IV Cannulation - Past Paper Documentiv

### Introduction ### learning package covers peripheral intravenous (IV) cannulation. Along with Week 2 (drug drawing) and Week 3 (fluid therapy), IV cannulation will be the major focus of your first block course.  This topic provides the theory and background information required before you begin...

### Introduction ### learning package covers peripheral intravenous (IV) cannulation. Along with Week 2 (drug drawing) and Week 3 (fluid therapy), IV cannulation will be the major focus of your first block course.  This topic provides the theory and background information required before you begin to practice your IV cannulation during the block course. Please ensure you read the lecture material and complete the formative activities prior to the first block course. During the block course, you will have the opportunity to practice IV cannulation and then undertake the summative IV cannulation assessment. Following successful completion of the assessment, you will be able to practice IV cannulation under direct clinical supervision during your clinical placements. IV cannulation is an essential skill for paramedics (Brinton, Fenton & Meadley, 2019). IV cannulation provides the opportunity to administer fluids and medications (and in some areas blood products) directly into a patient's bloodstream (Horrigan, 2006). This can provide both faster and more accurate dosing, as the drug reaches the bloodstream immediately. However, despite its regular use, it is crucial to remember that IV cannulation is an invasive skill; it provides an artificial opening through one of the body's major defensive barriers to infection (the skin) and carries a significant potential for adverse events to occur to both the patient and the practitioner. As such we must strive to develop and maintain a high standard of IV practice.   There can be considered two components to achieving your goal as a competent IV practitioner; (1) learning the skill, which involves this learning package, structured practice opportunities during the first block course, and summative assessment and sign-off of skill performance, followed by (2) supervised practice during your clinical shifts. There is considerable discussion on the number of cannulations it takes to become proficient; there is no set number of cannulations required for the course. Instead, you (together with your clinical supervisor) will be required to identify and undertake opportunities during your clinical placements. Confidence is a big part of mastering any skill, and several consecutive failed attempts can be quite damaging to your confidence. A failed attempt should be treated as a learning opportunity, so try to understand why you failed and what corrective action is needed. Such analysis is important to growing your skill bank. +-----------------------------------+-----------------------------------+ | | **Study Goals** | | | | | | 1. Describe the anatomy and | | | physiology of the blood | | | vessels, especially: | | | | | | - The three layers that | | | typically form the blood | | | vessel, and the function | | | of each layer | | | | | | - How the structure and | | | function of the veins, | | | and how the veins differ | | | from the arteries | | | | | | - The structure and | | | function of venous valves | | | | | | - The location and function | | | of the nerves located in | | | the peripheral limbs | | | (especially the arms and | | | hands) | | | | | | 2. Describe the importance of | | | infection control (and | | | especially asepsis and hand | | | hygiene) in IV cannulation | | | | | | 3. Identify the indications for | | | peripheral IV cannulation, | | | including for special | | | population groups i.e. | | | elderly, paediatrics | | | | | | 4. Identify key safety | | | considerations in relation to | | | cannulation and the steps to | | | take in relation to a needle | | | stick injury or blood/body | | | fluid exposure | | | | | | 5. Describe the key | | | considerations in vein | | | selection, and veins and | | | areas to avoid | | | | | | 6. Understand and describe the | | | process of peripheral IV | | | cannulation | | | | | | 7. Identify and describe common | | | complications related to IV | | | cannulation | +-----------------------------------+-----------------------------------+ **Anatomy and physiology review** Our second area of review looks at the anatomy and physiology of the skin and the blood vessels, especially the vein. +-----------------------------------+-----------------------------------+ | | **Required Reading** | | | | | | Read the following sections | | | in **Chapter 10 -- Anatomy and | | | Physiology Related to Infusion | | | Therapy** in Infusion Nursing | | | (3^rd^ ed.). | | | | | | - pp. 157-162 - **Blood vessel | | | structure** | | | | | | - pp. 163-166 - **Location of | | | important arteries and | | | vein**s | | | | | | This eBook is available through | | | the [[ClinicalKey Nursing | | | database]](https://we | | | ltec.spydus.co.nz/cgi-bin/spydus. | | | exe/MSGTRNGEN/WPAC/EBOOKS).  | +-----------------------------------+-----------------------------------+   **Over-the-catheter IV cannula with retractable needle** In IV cannulation, a **catheter** (consisting of an introducing **needle** and a hollow, plastic **cannula**) is introduced through the skin and into a peripheral vein. The cannula is then advanced off the needle, the needle is safely removed and disposed of, leaving the plastic cannula in the vein. An access port (**leur plug**) is attached to the hub of the cannula and the cannula and leur plug are then secured. The vein and bloodstream can now be accessed directly and repeatedly. **Position of cannula in vein** *Source: http://www.youtube.com/watch?feature=endscreen&NR=1&v=LNSTSA6x9dQ* **Layers of the skin** *Source: Marieb & Hoehn (2010)* The first barrier to successful cannulation is the skin. It consists of two main layers: 1. **The epidermis** -- is the least sensitive layer, largely comprised of dead squamous cells. In general, the epidermis is thickest on the palms of the hands and soles of the feet and thinnest on the inner surfaces of the extremities. But, the thickness can vary depending on age and exposure to the sun or wind. The most important function of the epidermis is to act as the first line of defence against infection.  2. **The dermis** -- is the thicker and more sensitive layer, as it is well supplied with nerves. It contains blood vessels, hair follicles, sweat glands, sebaceous glands, small muscles, and nerves. For example, one square cm contains 4 metres of nerves, 200 nerve endings for pain, and a metre of blood vessels.  **Structure of the blood vessels** *Source: http://antranik.org/blood-vessels/* An understanding of the structure of the blood vessels is also important to ensure safe cannulation. Veins and arteries each have three layers, or "coats", hence the Latin name \'tunica\'. 1. The outermost layer is the tunica externa or adventitia and is composed of connective tissue, which supports the vessel. 2. The middle layer, the tunica media is composed of primarily smooth muscle. It contains nerve fibres that cause veins to contract or relax in response to cold or heat. This layer also responds to chemical or mechanical stimulation, such as pain. 3. The third or inner layer is the tunica intima. This innermost layer is less muscular and thin, accounting for only about 10% of the vessel diameter. It consists of three parts: - - an innermost layer of squamous epithelium, - a basement membrane, overlying some connective tissue, and - a layer of elastic fibres, or elastin. The elastin fibres make the lumen very distensible. The thickness of the tunica layers will differ between veins and arteries because of the different pressures they encounter. In addition, the (low-pressure) veins contain one-way venous valves of endothelial tissue to direct blood flow. This means that the cannula should only be placed in the direction of blood flow. The valves are usually found near branches of the vein and may inhibit threading of the cannula into the lumen. There are approximately 40 venous valves between the hand and axilla alone. **Location of main veins, arteries and nerves in the antecubital fossa area of the arm** It is important to understand that any damage or abrasion occurring to the tunica intima during cannula insertion, the duration of cannula dwell, or during removal, encourages thrombus formation caused by cells and platelets adhering to the roughened vessel wall. Damage to this layer causes phlebitis, thrombophlebitis, or can even result in occlusion of the vessel from a thrombus. Your insertion technique and subsequent management of a cannula can contribute to these complications. As well as the veins, arteries and nerves also run through the arm and hands. It is important to know where these are located. The median nerve especially run very close to the veins in the antecubital fossa (ACF) area; care must be taken to avoid cannulating too deeply and thus damaging arteries, nerves or tendons. **Infection control** Before we start to look at IV cannulation, it is important to review two key areas associated with safe IV cannulation practice. +-----------------------------------+-----------------------------------+ | | **Review** | | | | | | Review the current infection | | | control policies and procedures | | | of your employer. | +-----------------------------------+-----------------------------------+ **1. Infection control policies and procedures** IV cannulation introduces an artificial opening through one of the body's key defenses against infection (the skin). At all times we should be employing an aseptic technique when: - preparing to cannulate - performing the cannulation itself (including securing the cannula) - any subsequent accessing of the cannula. **\ 2. Appropriate hand hygiene practice** Make sure you are familiar performing all aspects of appropriate hand hygiene in your practice. Hand hygiene is the single most important activity for minimising the risk of infection. Remember that wherever possible, soap and water should be used to clean hands. The use of alcohol gel should be used: - between different care activities for one patient (such as before and after IV cannulation) - between caring for different patients at a scene. Gloves should be used when performing the cannulation itself (to limit our exposure to blood-borne pathogens). It is crucial we understand that gloves do not remove the need to perform hand hygiene. If your hands are visibly soiled or you have been in contact with a spore-forming pathogen such as clostridium difficile (which is not killed by alcohol), firstly, use soap and water to wash your hands, and then followed with applying alcohol hand rub. If you hands are not visibly soiled just use alcohol gel, to clean your hands prior to donning gloves. After securing the cannula, remove your gloves, dispose your gloves appropriately and then reapply the alcohol gel ** ** +-----------------------------------------------------------------------+ | **Indications for intravenous cannulation** | | | | +--------------------------------+--------------------------------+ | | | | **Required Reading** | | | | | | | | | | Read the following sections | | | | | in **Chapter 16 - Clinical | | | | | Skills** in Emergency and | | | | | Trauma Care for Nurses and | | | | | Paramedics (3rd edition): | | | | | | | | | | - pp.358-359 - **Vascular | | | | | access** | | | | | | | | | | - p.359 - **Catheter | | | | | selection** | | | | | | | | | | - pp.359-360 - **Insertion** | | | | | | | | | | - pp.360-361 - **Paediatric | | | | | considerations** | | | | | | | | | | This is available through | | | | | the [[ClinicalKey Student | | | | | database]](https:/ | | | | | /weltec.spydus.co.nz/cgi-bin/s | | | | | pydus.exe/MSGTRNGEN/OPAC/EBOOK | | | | | S).  | | | +--------------------------------+--------------------------------+ | | | | You all should have observed the insertion of an IV catheter during | | clinical practice.  It is important to note that while the mechanical | | skill of IV insertion is important, the **rationale** for IV | | cannulation is just as crucial. | | | | As a paramedic, the indications for IV cannulation insertion fall | | into three categories: | | | | 1. **Drug administration** -- you are planning on administrating an | | intravenous drug to a patient\ | | \ | | *Question - What IV drugs are carried by your ambulance service?* | | | | 2. **Fluid therapy** -- you are planning on administrating | | intravenous fluid to a patient\ | | \ | | *Question - What forms of IV fluid does your ambulance service | | carry?* | | | | 3. **Prophylactic insertion **-- This is when an IV catheter is | | inserted, as drug administration or fluid therapy may be required | | later in the management of the patient (usually when the | | patient\'s condition deteriorates).\ | | \ | | *Questions - Do you have a rationale for when cannulation is | | required? Should every patient who is transported to a medical | | facility receive an IV cannula?* | | | | The decision to undertake prophylactic IV insertion can be | | challenging. As noted throughout this learning package, IV | | cannulation is an invasive skill that | | carries **benefits **and **risks **for the patient (and | | practitioner).  It is crucial to have **clear clinical | | rationale** for performing IV cannulation as distinct from \"just | | because we can\" or \"they *might *need it en-route or in the | | emergency department\" etc.   | | | | The Clinical Procedures and Guidelines (CPGs) provide guidance for | | whether (and when) pre-hospital IV cannulation is required, even if | | drug or fluid therapy is not immediately indicated. The following | | guidelines provide examples of different indications for IV access: | | | | **Guideline  4.6 - Hypovolaemia from uncontrolled bleeding** | | **Guideline 4.10 - | | Severe Traumatic Brain Injury** | | **Guideline 12.6 - Stroke ** | | ------------------------------------------------------------------- | | -------------------------------------------------- ------------------ | | --------------------------------------------------------------------- | | -------- ------------------------------------------------------------ | | ---------------------------------------------- | | | | | | | |   | | In this guideline, IV insertion is indicated *en route*, so as to d | | ecrease time to definitive care (i.e., surgery). IV insertion is re | | quired, even if the patient doesn\'t meet the indication for fluid th | | erapy. IV insertion is required for reperfusion therapy in hospital | | , rather than any pre-hospital intervention. | | | | The use of the CPGs can therefore help your decision-making about | | whether a patient requires prophylactic IV insertion, and avoid | | unnecessary cannulation.  However, it can be a difficult balance when | | we are looking to develop, practice, and maintain our IV cannulation | | skills. If we ensure we always have a clear rationale (we are | | planning to administer an IV drug or fluid and/or we | | have**appropriate clinical indicators** that the patient may | | deteriorate and require IV therapy) we can ethically and clinically | | justify the cannulation. | | | | +--------------------------------+--------------------------------+ | | | | **Required Reading** | | | | | | | | | | Read the following article | | | | | from Gonvers et al. (2020): | | | | | | | | | | [[Gonvers, G., Spichiger, T., | | | | | Albrecht, E., & Dami, F. | | | | | (2020). Use of peripheral | | | | | vascular access in the | | | | | prehospital setting: Is there | | | | | room for improvement? *BMC | | | | | Emergency Medicine, 20*(46). | | | | | https://doi.org/10.1186/s12873 | | | | | -020-00340-z.]](mo | | | | | odleappfs://localhost/_app_fil | | | | | e_/var/mobile/Containers/Data/ | | | | | Application/5646C75F-EF25-42C8 | | | | | -8C97-45A0D2E00948/Documents/s | | | | | ites/2ad3b6cda7ecae7627fda9474 | | | | | 8a3f414/filepool/Gonvers%20at% | | | | | 20al.%202020_90f6539aa36f55b78 | | | | | 9ec99bffcae8a8b.pdf) | | | | | | | | | | In this study, the authors\' | | | | | note that 46% of peripheral | | | | | vascular access (PVA) (IV or | | | | | IO) placed in a pre-hospital | | | | | setting were unused. 66% of | | | | | the unused PVAs were found to | | | | | be among patients with a lower | | | | | case severity (a National | | | | | Advisory Committee for | | | | | Aeronautics \[NACA\] score of | | | | | \< 4). While only 26% of | | | | | patients had a PVA inserted | | | | | during the study period, this | | | | | was still nearly 4000 patients | | | | | over a 12-month period. | | | | | Interestingly, the authors\' | | | | | noted \"EMS should not | | | | | anticipate the use of a | | | | | catheter by the hospital as | | | | | hospital personnel would be | | | | | able to place it under better | | | | | conditions and perform a blood | | | | | draw at the same time. It was | | | | | shown that a PVA inserted in | | | | | the prehospital setting but | | | | | unused in the field did not | | | | | shorten the time to accessing | | | | | treatment once the patient | | | | | arrived in the emergency | | | | | department.\" (p.4). | | | +--------------------------------+--------------------------------+ | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ | **IV cannulation** | | | | There are a number of factors which maximise the chances of success | | in IV cannulation. We will now look at the following factors: | | | | - Safety | | | | - Preparing the patient | | | | - Vein selection | | | | - Preparing the equipment | | | | - Cannulation technique | | | | - Securing the IV and documentation | | | | **\ | | Safety** | | | | When performing IV cannulation, safety is of paramount importance. | | There is a range of adverse events (or complications) that can occur | | to both the patient and the practitioner. The quiz activity for this | | topic will explore a number of the complications that can occur. We | | will now examine two other important areas, needles stick injuries | | and asepsis. | | | | Needle stick injuries can have grave consequences: reports indicate | | that there are about 20 pathogens that are transported by blood | | contact. The big three to be aware of are: | | | | - HIV ( Human immunodeficiency virus) | | | | - Hepatitis B | | | | - Hepatitis C | | | | How exposure occurs: | | | | - **Needlestick**: When the skin of a staff member is pricked or | | scratched by a sharp instrument or needle that has been | | previously used on a patient. This could be during the | | cannulation process, or if the IV catheter is not safely disposed | | of immediately. | | | | - **Splash**: When blood or body fluid is splashed onto a staff | | member and there is the potential for the fluid to enter the | | staff member\'s body. Entry points are broken skin or the eyes | | and mouth. | | | | - **Spill**: When a volume of blood or body fluid has escaped from | | its container and has spilled onto a staff member\'s skin. | | | | - **Bite**: When a patient bites a staff member and the skin is | | broken, there is a chance that there may be body-fluid exposure. | | Antibiotics and tetanus toxoid may be required to treat the | | person bitten.\ | |   | | | | +--------------------------------+--------------------------------+ | | | | **Important Point** | | | | | | | | | | Needlestick injury mostly | | | | | occurs through double handling | | | | | and can be avoided if the | | | | | person who performs the | | | | | procedure immediately disposes | | | | | of the needle. Remember that | | | | | while retractable safety IVs | | | | | decrease the risk of | | | | | needle-stick injury, they | | | | | don't remove the risk | | | | | entirely. | | | +--------------------------------+--------------------------------+ | | | |   | | | | +--------------------------------+--------------------------------+ | | | | **Universal precautions** | | | | | | | | | | - Gloves - change gloves | | | | | prior if required, plus | | | | | hand hygiene (see below) | | | | | | | | | | - Eye protection | | | | | | | | | | - Hand hygiene - before and | | | | | after the cannulation | | | | | +================================+================================+ | | | | **Sharp Containers** | | | | | | | | | | - Take the sharps container | | | | | with you and place it so | | | | | that you can reach it | | | | | | | | | | - Place your sharps directly | | | | | in the container without | | | | | double handling it (that | | | | | is, avoid swapping hands | | | | | or putting the sharp down | | | | | | | | | | - Make sure that the | | | | | container has plenty of | | | | | space available before you | | | | | start | | | | | | | | | | - Never try to retrieve | | | | | anything from a sharps | | | | | container | | | | | | | | | | - Don\'t shake the sharps | | | | | container to settle the | | | | | contents or attempt to | | | | | empty it | | | | | | | | | | - If you are forced to carry | | | | | sharps to a container, let | | | | | others around you know | | | | | what you are doing | | | | | | | | | | - Sharps containers are for | | | | | the disposal of sharps | | | | | only, they are not a | | | | | general rubbish bin | | | +--------------------------------+--------------------------------+ | | | | **Drawing up and administering | | | | | drugs** | | | | | | | | | | - Draw drugs up with a blunt | | | | | drawing-up needle | | | | | | | | | | - If required, switch to a | | | | | sharp needle for | | | | | intramuscular (IM) | | | | | administration immediately | | | | | prior to use | | | | | | | | | | - Keep hands behind needles | | | | | | | | | | - Don\'t recap needles (if | | | | | there is no other option, | | | | | recap with one hand only) | | | +--------------------------------+--------------------------------+ | | | |   | | | | In the event of blood/body fluid exposure: | | | | - Immediately rinse the affected area with soap and running warm | | water for at least 3 minutes. | | | | - If there is a puncture wound, squeeze it gently to flush out any | | contamination. | | | | - Paint puncture wound with an alcohol swab. | | | | - Cover with a dry, occlusive dressing, for example, gauze and | | Tegaderm or an Opsite. | | | | - Report the exposure to your manager as soon as first aid has been | | completed. | | | | **\ | |  \ | | Asepsis in cannulation** | | | | The areas that are in direct contact with the patient's bloodstream | | are highlighted in these photos, but in reality they look no | | different from the rest of the equipment. Therefore, constant | | vigilance is required when handling these pieces of | | equipment.  Preparation of the equipment, the environment, and the | | patient (see below) plus good cannulation and infection control | | practice (especially hand hygiene) will decrease the chance of | | pathogens contacting these areas.  | | | | Why is it so dire if a bug (pathogen) gets onto these things? What | | is the difference between these and an OPA, which goes into the mouth | | after all?  It is because the bugs bypass the first-line defence | | mechanisms of the body: the skin; the mucosa; the fact that a locally | | introduced pathogen will not be able to migrate easily; the fact that | | a locally introduced pathogen is generally infecting a non-vital body | | part (forearm vs myocardium, for example). This is an area where | | paramedics can make a huge difference in both directions; either | | worsening the problem of hospital-acquired infections or making it | | better.  | | | |  \ | | **How can infection develop?  How can pathogens be introduced into | | the system? ** | | | | - Skin flora -- we can introduce this by not preparing and swabbing | | the cannulation site appropriately   | | | | - Contamination of the catheter hub -- ensure aseptic technique | | when handling equipment  | | | | - Contamination of infusate -- check flushes, drugs, and fluids for | | clarity and expiry  | | | | | | | | - Hematogenous colonisation of the device -- inadequate flushing | | and maintenance of the IV device  | | | |  \ | | **Best practice to maintain asepsis and prevent infection | | involves: ** | | | | - The use and maintenance of sterile, in-date equipment  | | | | - Constant awareness by the paramedic of what parts of the | | equipment will be under the skin and/or part of the internal | | system   | | | | - A non-touch technique of the above areas (post-swab)  | | | | ** \ | |  \ | | Preparing the patient** | | | | *"Cannulation is preparation"* | | | | If there is one piece of advice I would like to pass on in regards to | | developing your cannulation technique, it is the above statement. As | | well as preparing your equipment, your environment and yourself, you | | need to prepare the patient for the procedure. | | | | Inserting an IV catheter is an invasive procedure.  It is imperative | | that the patient makes an informed choice and gives you consent | | before you proceed. If the patient is unconscious and you deem the IV | | to be an integral part of your management, consent for that IV is | | implied. | | | | Fear of needles is common and the best way to tackle this is to | | provide the patient with accurate information. For each patient, | | explain the reasons for the cannulation and the extent of the | | procedure. Include the consequences that could occur if the IV is not | | inserted. Consider what other drug administration routes are | | available (for example, oral or intranasal); paramedics have | | increasing options in terms of administration routes, especially in | | regard to analgesia. | | | | It is normal for some IV cannulations to be unsuccessful. For this | | reason, it may be appropriate to explain to the patient what will | | happen if this occurs. Consider the use of lignocaine to desensitise | | the IV insertion site, particularly if using the dorsal aspect of the | | hand. However, this would involve another (subcutaneous) injection | | and will increase the time to therapy while the lignocaine takes | | effect. | | | | Additionally, telling a patient what to expect can lower anxiety and | | allow them to cooperate. This can reduce flinching and improve the | | chances of success. | | | | Lastly, preparation of the patient may involve you positioning | | yourself or the patient in the most optimal position for successful | | cannulation. Don't be afraid to move the patient\'s arm or yourself | | to ensure the best access, light, and to minimise a potentially | | awkward or unsafe position (i.e. having to lean across the patient | | and/or away from your equipment). | | | | **\ | |  ** | | | | **Vein selection** | | | | Arguably, this is the most important phase of inserting an IV. You | | can set yourself up for failure by selecting an inappropriate vein to | | cannulate. Preferably, your venepuncture site should be located in | | the antecubital fossa, forearm, or dorsal aspect (back) of the hand. | | It is good practice to aim for the most distal part of the limb (but | | proximal to previous attempts) and then work up. | | | | **\ | | When selecting a vein, make sure it is:** | | | | -  round, firm, elastic, engorged | | | | -  not hard, bumpy, or flat | | | | **Ideal veins for IV cannulation include veins that are:** | | | | Soft, straight, and elastic | | | | - Easily palpated & stabilised | | | | - Without valves | | | | - Supported by intact, elastic skin | | | | - Proximal to (i.e. above) previous IV cannula sites/attempts. This | | may include recent phlebotomy procedures for blood tests. | | | | An important consideration in an awake patient is convenience for the | | patient, so in this situation the forearm may be the best choice, as | | they can still flex their elbow and use their hand.  However, these | | veins are the most mobile and the most difficult to cannulate. The | | non-dominant arm should always be your first choice in these | | patients. Likewise, avoid the hands and joints of arthritic patients | | or those using crutches or walkers (whenever possible). | | | | Veins to avoid include: | | | | - Areas of flexion & extension (including the wrist, and the ACF | | outside of rapid fluid therapy) | | | | - Areas of previous venepuncture -- signs of recent cannulation | | include the presence of a plaster, dressing, or operation sites | | | | - Areas of poor venous return or lymphoedema | | | | - On the side of mastectomies/CVA hemiparesis | | | | - AV fistulas or shunts | | | | - Lower extremities - these should be cannulated only in emergency | | situations by those expert in cannulation due to the increased | | risk of thrombophlebitis and PE | | | | - Areas displaying obvious cellulitis or broken skin | | | | - Anything that pulsates..... | | | | +--------------------------------+--------------------------------+ | | | **Metacarpal Veins** | **Cephalic/Basilic Veins** | | | +================================+================================+ | | | | | | | +--------------------------------+--------------------------------+ | | | Advantages: | Advantages | | | | | | | | | - Located on top of hand | - Runs length of arm | | | | | | | | | - Suitable for 18-24g | - Suitable for 16-24g | | | | | | | | | - Easy to feel and visualize | - Large vein in areas | | | | | | | | | - Distal site on the arm | - Can tolerate most | | | | | solutions, medications & | | | | | transfusions | | | | | | | | | |   | | | +--------------------------------+--------------------------------+ | | | Disadvantages: | Disadvantages: | | | | | | | | | - Reduces patient's | - Can roll in places | | | | mobility. | | | | | | - Access points in wrist & | | | | - Increased risk of | elbow can reduce movement | | | | infiltration & phlebitis | & increase complication | | | | | risk | | | |   | | | | | |   | | | +--------------------------------+--------------------------------+ | | | |  \ | | Veins in the ACF and above should not routinely be used for | | cannulation. Use of the antecubital fossa site particularly limits | | the patient's range of movement, is uncomfortable, interferes with | | blood sampling, results in positional fluid infusion, increases the | | risk of mechanical phlebitis and infiltration, and may limit | | cannulation distally if infection occurs (Wellington Free Ambulance, | | 2017). | | | | However, when urgent cannulation is required, as in a cardiac arrest | | or a severely obtunded patient requiring rapid fluid therapy, patient | | convenience has a lower priority. In these situations choosing the | | largest vein is appropriate, which are usually found in the ACF. | | | | +--------------------------------+--------------------------------+ | | | | **Important Point** | | | | | | | | | | Before you attend your first | | | | | block course, ask family and | | | | | friends if you can practice | | | | | vein selection on them. It is | | | | | worth taking the time to | | | | | practice this skill! During | | | | | your first block course, you | | | | | will learn about the equipment | | | | | required, cannulation | | | | | technique, and securing the | | | | | IV. | | | | | | | | | | Remember that | | | | | you *cannot* practice the | | | | | actual IV cannulation prior to | | | | | being signed off on the | | | | | course. | | | +--------------------------------+--------------------------------+ | | | | ** \ | | Cannulation and securing an IV** | | | | +--------------------------------+--------------------------------+ | | | | **Watch** | | | | | | | | | | The following videos show a | | | | | range of IV cannulation | | | | | techniques, including commonly | | | | | encountered problems.  | | | +--------------------------------+--------------------------------+ | | | | +--------------------------------+--------------------------------+ | | | | **Video 1** | | | | | | | | | | This video featuring Aimee and | | | | | Ken shows the full process of | | | | | IV cannulation from start to | | | | | finish (with the exception of | | | | | applying alcohol hand rub | | | | | prior to donning gloves!). | | | | | Study this video prior to your | | | | | block course. | | | +================================+================================+ | | | | **Video 2** | | | | | | | | | | 8-minute IV insertion.  A long | | | | | video, but some useful tips | | | | | for vein selection.  The video | | | | | also shows an extension leur | | | | | device and priming the | | | | | extension.  Note how the | | | | | packaging is used for placing | | | | | equipment into.  Some tips for | | | | | working up the vein are | | | | | provided. | | | | | | | | | | In the video, they talk about | | | | | advancing AND pulling out the | | | | | needle at the same time.  I | | | | | wouldn't recommend this until | | | | | the catheter is well advanced | | | | | and cannot slide back out of | | | | | the vein.  One point to note | | | | | is the need to IMMEDIATELY bin | | | | | the sharps and not just drop | | | | | it onto the bed.  If the | | | | | needle has not fully retracted | | | | | into the barrel, then this is | | | | | a needle-stick injury waiting | | | | | to happen.  Note the | | | | | discussion around | | | | | documentation. | | | +--------------------------------+--------------------------------+ | | | | **Video 3** | | | | | | | | | | 50-second IV attempt by | | | | | military personnel.  Good | | | | | flashback achieved, but didn't | | | | | advance the catheter far | | | | | enough.  Watch the | | | | | contaminated needle; this | | | | | needs to be binned | | | | | immediately.  This is a good | | | | | example of the user | | | | | momentarily distracted with | | | | | the contaminated sharps still | | | | | live and dangerous. | | | +--------------------------------+--------------------------------+ | | | | **Video 4** | | | | | | | | | | 2:30 minute IV insertion plus | | | | | hanging fluid.  Shows the | | | | | mobility of the skin and the | | | | | flashback.  Note the thumb | | | | | tractioning directly below the | | | | | IV site, which prevents the | | | | | needle from being lowered.  In | | | | | addition, there is trouble | | | | | with advancing the catheter | | | | | because skin traction is | | | | | released.  Once this traction | | | | | is applied again, the catheter | | | | | advances much more easily. | | | | | | | | | | Also, note the lignocaine | | | | | application to numb to site | | | | | prior to IV insertion. At | | | | | about 1min 15sec you get a | | | | | good view of the type of | | | | | cannula being used (Insyte | | | | | Autoguard).  It has a white | | | | | button which is pushed once | | | | | the catheter is fully | | | | | advanced.  This operates a | | | | | spring which automatically | | | | | retracts the needle into a | | | | | safety barrel. These cannulas | | | | | are used in a number of | | | | | medical centres. | | | +--------------------------------+--------------------------------+ | | | | **Video 5** | | | | | | | | | | 1:15 minute IV insertion by a | | | | | military medic. Insertion goes | | | | | well, but doesn't release the | | | | | tourniquet or tamponade. | | | +--------------------------------+--------------------------------+ | | | | **Video 6** | | | | | | | | | | 4:20 minutes. Clip shows x4 | | | | | insertions, 2 by an | | | | | instructor, 2 by students. | | | | | Good close-ups with commentary | | | | | from the instructor. All | | | | | attempts use lignocaine blebs | | | | | to numb the site before | | | | | insertion. Use a mixture of | | | | | cannula, some ProtectIV, some | | | | | Insyte Autoguard. They seem to | | | | | be using a slightly different | | | | | technique where they insert | | | | | parallel to the vein and then | | | | | presumably go sideways, not | | | | | coming in directly on top of | | | | | the vein. | | | | | | | | | | Once the IV cannulation has | | | | | been completed, the IV cannula | | | | | needs to be secured. Avoid | | | | | applying the securing tape | | | | | directly over the insertion | | | | | site. Apply a clear, occlusive | | | | | dressing over the insertion | | | | | site; the clear, occlusive | | | | | dressing allows you to observe | | | | | any bleeding, inflammation, or | | | | | reaction that may occur. Note | | | | | that the IV requires to be | | | | | both secured and dressed; the | | | | | dressing protects the | | | | | insertion site while securing | | | | | the IV limits the amount of | | | | | movement and thus mechanical | | | | | irritation experienced by the | | | | | vein. | | | +--------------------------------+--------------------------------+ | | | |  \ | | Finally document your cannulation attempt: | | | | - Date (at site) | | | | - Time (at site) | | | | - Size of needle (at site and PRF) | | | | - Who has placed it i.e. St John, WFA, etc | | | | - Number of attempts (PRF) | | | | - Location (PRF) | | | | - Any complications (PRF) | | | | The above information will allow the receiving facility to monitor | | the IV | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ | **What size catheter do I need?** | | | | Below is a table that shows the suggested uses for each size of | | catheter. Remember, the smaller the catheter gauge, the larger the | | catheter size!  The gauge use is Standard Wire Gauge (SWG), the same | | as used for No 8 wire, which more correctly would be written as 8 SWG | | wire! | | | | \* * | | | | ------------------------------------------------------------------- | | --------------------- | | **Size and Length** **Flow Rate** **Suggested Uses** | | --------------------- -- --------------- -------------------------- | | --------------------- | | 14Gx32mm 325ml/minute Rapid fluid administration | | /blood transfusions | | | | 16Gx32m 211ml/minute Rapid fluid administration | | /blood transfusions | | | | 18Gx32mm 110ml/minute Paediatric volume resuscit | | ation\ | | Adult drug administration | | | | 20Gx32mm 65ml/minute Paediatric volume resuscit | | ation\ | | Adult drug administration | | | | 22Gx25mm 38ml/minute Paediatric drug administra | | tion | | | | 24Gx19mm 24ml/minute Infants | | ------------------------------------------------------------------- | | --------------------- | | | |   | | | | From this chart we can deduce that 14g & 16g are suitable for fluid | | replacement, while the smaller gauge needle are more useful as a drug | | route. However, where vein selection is poor or a hypoperfused state | | exists you may only be able to gain access with a smaller needle. A | | smaller than desirable cannula is better than no IV access! | | | | As a general rule, use the smallest gauge with the shortest length to | | deliver your IV therapy. A smaller cannula reduces the mechanical | | irritation and trauma to the vein during insertion (and thus the | | potential for complications). Importantly, a smaller diameter also | | allows greater blood flow and haemodilation **around** the cannula | | while it is in the vein. This further reduces the damage to the | | tunica intima. | +-----------------------------------------------------------------------+ **Complications of IV cannulations** There are a number of complications associated with IV cannulation. These include infection, haematoma, extravasation (filtration or tissuing), phlebitis, and various forms of embolism (including air embolism from catheter sheer plus PE and thromboembolism.