INTRAVENOUS PERIPHERAL CANNULATION Midwifery Practice 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

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.

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.

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

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)

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

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

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.

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

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?

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

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

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

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?

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

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

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.

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.

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

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

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!!

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

CANNULA INSERTION Hold catheter in dominant hand “Anchor” vein Bevel up, quick, short, jabbing motion to enter skin (at about a 20-30 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

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

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.

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

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

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

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.

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

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

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

BIBLIOGRAPHY http://www.youtube.com/watch?v=E8MDwv5 YId0&feature=related http://www.youtube.com/watch?v=Vr g69FlHi6g