. Consent may be given verbally or non-verbally and may be the act of the patient holding out
their arm for the practitioner to carry out a procedure, providing the patient has received appropriate
information prior to this3.
The key principles of informed consent include:
• The patients right to consent voluntarily without pressure or coercion
• The patients right to withdraw consent at any time
• The provision of sufficient information to allow informed consent. This includes:
I. The reason for the procedure
II. What the procedure involves
III. Any significant potential complications
3.5 Complications:
Complications of peripheral venous cannulation include:
Prolonged bleeding time (caused by medical condition or drug therapy)
Haematoma (caused by puncturing the front and/or back wall of the vein or failure to apply correct
pressure post failed attempt or removal)
Infiltration (see definition)
Extravasation (see definition)
Phlebitis (see definition)
Accidental damage (of adjacent structures including nerves, tendon or artery)
Infection
3.6 Hand Hygiene:

Hand hygiene with liquid soap and water or alcohol hand-rub must be performed before and after
each patient procedure, before putting on gloves and after removing them4,5. The Trust standard 7-
stage hygiene technique should be used at all times.
3.7 Personal protective equipment (PPE):

When cannulating, practitioners should wear well-fitting sterile gloves. These are single use items and
must be disposed of immediately after use4,5.
3.8 Skin Preparation:

Skin must be prepared with 2% chlorhexidine gluconate in 70% isopropyl alcohol (2% CHG/70% IPA)
(Sanicloth) 3. Cleaning should cover the whole area, ensuring that the skin area is in contact with the
disinfectant for at least 15-30 seconds4,6. The area should then be allowed to dry4. If more than one
attempt is made to access the vessel, the site must be re-cleaned with a new wipe between attempts.
3.9 Number of attempts:

Only three attempts should be made to cannulate the patient, using new equipment on each occasion.
• Never re-introduce the needle into the cannula sheath as this may damage the sheath which
then has the potential to break and lodge inside the vein

If unsuccessful, support should be obtained from another member of staff qualified in peripheral
venous cannulation. Failed attempts should be documented in the patient notes.
Use of the AccuVein device (available from the Infection Prevention Department) can increase
successful cannulation in difficult patients (e.g. IVDU, oncology patients) and show valves and
bifurcations in vessels.
3.10 Site selection:

To reduce the risk of device related infection and phlebitis, it is preferable to use an upper extremity
site for inserting a peripheral venous cannula in adults and to replace a device inserted in a lower
extremity to a site in the upper extremity as soon as possible4.
Veins should be looked for in the following order:

• On the back of each hand
o Metacarpal veins
• Lower arm
o Cephalic or basilic veins
• Areas of flexion e.g. antecubital fossa should be avoided where possible for patient comfort4,6
• Sites close to existing wounds, or limbs affected by lymph node dissection or renal fistula
should be avoided7,8

Inspection will reveal clinical conditions that may prevent the arm being used whilst palpation of the
veins will reveal the position of the veins, direction in which they run and their size and other physical
features. The vein should be straight and feel soft, cylindrical in shape and ‘bouncy’ when lightly
pressed. Veins that are tender, sclerosed, thrombosed, fibrosed, hard or bruised from previous use
should be avoided.
3.11 Hair removal:

Hair removal may be required if excessive hair interferes with cannulation attempts or hinders device
fixation and application of an adhesive dressing.
• Hair removal around the insertion site should be accomplished using scissors or clippers7
• Shaving with a razor should not be performed because of the potential for causing
microabrasions, which increase the risk of infection8
• Depilatories should not be used because of the potential for allergic reaction or irritation8
• Electric clippers should have disposable heads for single-patient use8
3.12 Equipment required for insertion of a peripheral venous cannula:

• Cannulation pack, containing;
• Sterile gloves
• Sterile towels x2
• 2% chlorhexidine gluconate in 70% isopropyl alcohol wipe (2% CHG/70% IPA) (Sanicloth)
• 10mL pre-filled Sodium Chloride 0.9% flush
• Single use disposable tourniquet
• Transparent sterile occlusive dressing

• Sterile gauze
• Clinical waste bag
• Appropriate sized cannulae x2
• Extension set
• Sharps container
• Dedicated tray or identified prepared area, cleaned with detergent wipe or soap and warm
water
3.12.1 Process:
• Approach patient, introduce yourself and check allergies (e.g. chlorhexidine)
• Give rationale for cannula insertion and ensure patient consents to the procedure
• Adjust environment to comfortable working height and ensure adequate lighting- wherever
possible
• Decontaminate hands following the Trust Hand Hygiene Procedure
• Clean tray or dedicated surface with detergent wipe or soap and warm water
• Open the sterile cannulation pack and arrange contents on field by placing hand inside sterile
waste bag
• Open the cannula, extension set and 2% chlorhexidine gluconate in 70% isopropyl alcohol
wipe onto the sterile field
• Open 10mL pre-filled Sodium Chloride 0.9% flush and place to the side of the sterile field
• Identify/palpate suitable vessel
• When potential site is identified, position patient comfortably with appropriate limb below the
level of the heart
• Remove excess hair if required
• Place one sterile towel under the patients hand/arm
• Apply tourniquet
• Repeat hand decontamination with alcohol-based hand rub
• Apply sterile gloves
• Clean the site thoroughly with the 2% chlorhexidine gluconate in 70% isopropyl alcohol wipe
for at least 15 seconds and allow to air dry
• Place second sterile towel over the appropriate limb below the site of intended cannulation
• Gently pull on skin, distal and lateral to insertion site. Do not touch the cannula or the
insertion site (at this point local anaesthetic may be administered if prescribed and
appropriate)
• Insert cannula (bevel uppermost) through the cleaned skin area at an angle of 20-30 degrees
• Advance until just in the vein and then lower the cannula until it is parallel with the skin (a
flashback of blood is usually but not always seen at this point)
• Hold the needle still and advance the cannula over the needle until the cannula is inserted up
to the hilt
• (In the event of unsuccessful cannulation of the vein withdraw the cannula from the puncture
site and apply pressure with sterile gauze swab)
• Release the tourniquet using a piece of sterile gauze to protect the integrity of the sterile
gloves
• Remove the needle (ensuring the sharps safe mechanism has activated) and dispose of
immediately into a sharps container, using the sterile cap to occlude the cannula
• Secure the device with steri-strips and the transparent occlusive dressing
• Using the pre-filled saline syringe, flush through the extension set and attach to the cannula.
• Flush to the cannula with 5-10mLs of saline to check position
• Complete the time and date sticker from the occlusive dressing and apply near cannula site
(ensuring that the entry point is not obscured)

• Dispose of gloves, aprons and used equipment into the clinical waste stream
• Decontaminate hands
• Complete insertion documentation on VitalPAC or cannula insertion care bundle
3.13 Cannula care (see appendix):

• Peripheral venous cannulae insertion sites must be visually inspected and palpated for
tenderness a minimum of once per shift and a Visual Infusion Phlebitis (VIP) score recorded
either on VitalPAC or a paper cannula care bundle4,6
• Practitioners must act immediately if the VIP score is >=1
• Insertion sites and cannula components should be checked prior to the administration of any
intravenous medications or fluids with recording of these observations as best practice
• All peripheral venous cannulae, prior to use, must have:
• No evidence of phlebitis, infiltration, extravasation
• No reported pain at the site
• An intact transparent dressing which completely covers the entry site and secures the
device
• Needle free extension set in situ
• A valid date and time on the dressing
• Cannula dressings should cover the entry site and device up to the notch

• Leave the transparent semipermeable membrane dressing applied to the peripheral cannula
insertion site in situ for the life of the cannula, provided that the integrity of the dressing is
retained.5
3.14 Changing a peripheral cannula dressing:

• Cannula dressings should be changed if they become soiled or their integrity is
compromised4,6,8
• If the peripheral cannula is older than 48 hours, consideration should be given to removal and
re-cannulation, rather than dressing change
• Dressing changes may be done by a lone practitioner if the patient understands the procedure
and is able to co-operate. Two practitioners should change dressings for patients who are
confused or disoriented and who may move unexpectedly
3.15 Equipment required for a peripheral cannula dressing change:

• Non-sterile gloves and apron
• Replacement transparent cannula dressing
• 2% chlorhexidine gluconate in 70% isopropyl alcohol wipe (Sanicloth)
• Cleaned plastic tray
• Clinical waste bag or bin
3.16 Process:
• Give rationale for changing the cannula dressing and ensure patient consents to the procedure
possible
• Clean tray with detergent wipe or soap and warm water
• Open the 2% chlorhexidine gluconate in 70% isopropyl alcohol wipe and transparent dressing
into the clean tray
• Apply apron and non-sterile gloves
• Holding the cannula securely, gently remove soiled/non-intact dressing
• Once the dressing is removed (and ensuring not to touch any part of the cannula that will be
underneath the dressing), clean the site thoroughly with the 2% chlorhexidine gluconate in
70% isopropyl alcohol wipe and allow to air dry
• Ensuring that the cannula has not moved and is stable, release the cannula and apply the
dressing, ensure that the cannula hub is covered
• Date and time the new dressing with the date and time of the original cannula insertion
• Dispose of gloves, aprons and used dressing into the clinical waste stream
3.17 Cannula access:

• Access of peripheral cannulae should be performed using a aseptic non-touch technique
• Hands must be decontaminated with an alcohol-based hand rub or by washing with liquid
soap and water before and after any contact with the peripheral cannula or insertion site
• Gloves must be worn for all procedures
• All hubs or ports must be cleaned using a single-use application of 2% chlorhexidine gluconate
in 70% isopropyl alcohol prior to access. The hub should be cleaned for a minimum of 15
seconds and allowed to dry

• Primary and secondary solution administration sets used for a continuous infusion must be
changed every 72 hours and immediately upon suspected contamination or when the integrity
of the product or system has been compromised4,5
• Administration sets for blood and blood components should be changed every 12 hours, or
according to the manufacturer's recommendations 4,5
3.18 Cannula re-siting or removal:

• Peripheral venous cannulae should be electively re-sited:
o If a non-aseptic insertion is suspected (e.g. emergency situation)
o If sited in a lower limb (EPIC)
o If the cannula is more than 72 hours old
• The catheter should be removed when complications occur (or VIP >=1) or as soon as it is no
longer required4
3.19 Equipment required for removal of a peripheral cannula:

• Non-sterile gloves and apron
• Sterile gauze
• 2% chlorhexidine gluconate in 70% isopropyl alcohol wipe (Sanicloth)
• clean plastic tray
• small adhesive plaster
3.20 Process:
• Give rationale for removing the cannula and ensure patient consents to the procedure
possible
• Clean tray with detergent wipe or soap and warm water
• Open the 2% chlorhexidine gluconate in 70% isopropyl alcohol wipe and sterile gauze into the
clean tray
• Apply apron and non-sterile gloves
• Holding the cannula securely, gently remove soiled/non-intact dressing
• Once the dressing is removed, slide the cannula out and apply pressing using sterile gauze to
the puncture site. Do not press firmly on the puncture site until after the plastic sheath has
been removed to prevent shearing
• Apply gentle pressure until bleeding has stopped and raise limb if required
• Apply small adhesive plaster to site (do not tape gauze over the site as this is not secure)
• Dispose of gloves, aprons and gauze into the clinical waste stream
• Contaminated peripheral cannulae should be placed into sharps bins

4. TRAINING REQUIREMENTS
Prior to undertaking any cannulation procedure, all staff must be able to demonstrate clinical
competence and a clear understanding of the underlying principles of practice. This will be achieved by:
Nursing and other health care staff;
a) Completion of the Trust venous cannulation competency pack
b) Attendance at the trust cannulation study day
c) Completion of a period of supervised clinical practice
(Staff who have been trained and practised in a previous post may be allowed to demonstrate
an equivalent level of competence through a period of supervised practice only).
Medical staff;
Post registration house officer (PRHO) induction will include training by Trust trainers on local
policies and principles of practice. Senior House Officer’s and Registrars will be assumed
competent unless identified otherwise by their supervisor. If problems are identified, the staff
member will be required to:
a) Completion of the Trust venous cannulation competency pack
b) Attendance at the trust cannulation study day
c) Completion of a period of supervised clinical practice
Cannula care training for clinical staff is available from the Infection Prevention Team. For any HCSW
that has not attended the cannulation study day, there is a separate cannula care/removal competency
that requires completion.
Healthcare students;
Healthcare students who can demonstrate theoretical preparation can, in accordance with their
practice assessment documentation, undertake peripheral venous cannulation under direct and
constant supervision whilst they practice the skill. Once deemed competent they can undertake
peripheral venous cannulation independently as assessed against the competency
5. REFERENCES AND ASSOCIATED DOCUMENTATION

1. McCallum L, Higgins D. (2012). Care of peripheral venous cannula sites. Nursing Times; 108: 34/35,
12-15.
2. Easterlow et al (2010). Implementing and standardising the use of peripheral vascular access devices.
Journal of Clinical Nursing. Vol 19; 5-6: pg 721–727
3. Department of Health (2010). Reference guide to consent for examination or treatment. London:
HMSO
4. Loveday et al (2014). epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated

Infections in NHS Hospitals in England. Journal of Hospital Infection 86S1 (2014) S1–S70
5. NICE (2012). Prevention and control of healthcare –associated infections in primary and community
care. Clinical guideline 139. National Institute for Health and Clinical Excellence
6. RCN (2016). Standards for infusion therapy. fourth edition. Royal College of Nursing.
7. NMC (2018) Standards of proficiency for registered nurses.

https://www.nmc.org.uk/standards/standards-for-nurses/standards-of-proficiency-for-registered-

nurses/
8. Dougherty L and Watson J (2008). ‘Vascular access devices’, in Dougherty L and Lister S (editors) The
Royal Marsden Hospital Manual of clinical nursing procedures (7th edition), Oxford: Blackwell
Publishing, Chapter 44. (III)
9. Infusion Nurses Society (2006). Infusion nursing standards of practice, Cambridge, MA: INS and
Becton Dickinson.
10. Moureau N (2019). Vessel Health: The right Approach for Vascular Access. Springer Open.
6. EQUALITY IMPACT SCREENING

The following text must be included. The completed Equality Impact Assessment must be sent to the
Governance Co-ordinator.
The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services
to the public and the way we treat our staff reflects their individual needs and does not discriminate
against individuals or groups on any grounds.
This procedural document has been assessed accordingly. The assessment document is held centrally
and is available by contacting the Governance Co-ordinator.
7. MONITORING COMPLIANCE
Detail how compliance with the policy will be monitored. If possible this should make use of existing
outcomes metrics in the Trust that demonstrate effectiveness and compliance.
This procedural document will be monitored to ensure it is effective and to provide assurance of
compliance.
Element to be Frequency of Reporting

Lead Tool Lead
monitored Report arrangements
Cannulation Training Learning & Study day register Yearly Policy audit report Learning &
Development and competency to: Development
(supported by framework
Infection • Infection
Prevention) Prevention
Management
Committee
Cannula care and Infection TEAL audits of Monthly Policy audit report Lead Nurse
removal Prevention & peripheral venous to: Infection
Control cannula care, use Prevention
and removal • Infection
Prevention
Management
Committee
Cannula observations Infection VitalPAC reporting Daily Policy audit report Lead Nurse
Prevention to: Infection
Management Prevention
Committee • Infection
Prevention
Management
Committee
• Senior Lead Nurses
• Professional Board

Appendix A: Roles and Responsibilities
Infection Prevention Team: are responsible for providing cannulation training, reviewing competency
and managing the peripheral venous cannulation policy. The Infection Prevention team will also
undertake monitoring and clinical audit of insertion and aftercare practice.
Ward/Department/Line Managers: need to ensure adequate stock of equipment for peripheral

venous cannulation is held and that all staff members who are required to perform cannulation or
care for cannulae post insertion are appropriately trained or supervised if in training. Managers must
report to the Infection Prevention team any incidents of unsuitable or dangerous practice.
Medical Consultants: are responsible for ensuring that all peripheral venous cannulation is clinically
indicated and carried out in full accordance with this policy. Consultants are also responsible for
reviewing the need for existing devices daily and reporting any incidents of unsuitable or dangerous
practice.
Individuals undertaking peripheral venous cannulation: should ensure they meet the training
requirements, are safe and competent to undertake this skill and follow all relevant Trust policies to
support safe practice. Staff must be aware of their roles and responsibilities and must identify and
communicate any training needs to their Line Manager.
Healthcare Workers: are responsible for ensuring safe care, access and removal of peripheral
cannulae and reporting overdue or inappropriate devices to the Infection Prevention Team
Healthcare Students: who can demonstrate theoretical preparation can, in accordance with their
practice assessment documentation, undertake peripheral venous cannulation under direct and
constant supervision whilst they practice the skill. Once deemed competent they can undertake
peripheral venous cannulation independently as assessed against the competency.


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PERIPHERAL VENOUS CANNULATION (ADULTS) POLICY

Sub-committee approval group Infection Prevention Management Committee

Document Manager (job title) Lead Nurse Infection Prevention

Date ratified 15 October 2020

Date issued 29 March 2021

Review date 14 October 2023

Electronic location Infection Control Policies

Related Procedural Documents Hand hygiene, standard precautions, consent