1. INTRAVENOUS PERIPHERAL CANNULATION
Midwifery Practice 2

2. INTRODUCTION What do you already know?
What experiences have you had with iv cannulation?
What are your thoughts on this midwifery role?
What do you expect to gain from this session?
Introduce myself
My experience of IV cannulation, why & when I learnt, how I applied that in practice.
The most important single factor influencing learning is what the learner already knows. Ascertain this and teach accordingly.
I know that

3. To introduce the procedure of peripheral intravenous cannulation
AIM OF THE SESSION
To introduce the procedure of peripheral intravenous cannulation
How are we going to achieve our learning outcomes:
Firstly revise the anatomy in order to complete the skill competently
Set ground rules for the ‘hands on’ practical section of this session-sharps dangerous we need to be careful, understand and follow infection control procedures
Are those outcomes clear?
Is there anything you would like to add?
Outline session:
Theory will include revision and exercises
Practical, working in pairs or small groups, trial & error, collaborative learning.

4. LEARNING OUTCOMES
Understand the purpose and indications of iv cannulation
Gain an overview of the technique
Familiarise yourselves with equipment and procedure
Gain some practice
Understand common complications and how to solve them.

5. PURPOSE OF IV CANNULATION
To have quick and easy access to the patient’s blood stream for rapid or more effective administration of a required or potentially needed treatment

6. INDICATIONS Fluid administration or replacement (epidural, PPH..)
Drug administration
in an emergency
in cases where it is required that a drug is absorbed and metabolised more effectively than it would be by any other route (ie.IV antibiotics, Syntocinon..)
Administration of whole blood or blood products
In preparation for a potential complication (multiparity, multiple births)

7. ANATOMY & PHYSIOLOGY REVISION
Veins return _______ blood to the _____ against the flow of gravity.
This occurs under ____ pressure, therefore veins do not require ____ ______ walls like arteries. To maintain the direction of flow, veins are equipped with ___-___ valves.
Veins tend to be located more ______ than arteries and do not _______ on palpation.
Deoxygenated
Heart
Low
Thick muscular
One-way values
Superficially
pulsate

8. Tunica intima – smooth endothelial lining for easy flow
Tunica media – mainly smooth muscle/elasticity for constriction/dilation
Tunica adventitia – connective tissue for support

9. CHOICE OF VEIN Palpate using fingers (not thumb)
Feels like elastic tube filled full
Does not have a pulse!
Ideally in the lower half of the arm or back of the hand
Locate the straightest portion of the vein
The veins should feel bouncy and refill when depressed and should be straight, have a large lumen, be well supported, visible, and free of valves to ensure easy advancement of the cannula into the vein.
Valves can be felt as small lumps in the vein or may be visualized at bifurcations or more commonly seen in certain vessels.

10. STRUCTURES TO AVOID Dominant arm Joints Flexure of the elbow
Areas with compromised circulation, oedema or fracture
Valves in the veins (seen as bulges)
Arteries
It is best to avoid joints because:
- this will lead to an increased risk of mechanical phlebitis and an infusion that will infuse intermittently due to the woman's movement.
it can also be very awkward for the woman and may restrict her ability to carry out activities.
Tends to be used in emergencies

11. POINTS TO CONSIDER
Evidence of altered anatomy or physiology? Burns, scars…
Anticoagulant therapy, bleeding/clotting disorder (HELPP, liver disease…)?
Vascular or circulatory problems, or vascular or lymphatic surgery?
One arm or particular site being easier than any other?

12. MATERIALS / EQUIPMENT Torniquete Sterile gloves
Alcohol and/or clorhexidine wipes
IV cannula (and sharps bin!!)
IV dressing
Swabs
? Lidocaine
Protective cloth / pad for the bed

13. DEVICES Butterfly - mainly in neonates
- administration of small amounts of drugs
- drawing up blood

14. DEVICES - “Over the needle” cannula:
- It’s the most commonly used device
- Mounted over the needle:once device is pushed off of the needle into the vein, the stylet is removed
- Drug, blood and fluid administration

15. Colour Gauge Flow/Rate mls/min Type of infusion Orange 14 343 Grey 16
-Rapid blood transfusion
-Emergencies
Grey 16
196
Green 18 90
Blood products, medicines, fluids
Pink 20 61
General crystalloid use
Blue 22 36
Paediatrics, oncology
Yellow 24
Paediatrics, oncology, neonatology, elderly
IV cannulas come in many different sizes:
The bigger the gauge size, the smaller the diameter of the catheter lumen is
In maternity, the ideal size used should be 14 or 16g.
WHY?

16. A LATEX GLOVE MUST NEVER BE USED
TOURNIQUET
- Know how to use it before approaching patient!
- 5 cm above site (3 finger breadths)
- 2 fingered gap
- Apply tourniquet to the upper arm ensuring it does not obstruct arterial flow
- Check patient is comfortable
A LATEX GLOVE MUST NEVER BE USED

17. In these diagrams - Veins are blue – arteries red and nerves are yellow
Look at the diagram on the left we are going to focus on the anatomy of the arm

18. THE CEPHALIC VEIN 
It readily accommodates a large-gauge cannula and, by its position on the forearm, provides a natural splint.
However, its position at a joint may increase complications such as mechanical phlebitis and even general discomfort.
The tendons controlling the thumb obscure the vein during insertion and care must be taken not to touch the radial nerve.

19. THE BASILIC VEIN
The basilic vein is a large vessel, which is often overlooked due to its inconspicuous position on the ulnar border of the hand and forearm. Cannulation can be awkward due to its position, its tendency to have many valves and to roll easily.

20. METACARPAL VEINS Ideal position for IV;
primary choice in pregnancy although veins are thin with inadequate tissue and muscle support in the elderly

21. Dorsal venous network Not very stable:
Usually easily visualized and palpated but can only accommodate smaller gauge catheters
Last resort for short-term therapy

22. CONSIDERATIONS
-Appropriate preparation of environment – including consent and adequate lighting / client comfort.
-Use equipment designed for the specific purpose /task e.g. a proper tourniquet, skin prep, small sharps bin
-Awareness of woman’s history
-Good technique – including assessment of vessel and woman throughout, and insertion of cannula along the line of the vein NOT across.
-Adequate infection control/skin cleansing and wearing of gloves. Beware of sharps!!

23. TECHNIQUE Introduce yourself and explain procedure Wash hands
Apply tourniquet
Ask the woman to clench her fist
Identify vein
Put on gloves
Clean the skin
-5 cm above antecubital fossa (avoid obsttructing arterial flow)
-a few times: this will promote venous engorgement
-chosen site with alcohol and/or clorhexidine, for 30 secs, in a circular motion starting at the entry site and extending outward about 2 inches. Allow 30 seconds to dry

24. CANNULA INSERTION Hold catheter in dominant hand “Anchor” vein
Bevel up, quick, short, jabbing motion to enter skin (at about a degree angle in the direction of the vein)
As you enter the vein, you will see flashback
Advance catheter whilst simultaneously withdrawing needle to enter vein until 2nd flashback is seen along cannula

25. ONCE INSIDE THE VEIN Advance plastic catheter
Should slide easily: do not force it
Release tourniquet, ask the woman to bend arm and apply pressure at the distal end on the catheter.
Withdraw needle ensuring the catheter stays in vein
Never insert a needle into the catheter while it is in the woman’s arm

26. YOU HAVE DONE IT!! Dispose of needle in sharps container
Secure the cannula as per hospital policy
Draw bloods if you need to or connect purged giving set
Write date and time of insertion of cannula on dressing
Document: location of insertion, type and gauge, date and time, bloods taken, number and location of attempts, adverse events.

27. TROUBLESHOOTING
If you don’t get flashback, do not remove cannula
Slowly withdraw while watching for flashback
If not in vein, change direction of the needle slighltly
If still unsuccessful, do not panic: we all have failed at some point!
Release tourniquet, place gauze over puncture, remove catheter, tape down gauze
?Try on another arm / ?Ask another team member
If you hit an artery, remove catheter and apply firm pressure for at least 5 minutes

28. PRINCIPLES OF CARE
To prevent morbidity - infection and trauma. To maintain a ‘closed’ IV system with few connections to reduce the risk of contamination. To maintain a patent device. To prevent damage to the device and associated equipment

29. CANNULA CARE Change catheter site every 48-72 hrs
Inspection and documentation of status of cannula and area on each shift
? Flush device prior to administering a drug or connecting fluids

30. RISKS & COMPLICATIONS
- Damage to nerves and local tissue caused by poor technique
- Fibrosis of vessels caused by intima layer of vessel becoming roughened by scarring with the cannula.
- Haematoma – caused by ‘overshooting’ the vessel.
- Alcohol must be allowed to dry to avoid irritation to tissues
Associated with rotation of the cannula and application of pressure whilst stylet still in place.

31. COMPLICATIONS
- Extravasation: inadvertent administration of a vesicant solution or drug into the tissues
- Phlebitis caused by inadequate cleansing or poor infection control technique allowing entry of bacteria or micro-organisms
Tissue necrosis may follow

32. COMPLICATIONS: Phlebitis
SIGNS & SYMPTOMS:
Redness or tenderness at tip of catheter or along infusion site
Puffy tissue over vein
Elevated temperature
WHAT TO DO:
Stop infusion
Remove catheter
Call for help
Document

34. COMPLICATIONS: Cellulitis/infection
SINGS & SYMPTOMS
Warm/hot
Swelling
Possibly febrile
Malaise
WHAT TO DO:
- Stop infusion
- Remove catheter
- Call for help
- Document

35. BIBLIOGRAPHY
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