Module 4 - Parental Access

Intravenous Cannulation (IVC)

• IVC involves puncturing a vein with a needle for access to administer pharmacology, fluids, and blood products.
• Correct IVC enhances patient care quality.
• Veins carry non-oxygenated blood and have low blood pressure, enabling medications to reach the heart.

Cannulation Sites

• Preferred cannulation sites include the dorsal metacarpal and forearm veins, such as the dorsal metacarpal, cephalic, and basilic veins.
• If initial sites are unsuitable, move proximally along the arm, considering antecubital fossa veins like the cephalic, basilic, and median cubital veins as alternatives.
• Lower extremity veins (dorsal venous arch, small and great saphenous veins) are options.
• Scalp veins (frontal, occipital, superficial temporal, and posterior auricular) are considered particularly in pediatrics.

Vein Selection Process

• Begin distally and move proximally for IV attempts.
• Subsequent attempts must be more proximal than the first.
• Hand and forearm are the most preferred sites of action
• Cannulation in lower extremities is less preferred due to delayed medication effect.
• Medical conditions, such as diabetes (lower perfusion in lower extremities), should be considered when selecting a site.

Foundations and Decision Making

• Veins should be visible, soft, bouncy upon palpation (without a pulse), and straight (not bifurcated).
• Avoid cannulating at joints or areas of flexion, areas affected by burns or infection, sites near a mastectomy (risk of infection due to lymph node removal), arteriovenous fistulas, or areas with scarring, bruising, or damage.
• Cannulation can be challenging in pediatrics (size and compliance), geriatrics (difficult to anchor veins due to skin elasticity), bariatrics (finding veins due to extra fat deposits), individuals with darker skin tones (visualisation), those in shock (peripheral shutdown), people who are dehydrated (less blood and fluid in circulation) and individuals with a history of chemotherapy, surgical interventions, or IV drug abuse (vein collapse).

Risks and Complications

• Risks include infection (from improper site cleaning), haematoma (from unsuccessful attempts going through the vein), infiltration and extravasation (fluid leakage into surrounding tissues), phlebitis (vein irritation), and thrombophlebitis (blood clot formation in the vein).

Cannula Size

• Cannula sizes range from 14G to 24G; a higher gauge number indicates a smaller, thinner cannula.
• Cannulas are colour-coded to indicate gauge.
• Large cannulas can cause increased trauma, blood or drug stagnation, and phlebitis.
• Cannula size choice depends on required treatment.

Cannulation Preparation Acronym

• Preparation includes having an alcohol swab, bung, cannula, dressing (Tegaderm), elastic (tourniquet), flush (10mL syringe with NaCl), gauze/garbage (sharps), and glasses. This can be remembered by the acronym ABCDEFG.

Cannulation Principles

• IVC should be performed when therapeutically valuable, not for personal challenge.
• IVC causes discomfort and carries risks of blood-borne infection and tissue trauma that can cause damage over the coming days after intervention.

Cannulation Procedure and Technique

• Aseptic technique requires gloves only during the cannulation itself; hand hygiene is sufficient during preparation.
• Only unsheathe the cannula when ready to cannulate, otherwise, discard it safely.
• Insert the cannula at an appropriate angle to confirm insertion by observing blood in the flashback chamber, then advance the Teflon while removing the needle. Pulling out cannula should make a "click" sound and tourniquet should "clack" off after.
• Avoid taping over the clear window of the Tegaderm to allow site observation.

Cannulation Preparation and Process

1. Draw up flush into a 10mL syringe with a solution of NaCl.
2. Sanitise hands thoroughly.
3. Open the bung, remove the cap, and place it back into its packaging.
4. Open the cannula to loosen the cap and open the wings, then place it back into its packaging.
5. Open the dressing (Tegaderm) and place the backing part onto the paper, folding over the bottoms and top.
6. Sanitise hands again.
7. Apply the tourniquet above the elbow, ensuring it clicks in and pulls tight above the intended cannulation site. If veins start to become prominent, instruct the patient to lower their arm or squeeze their hand.
8. Clean the area with an alcohol swab, starting small and gradually moving outward.
9. Put on gloves.
10. Pull off the cannula cap.
11. Apply tension by either pushing/pulling their arm or holding their arm and pulling the skin towards you.
12. Enter the vein at a 45-degree angle and observe for blood in the flashback chamber.
13. Once blood is seen, flatten the angle. Push the cannula all the way in while retracting the needle part, and safely dispose of the needle in a sharps container.
14. Remove the tourniquet.
15. Flatten the cannula and twist the bung on securely.
16. Apply the Tegaderm dressing, positioning the end of the white part over the cannula so the insertion site is visible.
17. Remove the white outer part of the Tegaderm and add strips to further secure the cannula, one over the end of the cannula and another over the bung.
18. Wipe the end of the bung with an alcohol wipe and insert the flush, ensuring there is no resistance (resistance indicates incorrect placement).
19. As you administer the flush, observe for any abnormalities in the veins and ask the patient if they are experiencing any pain.

Cannula Sizes and Uses

• A higher gauge number indicates a smaller cannula.
• 16G cannulas are suitable for trauma cases requiring blood products or rapid fluid administration.
• 18G cannulas are used for fluid administration when necessary.
• 20G cannulas are versatile and can be used for most purposes.
• 22G cannulas are ideal for patients with small veins, such as paediatrics and geriatrics.
• 24G cannulas are used for patients with very small veins, typically in paediatrics and geriatrics.

Flush Preparation

• Use a 10mL syringe with a solution (NaCl).
• Flushing helps push medication into the bloodstream.
• Before adding the solution, remove the vacuum seal by pushing out any air, then add the solution.
• Use either a combi stopper or a solution bottle on top of the syringe.

Elbow Immobilisation Splint

• Elbow Immobilisation Splints prevent patients form bending their arm when a cannula is in place.
• Splints go over the bicep and forearm and strap to itself
• Useful for patients moving around a lot, combative, medical conditions etc.

Learning Outcomes for Cannulation Procedures

• Learning outcomes include demonstrating safe and effective techniques for inserting IV and intraosseous cannulas.
• Focus on safe/appropriate decision-making for choosing IV or IO procedures.
• The goal is to reason how to integrate IV and/or IO into the sequence of patient care.

Intraosseous Vascular Access (IO)

• IO access is a fast, reliable route for infusions of any type.
• IO access refers to inserting a hollow-bore needle through the bone cortex into the medullary space for medical therapy infusion, traditionally used when IV attempts are unsuccessful, especially in paediatric cases or major trauma.
• IO success rates are twice as high as intravenous line placement in critical trauma patients without a blood pressure

Anatomy and Physiology of IO placement

• Potential IO access sites includes sturnum, clavicle, humeral head, iliac crest, distal femur, proximal tibia, distal tibia, and calcaneus.
• Preferred sites in adults include the proximal tibia, humeral head, and sternum.
• Preferred sites for infants and neonates include the distal femur, proximal tibia, and distal tibia.

Indications vs Contraindications

• Indications include inability to obtain venous access, immediate vascular access requirement, blood for lab analysis, or contrast injection access needed.
• Contraindications includes adequate venous access, fracture/burn/cellulitis/infection at insertion site, osteogenesis imperfecta, osteoporosis, previous attempts on sites, and recent orthopedic surgery.

Equipment

• IO equipment includes First access for shock and trauma (FAST 1), EZ-IO and the bone injection gun (BIG).

Technique & Treatment

• IO needles are placed perpendicular to the bone until a hard stop is felt, with at least 5 mm of the needle visible above the skin.
• Confirm the IO needle's placement by checking for stability in the bone, aspiration of marrow, ability to flush with saline, and good IV flow rates using 5-10cc saline for adults, 2-5ml for children.
• Stabilisation of the needle is mandatory to avoid inadvertently dislodging or bending the IO needle.
• The team should document the date and time of placement of the IO to ensure it will be in use for less than 24 hours.
• Following the obtaining of adequate IV access, the IO device should be removed and bandaged.

Australian IO Device

• The most common powered IO device in Australia is the Arrow EZ-IO, with colour coded length needles.