CANNULATION & CANNULATION & VENESECTIONVENESECTION

AMANDA HARPERAMANDA HARPER

CLINICAL SKILLS CLINICAL SKILLS COORDINATORCOORDINATOR

LEARNING OUTCOMES OF LEARNING OUTCOMES OF THE WORKSHOPTHE WORKSHOP

• Assessment of patientAssessment of patient

• Demonstrate the correct technique for Demonstrate the correct technique for performing cannulation & venesection as per performing cannulation & venesection as per SUHT policy & procedureSUHT policy & procedure

• Selection of the appropriate deviceSelection of the appropriate device

• Identify and recognise the complications that are Identify and recognise the complications that are associated with cannulation & venesectionassociated with cannulation & venesection

• Correct documentation as per SUHT policyCorrect documentation as per SUHT policy

Patient Assessment Patient Assessment

& & Vein SelectionVein Selection

THE ASSESSMENTTHE ASSESSMENTCONSIDER THE FOLLOWING POINTS:CONSIDER THE FOLLOWING POINTS:

• Age / size / history / condition / dependency Age / size / history / condition / dependency of the patientof the patient

• History of previous cannulation / History of previous cannulation / venesectionvenesection

• Type / length of treatment requiredType / length of treatment required

• Number of tests orderedNumber of tests ordered

• What medication is the patient on?What medication is the patient on?

• Fluid statusFluid status

• History of blood disordersHistory of blood disorders

Conditions that affect the Conditions that affect the position of the device: -position of the device: -• AmputationAmputation

• StrokeStroke

• Mastectomy or other Breast / Lymph Mastectomy or other Breast / Lymph SurgerySurgery

• Renal Fistula Renal Fistula

• Lymphoedema or CellulitsisLymphoedema or Cellulitsis

• Diabetes / Vascular Disease / ArthritisDiabetes / Vascular Disease / Arthritis

• Trauma / Fractures / BurnsTrauma / Fractures / Burns

• Social HistorySocial History

Questions to ask the Questions to ask the patientpatient• OBTAIN CONSENTOBTAIN CONSENT

• Have you had a cannula / blood test Have you had a cannula / blood test before?before?

• Were there any complications / adverse Were there any complications / adverse reactions?reactions?

• Do you have any allergies?Do you have any allergies?

• Consider needle phobiaConsider needle phobia

• Would you like a local topical anaesthetic Would you like a local topical anaesthetic before I insert the cannula or take blood? before I insert the cannula or take blood?

• Which is your dominant arm?Which is your dominant arm?

Attributes of an ideal Attributes of an ideal vein are: -vein are: -

• Be engorged, bouncy & softBe engorged, bouncy & soft

• Refill after it has been depressedRefill after it has been depressed

• Be visible Be visible

• Feel roundFeel round

• Be well supported by surrounding Be well supported by surrounding structuresstructures

• Be straight & ‘free of valves’Be straight & ‘free of valves’

Veins to be avoided: -Veins to be avoided: -

• Thrombosed, fibrosed or sclerosedThrombosed, fibrosed or sclerosed• Inflamed or bruised or painfulInflamed or bruised or painful• Thin or fragileThin or fragile• MobileMobile• Near bony prominences and jointsNear bony prominences and joints• Near sites of infection or oedemaNear sites of infection or oedema• AVOID THE VALVESAVOID THE VALVES• For For venesectionvenesection avoidavoid the arm with the arm with

an an IVIV line runningline running

Methods for improving Methods for improving venous access:venous access:

• Apply a Apply a disposabledisposable tourniquet tourniquet

• Lower the level of the arm below the heartLower the level of the arm below the heart

• Ask the patient to open and close their fistAsk the patient to open and close their fist

• Light tapping / rubbing of the veinsLight tapping / rubbing of the veins

• Warm compresses over the selected veinWarm compresses over the selected vein

• Warm waterWarm water

• Relax the patient / consider the environmentRelax the patient / consider the environment

WHICH VEIN?

Antecubital FossaAntecubital Fossa

Brachial Artery

Ulnar Artery

Radial Artery

Basillic

Cephalic

Median Cubital Vein

Veins Arteries Nerves

Radial

1st Intercostal

Ulnar

Median

BASILLIC

VEIN

DORSAL VENOUS NETWORK

CEPHALICVEIN

DORSAL METACARPAL VEINS

DIGITAL

DORSAL

VEIN

VEINS TO BE USED ARE:VEINS TO BE USED ARE:

• METACARPAL VEINSMETACARPAL VEINS

• CEPHALIC VEINCEPHALIC VEIN

• BASILIC VEINBASILIC VEIN

• MEDIAN CUBITAL VEINMEDIAN CUBITAL VEIN

GROUP EXERCISEGROUP EXERCISE

In pairs, use a tourniquet to identify In pairs, use a tourniquet to identify each others:each others:

• VeinsVeins

• ArteriesArteries

• ValvesValves

• LigamentsLigaments

CANNULA CANNULA SELECTIONSELECTION

Selecting the right Selecting the right cannulacannulaTwo key points to consider:Two key points to consider:

• What is the cannula going to used for?What is the cannula going to used for?

• The condition, location and size of the The condition, location and size of the vein selected?vein selected?

You should try to select the smallest You should try to select the smallest gauge possible that will accommodate gauge possible that will accommodate the intravenous therapy that is the intravenous therapy that is prescribed.prescribed.

ColourColour SizeSize FlowFlow

Ml/minMl/minUsesUses

BrownBrown 1414 275275 Rapid transfusions of whole Rapid transfusions of whole blood. Emergency situations.blood. Emergency situations.

GreyGrey 1616 173173 Rapid transfusions of whole Rapid transfusions of whole blood. Emergency situationsblood. Emergency situations

GreenGreen 1818 100100 Blood transfusionsBlood transfusions

PinkPink 2020 6060 IV infusions. Bolus’IV infusions. Bolus’

BlueBlue 2222 2525 Bolus’. Maintenance infusionsBolus’. Maintenance infusions

YellowYellow 2424 1313 Bolus medications. Short term Bolus medications. Short term infusions. Neonatesinfusions. Neonates

PurplePurple 2626 NeonatesNeonates

SGH, exceptions to this SGH, exceptions to this rule: -rule: -

Patients ConditionPatients Condition Cannula SizeCannula Size

All obstetric patientsAll obstetric patients GreyGrey

Active gastrointestinalActive gastrointestinal

(GI bleed)(GI bleed)BrownBrown oror GreyGrey

At risk of GI bleedAt risk of GI bleed GreyGrey

At risk of epileptic fitAt risk of epileptic fit GreenGreen

At risk of cardiac eventAt risk of cardiac event GreenGreen

At risk of neurological eventAt risk of neurological event GreenGreen

VENESECTIONVENESECTION

DEVICE SELECTIONDEVICE SELECTION

VACUTAINERVACUTAINER

• Quicker collection than other methodsQuicker collection than other methods

• Closed systemClosed system

• Exact amount of blood obtainedExact amount of blood obtained

• Reduces the risk of haemolysis of the Reduces the risk of haemolysis of the samplesample

• Reduces the risk of needlestick injuryReduces the risk of needlestick injury

BOTTLES & BLOOD BOTTLES & BLOOD FORMSFORMS• E-QUEST SYSTEM E-QUEST SYSTEM for blood requests & for blood requests &

results within SUHTresults within SUHT

• ALWAYS ALWAYS ensure that the ensure that the GROUP &GROUP & SAVESAVE or or CROSSMATCHCROSSMATCH request has request has been correctly completed & signed for been correctly completed & signed for by the requesting by the requesting MEDICAL MEDICAL PRACTIONERPRACTIONER

Serum

AB Levels

Coagulation INR / APTR

Lithium Heparin, PST, U&E’s, Bone & Liver

E.D.T.A.

FBC & ESR

Cross Match Group & Save

Glucose

Trace Elements

ORDER OF DRAWORDER OF DRAW

• NO ADDITIVESNO ADDITIVES ( (Green, Green, Red, Red, Dark BlueDark Blue))

• COAGULATION COAGULATION ((Light BlueLight Blue))

• OTHER ADDITIVES OTHER ADDITIVES ((GoldGold, , LilacLilac,, Pink Pink && GreyGrey))

EXCEPTIONEXCEPTION to this is when to this is when Blood CulturesBlood Cultures have have been requested, these been requested, these MUST BEMUST BE filledfilled firstfirst –– aerobic aerobic (Blue)(Blue) followed byfollowed by anaerobic anaerobic (Pink)(Pink)

Risks and Risks and Complications of Complications of

Cannulation & Cannulation & VenesectionVenesection

Risks - During InsertionRisks - During Insertion• InfectionInfection

• HaemorrhageHaemorrhage

• HaematomaHaematoma

• Vaso-vagal episodeVaso-vagal episode

• Needle phobiasNeedle phobias

• Catheter embolism Catheter embolism ((cannulationcannulation))

• TransfixationTransfixation

• PainPain

• Nerve damageNerve damage

• Arterial punctureArterial puncture

• AllergiesAllergies

• Needlestick injuryNeedlestick injury

TransfixationTransfixation

SkinSkin

Vein wallVein wall

Vein wallVein wall

Haematoma/BruisingHaematoma/Bruising

• TransfixationTransfixation

• Tourniquet too tight / left on too Tourniquet too tight / left on too long long

/ use of RUBBER GLOVE!/ use of RUBBER GLOVE!

• Arterial punctureArterial puncture

• Repeated insertion sitesRepeated insertion sites

Future Complications of Future Complications of CannulationCannulation• Phlebitis — septic / mechanical / Phlebitis — septic / mechanical /

chemical chemical • Infection Infection • Drug reaction / AllergyDrug reaction / Allergy• InfiltrationInfiltration• ExtravasationExtravasation• Thrombosis / Embolism Thrombosis / Embolism • Speed shockSpeed shock• Fluid overloadFluid overload

PhlebitisPhlebitis•TYPES OF:TYPES OF:

InfiltrationInfiltration

• ““The inadvertent administration of The inadvertent administration of non-non-vesicantvesicant (non-toxic)(non-toxic) solution/medication solution/medication into surrounding tissues."into surrounding tissues."

(Royal Marsden Manual, 2004)(Royal Marsden Manual, 2004)

• The cannula may still appear to be patent, The cannula may still appear to be patent, so early recognition is vital to avoid tissue so early recognition is vital to avoid tissue damage.damage.

• ExamplesExamples of fluidof fluid include:include: Normal Saline Normal Saline & &

5% Dextrose5% Dextrose

ExtravasationExtravasation

• ““the inadvertent administration of a the inadvertent administration of a vesicant substancevesicant substance (toxic)(toxic) into the into the tissues surrounding a vein.”tissues surrounding a vein.”

(Royal Marsden Manual, 2004)(Royal Marsden Manual, 2004)

• Examples of fluid include:Examples of fluid include: 10% 10% Dextrose, Chemotherapy & PotassiumDextrose, Chemotherapy & Potassium

Thrombus FormationThrombus Formation

• Correct flushing technique - pulsated Correct flushing technique - pulsated push-pause & positive pressure, prevents push-pause & positive pressure, prevents blood being left in the cannula & removes blood being left in the cannula & removes debris from the internal catheter wall (use debris from the internal catheter wall (use 5mls5mls of of Normal SalineNormal Saline).).

• Flushing blocked cannula can lead to Flushing blocked cannula can lead to pulmonary embolus pulmonary embolus (30% PMs show (30% PMs show undiagnosed PE)undiagnosed PE)..

Signs of CannulaSigns of Cannula Related InfectionRelated Infection

• PhlebitisPhlebitis

• PyrexiaPyrexia

• Feeling unwellFeeling unwell

• Raised white blood cell countRaised white blood cell count

Site preparationSite preparation• As cannulation / venesection is As cannulation / venesection is performed using performed using

an an aseptic non-touch techniqueaseptic non-touch technique it is it is imperative that the vein is cleaned imperative that the vein is cleaned PRIORPRIOR TO TO THETHE PROCEDURE, wearing clean non-latex PROCEDURE, wearing clean non-latex glovesgloves

• CleanClean the the veinvein for for 30 seconds30 seconds with 2% with 2% chlorhexidine in 70% alcohol solution, cleaning chlorhexidine in 70% alcohol solution, cleaning the vein in a criss-cross motionthe vein in a criss-cross motion

• Allow Allow veinvein to to air dryair dry

• DO NOTDO NOT re-touchre-touch or or palpatepalpate the the veinvein once once cleanedcleaned

• ConsiderConsider hair clipping if appropriate hair clipping if appropriate

DOCUMENTATIONDOCUMENTATION• SEE CANNULA CARE PLAN includes:SEE CANNULA CARE PLAN includes:• Time & date of blood sample / cannula Time & date of blood sample / cannula

insertioninsertion• Site of insertionSite of insertion• Gauge and batch number of the cannulaGauge and batch number of the cannula• What blood samples have been takenWhat blood samples have been taken• Number of attempts Number of attempts ((MAX 2 per personMAX 2 per person))• Any complications noted (e.g. haematoma)Any complications noted (e.g. haematoma)• Print & sign your namePrint & sign your name• Evidence verbal consent has been Evidence verbal consent has been

obtained obtained