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Circulation - Peripheral cannulation

Indications

Venous blood sampling

Fluid or medication infusion

Blood transfusion

Contrast injection

Contraindications (absolute in bold)

Ipsilateral fistula

Ipsilateral radical mastectomy

Overlying infection

Phlebitis or thrombosis

Burns

Sclerosis

Alternatives

Oral medication or fluids

Venepuncture

Interosseous venous access

Central venous access

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Pain

Vasovagal reaction on insertion (syncope)

Failure (with or without local tissue infiltration)

Vessel injury (haematoma, haemorrhage, thrombophlebitis)

Nerve injury

Air embolism (particularly large cannula)

Thrombosis

Infection

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: non-sterile gloves

Area

Any clinical area

Staff

Procedural clinician

Equipment

Venous cannula (with a safety device)

Tourniquet (single patient use)

2ml Luer lock syringe and 30g needle (if local anaesthetic used)

10ml Luer lock syringe and 0.9% saline (flush)

Capless valve

Sterile gauze squares

Sterile adhesive strips and transparent dressing

PIVC insertion sticker

Sharps bin

Positioning

Sitting or supine, non-dominant forearm preferred

Inspect forearm starting distally and locate firm, round, elastic, well filled veins

Basilic or cephalic veins on the posterior (dorsal) forearm preferred if possible

Dorsal hand and cubital fossa veins considered as first alternatives

Medication

2ml 1% lignocaine (if local anaesthetic used)

Sequence

Place a tourniquet around the limb proximal to where the PIVC is to be inserted

Stroke or tap the vein with your fingers to dilate vein (before skin disinfection)

Consider handing the arm over the side of the bed or applying a warm compress (if no identified vein)

Decontaminate skin, allow to air dry

Using the thumb of the non-dominant hand stretch the skin distally to steady the vein

Insert finding needle 30 degrees to skin

Obtain flashback

Hold needle steady, flatten the cannula, advance needle 5mm

Advance the cannula over the needle

Release tourniquet

Apply pressure to skin over tip of PIVC (preventing blood spillage)

Remove needle and attach capless valve

Apply sterile tape and transparent occlusive dressing

Aspirate required blood amount via the capless valve and transfer into vacutainers

Flush PIVC with 5ml of 0.9% saline

Post-procedure care

Patient advice:

Not touch the insertion site or dressing

Keep the site dry and minimise excessive movement while PIVC in situ

Notify staff if pain, swelling or redness is experienced.

Document:

On dressing or apply PIVC insertion sticker

In notes: insertion date, time and site of insertion

Tips

Time spent optimising preparation is rarely wasted

Do not touch the planned insertion site after decontamination

Inexperienced clinicians should make no more than two attempts at cannulation, except during an emergency

Ultrasound machines and other devices can be useful to assist identifying peripheral veins

Discussion

There is evidence that local anaesthetics reduce the pain of insertion and persistent discomfort at the site of cannulation regardless of PIVC size and age of patient. Their use should be considered before the insertion of any PIVC. As well as minimising discomfort, anaesthetic can reduce patient movement and increase success.

Accurate basic electrolytes and haematologic values can be drawn from peripheral IV lines when infusions are shut off at least two minutes, at least 5ml of blood are discarded, and tubes are filled to the top to avoid inaccurate bicarbonate readings. Avoid excessive suction on the cannula which can cause haemolysis.

We suggest the follow sized cannulas for general emergency department use:

14g or rapid infusion catheter if major fluid resuscitation required

16g if blood products likely to be used

18g as standard for most situations

20g for difficult IV access

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

World Health Organization. World Health Organization guidelines on drawing blood: best practices in phlebotomy. 2010. 125pp. Available from: https://www.who.int/infection-prevention/publications/drawing_blood_best/en/

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Frank RL. Peripheral venous access in adults. In: UpToDate. Waltham (MA): UpToDate. Accessed June 2019. Available from: https://www.uptodate.com/contents/peripheral-venous-access-in-adults

Nickson, C. Peripheral venous cannulation. Life in the fast lane. 2019. Available from https://litfl.com/peripheral-intravenous-cannula/

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