PERIPHERAL VENOUS CANNULATION GUIDELINES

Reference
1271
Date approved
July 2013
Approving Body
Matrons Forum
Supporting Policy/ Working in Working in New Ways Package for
New Ways (WINW) Package Venepuncture and cannulation
Implementation date
July 2013
Supersedes
Version 1
Consultation undertaken
Nursing Practice Guidelines Group, Ward
Sisters/Charge Nurses, Practice
Development Matrons (PDMs), Clinical
Leads, Matrons.
Target audience
Document derivation /
evidence base:

Registered Nurses and Midwives

Department of Health (2007) Saving L
reducing infection, delivering clean safe
(revised edition), London, Crown Copyright
DH Saving Lives High Impact Interventions:
Peripheral intravenous cannula care bundle

Review Date
Lead Executive
Author/Lead Manager
Further Guidance/Information
Distribution:

July 2018
Director of Nursing
Diane Ryan, Stuart Thompson-Mchale
Ward Sisters/Charge Nurses, PDMs, Clinical
Leads, Matrons, Nursing Practice Guidelines
Group (includes University of Nottingham
representative), Clinical Quality, Risk and
Safety Manager, Trust Intranet.

This guideline has been registered with the Trust. However, clinical
guidelines are guidelines only. The interpretation and application of
clinical guidelines will remain the responsibility of the individual
clinician. If in doubt contact a senior colleague or expert. Caution is
advised when using the guidelines after the review date.

CONTENTS

Page

SUMMARY OF APPLICATION
INTRODUCTION

3
4

INFECTION CONTROL
INDICATIONS
CONTRAINDICATIONS

4
5
5

OTHER COMPLICATIONS

FACTORS AFFECTING THE

SUCCESS OF CANULATION

SELECTING A SITE FOR

CANNULATION
DEVICE INFORMATION AND
CHOICE OF CANNULA
EQUIPMENT LIST
THE PRINCIPLE AND
RATIONALLE OF CANNULA
INSERTION
REFERRENCES
BIBLIOGRAPHY

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9
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Summary of Venous Cannulation

Nursing actions
Ensure there are no contraindications for the insertion of the
cannula.
Inform the patient of the procedure and obtain consent.
Inform the patient of possible complications that can occur as a
result of having a cannula in-situ.
.
Preparation and site selection
Select a site where the vein is long straight and accessible
ensuring not on the ante-cubital fossa or near a bony
prominence.
Wash hands and prepare the equipment needed.
Extend the limb and apply a tourniquet.
Palpate the selected vein and thoroughly clean the site with an
alcohol swab.
Principles of the procedure
Put on disposable gloves.
Remove the cannula cover and loosen the introducer from the
cannula.
Anchor the vein by holding the surrounding skin taut using your
non-dominant hand.
Insert the cannual at an angle of between 5-10 degrees.
Observe flashback of blood in the cannula chamber. Level off
the cannula and advance a few millimetres into the vein.
Withdraw introducer approximately 5mm. Advance the cannula
further into the vein, observing for continued flashback of blood
along the cannula.
Release the tourniquet. Apply firm pressure over the vein at the
distal end of the cannual and then withdraw.
Attach an extension set or sterile bung to the end of the cannula
Flush the cannula with 5mls of sterile saline and then apply a
sterile transparent dressing.
Additional instructions
There should be no more than 2 unsuccessful attempts by the
same practitioner on the same patient.

NURSING PRACTICE GUIDELINES

PERIPHERAL VENOUS CANNULATION GUIDELINES

INTRODUCTION
Peripheral venous cannulation is the insertion of a Vascular Access Device
(VAD) into a peripheral vein (RCN, 2010).
A cannula is a flexible tube containing an introducer which may be inserted
into a blood vessel (Anderson & Anderson 1995; Phillips 2005) and are
usually placed in the peripheral veins of the lower arms. There are occasions
when they may be inserted into the veins of the foot, but they should not be
used routinely due to the increased risk of thrombophlebitis (RCN, 2010;
Weinstein 2007). If veins of the feet are used, the cannula should be re-sited
as soon as possible (Phillips, Collins and Dougherty 2011). It is thought that
approximately 70% of all patients will have a cannula inserted during their
admission (Rivera, Strauss, Van Zundert et.al., 2007).
Although there is a wide range of VADs available to allow for the type of
therapy being given, and for the patients quality of life needs, the principles of
care for the device remain the same:
To prevent infection
To maintain a closed intravenous system with few connections to
reduce the risk of contamination
To maintain a patent device
To prevent damage to the device & associated intravenous equipment
(Dougherty & Lister, 2011)
The cannulation procedure may be performed by a practitioner who can
demonstrate relevant theoretical knowledge & who has been assessed as
competent using a cannulation package as part of the Working in New Ways
initiative (Nottingham University Hospitals NHS Trust, 2011a). In addition, the
practitioner must be satisfied that the cannula needs to be inserted and that
the patient consents to the procedure (NUH, 2010).

INFECTION CONTROL
Insertion of a cannula must be performed using an aseptic non-touch
technique (Department of Health, 2003). Thorough hand cleaning according
to the Hand Hygiene Policy (NUH 2011b) must be performed to reduce the
risk of cross-infection to the patient. Gloves should be worn in line with
standard precautions and the NUH Glove selection Guideline (2011c).

All disposable equipment must be sterile and single use only, and should be
disposed of in accordance with local policy. (RCN 2010; NUH 2011d)
Visibly dirty skin should be washed with soap & water (Perucca, 2001). The
following procedure is then applied: Clean and prepare the skin with 2%
chlorhexidine gluconate in 70%alcohol solution using a swab, cloth or other
applicator. Apply ensuring the skin is wet for 30-60 seconds (rub for 5-10
seconds and then lay swab over the skin for the rest of the time). This should
be allowed to air dry for up to 1 minute (Weinstein, 2007). Following
cleaning, the skin should not be touched or re-palpated, as the cleaning
regimen will have to be repeated (Dougherty and Lister, 2011). The need to
remove hair by shaving has not been substantiated (Weinstein 2007).
Shaving the skin prior to cannulation is not recommended as it can cause
micro abrasions which can become a focus for infection. If excessive hair
needs to be removed it should be clipped (RCN, 2010d).
The cannula should be secured & covered with a sterile dressing which
should be transparent, easy to apply and remove, waterproof, semipermeable and comfortable for the patient (McGovern 2010; Dougherty and
Lister 2011).
INDICATIONS
The main indications for the insertion of a peripheral venous cannula are:

administration of intravenous medicines.

transfusions of blood or blood components.
maintenance or correction of hydration levels if unable to tolerate oral
fluids.
potential venous access.

CONTRA-INDICATIONS
The advantages of using a peripheral cannula are that they are usually easy
to insert and have few associated complications. However, they are known to
increase phlebitis and when necessary need re-siting (Dougherty and Lister,
2011). In addition, some patients may not be able to tolerate the presence of
a cannula. In such cases an alternative may be required such as a
peripherally inserted central venous catheters (PiCC), or a central line.
The selection of a site for cannulation may be contra-indicated by:
The presence of injury or damage (e.g. fracture, cerebrovascular
accident, oedema, lymphadenopathy, thrombosis caused by multiple
attempts of cannulation or venepuncture).
The presence of infection as suggested by inflammation, phlebitis,
cellulitis.
Veins which are mobile or tortuous, or sited near a bony prominence.
If intravenous therapy is predicted to be long-term.
Continuous infusions or therapies which are vesicant or have a pH of
<5 or >9 (Hadaway, 2010).

OTHER COMPLICATIONS
Accidental Damage
A nerve, tendon or artery may be inadvertently punctured causing pain,
damage or haemorrhage as well as loss of confidence for the nurse.
The nurse may also lose confidence in undertaking the procedure
Phlebitis
This is characterised by pain and discomfort resulting from inflammation of the
intima of the vein.
The three main types are:
Mechanical - damage/irritation by a cannula that is too large for the vein, or
inadequate securement of the cannula which allows for movement.
Chemical drugs which cause irritation (ph <5 or >9 or extreme osmolarity or
vesicant. Vesicant drugs can cause blistering and necrosis if they leak into the
surrounding tissues (Scales, 2008).
Bacterial - poor hygiene or aseptic techniques leading to infection (Dougherty
and Lister, 2011).
Haematoma
Haematoma may form if the cannula pierces the front and/or back wall of a
vein. This can occur during insertion or removal of the cannula and may
render the vein unsuitable for further cannulation (Perucca, 2010). In the
event of a haematoma occurring, firm pressure should be applied for 3-5
minutes. The risk of this occurring can be reduced through good vein and
device selection and competent technique.
Extravasation
This is the leakage of vesicant fluids or drugs into surrounding tissues which
can cause local necrosis (East Midlands Cancer Network, 2012).
Prolonged Bleeding Time
This may be due to a medical condition or drug therapy. It increases the risk
of bruising/haematoma formation, and worsens the consequences of
inadvertent arterial puncture.
Blood Spillage
See local infection control guidelines (NUH, 2010d)
Needle or Blood Phobia
Patients may experience mild to severe needle/blood phobias due to past
experiences (Dougherty and Lister, 2011). It is advisable to establish if the
patient is known to have any concerns or anxieties before commencing
cannulation as this may adversely affect the practitioners success and further
compound the patients fears (Weinstein, 2007).
Anxiety can cause constriction of peripheral veins thereby making the
procedure more difficult (Dougherty and Lister, 2011). A careful explanation
and a confident manner is essential.

Vasovagal Faint/Syncope
This is due to enervation of the autonomic nervous system. It is important to
ensure that the patient is sitting/lying in a chair/bed whilst undertaking the
procedure (Phillips, Collins and Dougherty 2011). However, if the patient
begins to feel faint or appears pale and sweaty, the procedure should be
stopped immediately.

FACTORS AFFECTING THE SUCCESS OF CANNULATION

The success of cannulation can be affected by factors influencing venous
dilation. The tunica media is composed of muscle fibres that constrict or dilate
in response to stimuli from the vasomotor centre in the medulla, via
sympathetic nerve transmission. Factors which impede venous dilation
include:

patient anxiety.
patient temperature.
mechanical or chemical irritants e.g. introduction of needle into vein,
drugs.
clinical state of patient e.g. dehydrated, vasoconstricted (Mallett and
Bailey, 1996).

Other factors affecting the success of cannulation include:

thrombosed or hardened veins;

choice of cannula size;
patient co-operation, previous experiences and preferences;
skill of the person performing the cannulation.

SELECTING A SITE FOR CANNULATION

Preference should be given to a site where the veins are accessible, unused,
easily detected by palpation and/or visual inspection and appear healthy and
patent. Such veins feel soft and bouncy to the touch and refill quickly following
compression (Weinstein, 2007). Long, straight veins with a large lumen are
ideal (Dougherty and Lister, 2011). However, there are many patients who do
not have ideal veins and practitioners will need to rely on their knowledge of
the anatomy and experience of the procedure in general to determine the best
site for cannulation in such situations.
The most common veins used are the basilic or cephalic veins of the forearm,
which allow the placement of a variety of different sized cannulae in an area
which is easily immobilised and does not cause too much restriction in patient
activity. The ante-cubical fossa should only be used as a last resort as the
effects of extravasation are more devastating, it is difficult to immobilise,
uncomfortable for the patient and may hamper other procedures such as
venepuncture and blood pressure recording (Weinstein 2007).

There are many factors that influence choice of site but if the patient is able to
carry out normal activities while a cannula is in situ, and it is secured and
dressed appropriately then the patient will receive their intravenous therapy
with few interruptions avoiding unnecessary delays (Doherty and Lister,
2011). The use of the patients dominant arm should be avoided, whenever
possible.

Best Practice
When inserting a cannula, the introducer should never be reinserted as this may cause the distal part of the sheath of the
cannula to shear off and enter the circulation system.
In addition, a cannula, following an abortive attempt, should
never be re-inserted as this increases the risk of sepsis.
(Philips, Collins and Doherty, 2011.)

DEVICE INFORMATION AND CHOICE OF CANNULA

A number of different types of peripheral cannula are available. It has been
shown that the incidence of vascular complications increases as the ratio of
cannula external diameter to vessel lumen increases (Dougherty & Lister,
2011). Therefore, the smallest, shortest gauge cannula should be used in any
given situation (RCN, 2010). Some of the factors which influence choice of
cannula are:
the purpose of the cannulation;
proposed drug administration;
the expected duration of cannula placement;
the size of the vein to be cannulated.
Each cannula has the volume of fluid that can be infused on the external
package. This will also inform the practitioner of an appropriate size. For the
administration of viscous fluids/drugs, larger gauge needles may be required.
In addition, larger gauge needles are used routinely in emergency situations

Best Practice
The smallest, shortest gauge cannula should be used in any given
situation (RCN, 2010)

EQUIPMENT LIST
Sharps container
Procedure tray
Cannulation Pack which includes;
1 small drape
1 Clinell wipe
2 dry Swabs
1 IV cannula dressing
1 Customised cannulation label
1 needle free extension set
Gloves in accordance with risk assessment and local policies
Appropriate cannula for the purpose and length of infusion
5mls sterile saline and syringe
Disposable tourniquet
Prepared infusion or needle free bung
Alcohol hand rub
VIPS chart (NUH01290S)

The Principle and Rationale of Cannula Insertion

PRINCIPLE
Explain and discuss the procedure to
the patient and gain verbal consent.

RATIONALE
To ensure the patient understands
the procedure and gives their
informed consent. Document consent.
Where doubt exists over the patients
ability to consent to the procedure
follow the guidance in Consent to
Examination or Treatment Policy
(NUH, 2012).
Where possible involve patient in To reduce anxiety, understand
selection of cannulation site, taking patients previous IV History, and
into account factors discussed in the obtain consent.
previous introduction, indications,
contraindications
and
hazards Avoid using unsuitable limbs with
sections.
limited venous return or access.
Also ensure that, if the patient is
seated on a bed/chair, he/she has To reduce the risk if injury from falling
back support.
backwards if the patient has a
vasovagal
attack
during
the
procedure.
The use of a local anaesthetic To reduce patient discomfort
injection (which needs to be
administered a few minutes before
cannulation) or anaesthetic cream
(e.g.Emla
Cream/Ametrop
gel,
cryogesic
spray)
should
be
considered. Cream needs to be
applied according to manufacturers
instructions (i.e. between 15-60
minutes prior to procedure) in order to
take effect. Cryogesic spray if used
acts immediately

CONSIDERATIONS
Clean hands as per Hand Hygiene
policy ( NUH, 2011b)
Collect equipment identified in
equipment list.
Where possible, establish if the
patient is known to be at risk, due to
prolonged bleeding time.
Ascertain if the patient has any
known allergies to the dressing which
is to be used.
Use an alternative dressing if
necessary.

RATIONALE

So procedure has no unnecessary

interruptions.
To promote safety for patient and
staff.
To prevent an allergic reaction

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Prepare equipment on the procedure

tray using an aseptic non-touch
technique (see
Aseptic Non Touch Technique
guidelines,
NUH 2012b).
Clean hands before and after
palpating skin
Extend the limb and support on a
pillow
Apply tourniquet to the chosen limb.

To minimise transmission of infection

(DoH, 2007)

Use the following methods to

encourage venous access: ask the patient to clench and
unclench his/her fist;
lower the extremity below the
level of the heart;
stroke veins with fingertips;
apply heat pad (under
supervision) or
immerse hand/arm in warm
water.
Lightly palpate selected vein and
assess its suitability for cannulation.

To assess availability and suitability

of veins and to promote blood flow
and venous engorgement/ distension.

Thoroughly clean the site with alcohol

swab and then allow to air dry for at
least 1 minute.

To reduce the risk of infection.

Put on disposable gloves according

to the Glove Selection Guideline
(NUH 2011c).

To reduce the risk of cross infection

Check expiry date of cannula.

Remove the cannula cover and
inspect for signs of damage. Loosen
the introducer from the
cannula. Do not completely remove
introducer

To reduce the risk of cross infection

and to prevent
accidental injury to the skin or vein.

Anchor the vein by holding the

surrounding skin taut using your nondominant hand.

To help immobilise the vein and

facilitate entry

To maintain asepsis.
To increase accessibility and patient
comfort.
To cause venous dilation and aid
cannula insertion.
Allows the limb to be restrained whilst
also having more flexibility and
control on the amount of pressure
applied

Palpation helps reduce the risk of

accidental puncture of artery, nerve
or tendon.

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Insert the cannula, bevel up, in line

with the vein and at an angle of
between 5-10.

To facilitate entry into the vein and

minimise trauma.

Observe flashback of blood in the

cannula chamber.

To ensure the cannula tip is in the

vein.

Level off the cannula and advance a

few millimetres further into the vein.

To ensure cannula is in the vein.

Withdraw introducer approximately

5mm

To avoid exiting through the posterior

wall of the vein.

Advance the cannula further into the

vein, observing for continued
flashback of blood
along the cannula.

To ensure cannula is inserted

completely into the vein.

Release tourniquet

To reduce venous engorgement

Apply gentle but firm pressure over

the vein at distal end of cannula and
then withdraw
the introducer and place it directly
into the sharps container.
Attach an extension set plus either a
sterile bung , needle-free extension
set or prepared infusion set to the
end of the
cannula.
Flush the cannula with 5mls of 0.9%
sodium chloride. Observe for signs of
swelling or discomfort.

To reduce the risk of blood spillage

and needle
stick injury

Apply a sterile transparent dressing

using an aseptic technique, ensuring
that the
entry site is visible and the date label
is completed and attached to the
dressing. If an infusion set is being
used, ensure this is secured in a
double loop on the patients arm
using
hypo-allergenic adhesive tape.
Dispose of clinical waste as per local
policy

To reduce the risk of the cannula

being dislodged
and trauma to the vein wall.

To close the system and prepare for

use.
Ensures the cannula is secure even
when lines are being changed
To check patency and position and
prevent occlusion by blood.

To allow inspection of the insertion

site and reduce
the risk of infection (Wilson, 2001).

To reduce the risk of cross infection.

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Document date, time, position and

size of cannula in the relevant
documentation as
per local policy.

Ensure the insertion site is inspected

regularly for signs of
infection/phlebitis
(DoH, 2003). Sites must be inspected
prior to administration of medication,
four hourly if an infusion is in
progress or if the patient complains of
pain or discomfort around the site.
This should be documented on the
VIP chart.
When the cannula is removed, this
must be recorded in the relevant
documentation as
per local policy (DoH, 2003).

Best Practice

To allow replacement at 72 hours

irrespective of
the presence of infection (DoH, 2003)
and to maintain an accurate record.
Note that writing the date and time of
insertion on the dressing does not
replace the need to record the
insertion in the patients notes.( VIP
chart)
To ensure site remains patent and, if
infection or phlebitis is noted, the
cannula can be removed.

To maintain accurate records.

Attempts at cannulation

There should be no more than 2 unsuccessful attempts by the same

practitioner on one patient at any given time. If the attempts are unsuccessful,
the patient must be reassured and another (more experienced practitioner)
should undertake subsequent cannulation (Weinstein 2007.)

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References
Anderson KN & Anderson LE (Eds) (1995) Mosbys Pocket Dictionary of
Nursing, Medicine and Professionals Allied to Medicine. London:Mosby.
Department of Health (2007a) Saving Lives: reducing infection, delivering clean safe
care (revised edition), London, Crown Copyright
Department of Health (2007b) Saving Lives High Impact Interventions:
Peripheral intravenous cannula care bundle. London: HMSO.
Department of Health (2003) Winning Ways: Working together to reduce
healthcare associated infection in England. London: HMSO.
Dougherty, L. and Lister, S. (Eds.) (2011) The Royal Marsden Hospital
Manual of Clinical Nursing Procedures. 8th ed. Oxford: Blackwell
Publishing.
East Midlands Cancer Network (2011) Guidelines on the Management of
Extravasation
Hadaway, L. (2000) Peripheral IV therapy in adults Self-study Workbook.
Georgia, USA: Hadaway Associates
Mallett J and Bailey C (1996) Manual of Clinical Nursing Procedures 4th ed.
Oxford: Blackwell Science
McGovern, D. (2010). Peripheral IV cannulation in chemotherapy
administration. British journal of Nursing 9(14):pp 878
Nottingham University Hospitals NHS Trust (2012a) Consent to examination
or treatment policy.
Nottingham University Hospitals NHS Trust (2012b) Aseptic non touch
technique (ANTT) policy.
Nottingham University Hospitals NHS Trust (2011a) Working In New Ways
Expanding the Scope of Professional Practice.
Nottingham University Hospitals NHS Trust (2011b) Hand Hygiene Policy.
Nottingham University Hospitals NHS Trust (2011c) Glove Selection
Guideline: Examination and Surgical Gloves.
Nottingham University Hospitals NHS Trust (2011d) Infection Prevention and
Control Cleaning and Decontamination Policy
Nottingham University Hospitals NHS Trust (2010) Guide to intravenous
Therapy

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Perucca R (2001) Obtaining vascular access Infusion Therapy in Clinical

Practice 2nd edition (Eds. J Hankin et al Philadelphia, USA: W B Saunders.
Phillips, L. (2005) Manual of IV therapeutics. 4th ed. FA Davis, Philadelphia
Phillips S, Collins M, and Dougherty L (eds) (2011) Venepuncture and
cannulation. London:Wiley Blackwell.
Rivera, A.M, Strauss, K.W., Van Zundert, A.A.J. and Mortier, E.P. (2007)
Matching the peripheral intravenous catheter to the individual patient. Acta
Anaesth. Belg. 58(1): pp. 19-25.
RCN (2010) Standards for Infusion Therapy 3rd. Edition. Royal College of
Nursing, London.
Scales, K. (2008) Intravenous therapy: a guide to good practice. British Journal of
Nursing. 17(19): pp S4-S12
Weinstein, S (2007) Plumers Principles and practice of Intravenous therapy 8th
ed. London: Lippincott, Williams and Wilkins.

Bibliography
Hudek K (1986) Compliance in Intravenous Therapy CINA 2(3): pp 7-8
Infection Nurses Society (INS) (2000) Standards for Infusion Therapy
Massachusetts, USA: INS
Infection Control Nurses Association (ICNA) (2001) Guidelines for Preventing
Intravascular Catheter Related Infection London: ICNA
Nottingham Acute Trusts (2009) Venepuncture and Cannulation: An
Educational Self-Directed Package Nottingham: NAT

Authors:
NPGG Link:

modified by Diane Ryan

Stuart Thompson-Mchale

For Review: 2018

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