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Cannulation and Venepuncture

Workbook and Competencies


Copyright Royal United Hospital Bath NHS Trust. 2012 Version.

Copyright Royal United Hospital Bath For use by RUH employees only

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This book has been issued to. Date.

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Ward.
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Name(s) of assessor(s) (please print).


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For audit and verification purposes, please complete the above section. You
are reminded that only staff, who have completed the RUH NHS Trusts
Cannulation and venepunture Practical Skills Course and are competent in the
practical skills should assess you.

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Contents

Introduction............................................................................................................................4
The assessment Strategy for Cannulation and Venepuncture.........................................6
Section 1. Guidelines for Professional Practice................................................................8

Section 2. Venous Anatomy and Physiology....................................................................11

Section 3. Infection Prevention and Control....................................................................20

Section 4. Venepunture.......................................................................................................24

Section 5. Cannulation........................................................................................................28

Section 6. Potential Complications...................................................................................32

Section 7. Flushing of Peripheral Venous Cannulae.......................................................39

Section 8. References.........................................................................................................41

Appendix 1: Questions......................................................................................................43

Appendix 2: Student Note Page........................................................................................46

Appendix 3: Record of Supervised Practice...................................................................47

Appendix 4: Competency Assessment for Peripheral Venous Cannulation ...............48

Appendix 5: Peripheral Venous Cannulation Procedure Guidelines ............................52

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Introduction

The Cannulation and Venepuncture Workbook is a pre-course workbook


designed for the purpose of developing your knowledge and understanding
with regards to the theory of important topics relating to Cannulation and
Venepuncture. Many aspects of cannulation and venepuncture are covered.
However this book has not been designed as a definitive text and should be
read in conjunction with other published material, for which some references
are provided. In conjunction with this workbook, you should also access the
policies and the health and Safety teaching slides, Back Care for Cannulation
and Venepuncture. These are accessed through the Clinical Skills Intranet
Pages, under Peripheral Cannulation and Venepuncture. Health Care
Assistance must ensure that the specific QCF modules are completed with the
skills. Please speak to the Vocational Education Team for further information
about appropriate QCF Modules. Following the Practical Skills Teach you are
expected to complete the competencies within a three month period.

The workbook is to be used in conjunction with attending the 4 hour taught


practical skills session, where your knowledge of the skills obtained from the
pre-course material will be continually assessed. The pre-course questionnaire
must be completed prior to the skills session and be brought with you on the
day of your Practical Skills Teach. This workbook is intended to be used as a
guide, reference tool and assessment record.

Failure to provide this evidence may result in you being asked to rebook
your Skills Teach for another time.

Additional information and competencies are available on the Royal


United Hospitals intranet site. Coupled with the Royal Marsden which is
located on the desktops. Staff should complete the additional
competencies relevant to their clinical practice after having been signed
off as competent in Cannulation and Venepuncture by their assessor.
Please note that staff members are also required to complete their
Intravenous Flushing Competency.

You are reminded that issues relating to accountability and competence


encompass all aspects of health care, not just Cannulation and Venepuncture.
You are strongly advised to read the Nursing & Midwifery Councils or your

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own professional bodys Code of Professional Conduct. Furthermore it is
essential that you refer to the RUH NHS Trust IV Medicine Administration
Policy if you have any doubts as to the correct procedure for the administration
of a given medicine, ie Normal Saline Flush.

Before training in the competency of cannulation and venepuncture, you


should discuss with your manager and peers that other aspects of care that
you are expected to perform will not be compromised.

Remember, Cannulation and venepuncture are extended roles and should not
come before basic nursing care needs. Ensure you prioritise your work load
accordingly.

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The assessment Strategy for Cannulation and Venepuncture

This section should be read in conjunction with the assessment strategy flow
chart, a copy of which can be found overleaf.

Staff in clinical areas must have completed the RUH Cannulation and
Venepuncture Competencies to enable them to assess you. Assessors do not
have to have attended the RUH training course if they are able to demonstrate
equivalent training, however they must have completed the RUH
Competencies. In this way minimum standards can be maintained Trust-Wide.
You MUST NOT be assessed by anyone who has not completed RUH
Competencies. Prior to undertaking the course please ensure that there is an
assessor in your work area and that you have ample opportunity to practice
the skills and keep up to date.

This workbook is designed as a self-study document for practitioners to work


through at your own pace. It is expected however that completion of the book
will take a maximum of 4 hours and will be completed prior to attending the
Practical Skills Teach. If you are having difficulty in completing the book within
this time period you should discuss this with your assessor and /or the
Resuscitation and Clinical Skills Team at the earliest opportunity.

Near the end of the book is a section of questions which must be completed.
These will be marked by a member of the resuscitation and Clinical skills
Team on the day of your Skills Teach. Questions must be answered correctly.
In addition, your assessor will question you verbally to assess your knowledge
and competence in your work area.

At the end of this document is a competency section that needs to be


completed with your assessor after a period of supervised practice.. However
it is your professional responsibility to ensure that you maintain your skills and
theoretical knowledge. If you have any queries regarding the assessment
process you should contact your assessor or Resuscitation and clinical Skills
Team for advice.

These competencies apply to all practitioners employed at the Royal United Hospital NHS
Trust
For newly qualified nurses access to this programme is at your managers discretion

Competency documents should be available for audit or investigation purposes

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Cannulation and Venepuncture Training Process

Line manager identifies a clinical need for staff to be trained in


Cannulation and/or venepunture

Staff member agrees and is willing to complete training and NO STOP


competencies and an assessor is available in clinical area
N.B If you
YES are not
willing to
Candidate books a place for the taught skills teach and accesses the practice the
Pre-course Workbook via the intranet. skills do
not attend
the course.
Candidate completes the Workbook modules and relevant
training e.g. NVQ modules

Supervised Practice

Candidate attends the taught skills teach 4 hour session
With a patient, the
candidate demonstrates
competence to the
Assessed as competent? assessor using the skills
and knowledge from the
YES NO pre-course workbook and
skills teach
Assessor and candidate sign off
competencies to be kept by
candidate but a copy given to Assessor addresses
learning needs and
ward or department manager
offers a further period of
supervised practice

Candidate now competent to practice Intravenous Cannulation


and/or venepunture. Annual self-re-assessment required
Candidate and assessor identify a time frame for
completion of any additional competencies

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Section 1. Guidelines for Professional Practice

Professional responsibility:

All staff who perform venepuncture & cannulation must have received
approved trained and documented, supervised practice.
The onus is also on individuals to ensure that their knowledge and skills
are maintained, both from a theoretical and practical perspective.
All practitioners must operate within the Policies, Protocols and Guidelines
of their particular organisation.

Accountability:

Cannulation and Venepuncture should only being carried out by an


accountable practitioner. These include for example:

Medical Staff, Registered Nurses, Midwives, Radiographers, Other non


registered staff (after approved training and competencies)

The description of accountability used by the Department of health is;

the obligation of one party to provide a justication and to be held responsible


for its actions by another interested party

These interested parties can include yourselves, Professional Regulating


Bodies (NMC), the patient/ client, Employer and general public.

Professional and Legal Issues

The Code of Professional Conduct (NMC 2004), Guidelines for Records and
Record Keeping (NMC 2005) and your Trusts policies and guidelines will
assist you in understanding your professional accountability (RCN 2005).

Radiographers, Clinicians Assistants and Health Care Assistant Practitioners


will have local policies and procedures to govern their practice.

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Health and Safety at Work Act

Your most important responsibilities as an employee are:

to take reasonable care of your own health and safety


to take reasonable care not to put other people - fellow employees,
patients and members of the public - at risk by what you do or don't do
in the course of your work
to co-operate with your employer, making sure you get proper training
and you understand and follow the trusts Health and Safety Policies
Do not interfere with or misuse anything that's been provided for your
health, safety or welfare
to report any injuries or accidents that you suffer as a result of doing
your job (for example, reporting needle-stick injuries)

Find definitions and explain how these relate to your practice with
regards to both cannulation and venepunture.

Direct Liability:

Vicarious Liability:

IGNORANCE IS NOT A DEFENCE


It is your responsibility to keep up to date with current practices, and changes
to evidence in practice.

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Extended Roles

Where do your responsibilities lie?

Consent

Informed consent must be obtained from your patients.

What does this mean? How will you do this?

Summary

Never carry out a procedure that you have not been trained to do, signed as
competent to do or do not feel confident to do.

Registered and non-registered staff have responsibilities to act professionally


& lawfully

Ensure you keep up to date with current evidence based practice

Remember these skills are extended roles and should not take priority over
basic nursing care. Prioritise your work load accordingly.

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Section 2. Venous Anatomy and Physiology

Objectives: To be able to...

Differentiate between an artery and a vein

Identify and name the commonly used veins for venepuncture and
cannulation

Be aware of nerves in the arm

Understand how to choose an appropriate vein for venepuncture and


cannulation avoiding hazardous anatomical structures

Always use veins in the upper extremities before using lower extremity sites
for venepuncture. Veins of the lower limbs should only be used in exceptional
circumstances and by a trained and competent practitioner. The most
common site for venepuncture is at the antecubital fossa. The antecubital
fossa is located at the medial aspect of the elbow. At this point the median
cubital, cephalic and basilica veins lie close to the surface of the skin, this
makes them easily accessible and visible. Research has also found these
veins to minimise discomfort.

The Cephalic vein travels along the radial surface of the forearm. The
Accessory Cephalic is located on the posterior aspect of the forearm joining
the cephalic below the elbow. It is fairly easily palpated if not visible.

The Basilic vein journeys up the ulnar surface of the forearm joining with both
the median cubital and median antebrachial vein below the elbow.

Metacarpal veins located on the dorsum of the hand are often readily visible.
For venipuncture, these veins are used as a last resort, except for small
infants.

However for cannulation the dorsum veins should be attempted first, moving
proximally to the antecubital fossa (ACF). In an Emergency, the veins in the
ACF will be used.

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Study the picture on page 12 and try to identify your own veins at the
antecubital fossa. Attempt to locate your own vein without looking, only by
palpation.

Studying the picture below, note how close the arteries are to the veins.
Think about how you may differentiate between veins and arteries?
Why do you think it is important to differentiate between the two?

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Which veins would you chose to use and why?

Veins and arteries consist of three main layers;

The Tunica Externa (the outer layer) A fibrous layer of connective tissue,
collagen and nerve fibres that surrounds and supports the vessel.

The Tunica Media (the middle layer) A muscular layer containing elastic
tissue and smooth muscle fibres.

The Tunica Intima (the inner layer) A thin layer of endothelium that
facilitates blood flow and prevents adherence of blood cells to the vessel wall.
Trauma to the endothelium encourages platelet adherence and thrombus
formation.

The walls of veins are thinner and less elastic than the corresponding layers of
arteries. Veins include valves which aid the return of blood to the heart by
preventing blood from flowing in the reverse direction.

Why are valves sometimes problematic when taking blood or cannulating?

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Differences between arteries and Veins

ARTERIES

Take oxygenated blood from the heart to tissues


Have thick walls
Small Lumen
Elastic
No valves
Deep seated (Usually)
Do not collapse
High pressure

VEINS

Take deoxygenated blood from the tissues to the heart


Thin walls
Large lumen
Less elastic
Have valves to prevent any backflow of blood
Lie closer to the skin
Tendency to collapse

It is important to check for and locate the patients pulse to ensure that you are
not attempting to cannulate or take blood from an artery. Veins do not have a
pulse.

How will you know when you have taken blood from or cannulated an artery
and what action should you take following this?

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Nerves of the arm

Three main nerves run past the elbow and wrist to the hand.

The Median Nerve passes down the inside of the arm and crosses the front of
the elbow. The median nerve supplies muscles that help bend the wrist and
fingers. It is a main nerve for the muscles that bend the thumb. The median
nerve also gives feeling to the skin on much of the hand around the palm, the
thumb, and the index and middle fingers. When the median nerve is
compressed over a long period it can cause carpal tunnel syndrome.

The Ulnar Nerve passes down the inside of the arm. It then passes behind the
elbow, where it lies in a groove between two bony points on the back and inner
side of the elbow. The ulnar nerve supplies muscles that help bend the wrist
and fingers, and that help move the fingers from side to side. It also gives
feeling to the skin of the outer part of the hand, including the little finger and
the outer half of the back of the hand, palm, and ring finger. When the elbow
is bumped over the ulnar nerve, it's often called hitting the "funny bone."

The Radial Nerve passes down the back and outside of the upper arm. The
radial nerve supplies muscles that straighten the elbow, and lift and straighten
the wrist, thumb, and fingers. The radial nerve gives feeling to the skin on the
outside of the thumb and on the back of the hand and the index finger, middle
finger, and half of the ring finger.

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Study the picture of the nerves: Which nerves do you think you need to
be aware of when taking blood from the antecubital fossa?

How would you know if you damaged a nerve during Venepuncture or


Cannulation and what would you do?

When assessing your patient to obtain blood or for cannulation you need to
choose an appropriate vein. It is essential that you assess for a suitable vein
to ensure for;

1. Successful treatment
2. Viability of venepuncture site
3. to help reduce mechanical phlebitis and chemical phlebitis

Veins should be;

Visible
Palpable
Bouncy
Soft
Well supported

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Refills when depressed
Straight and non-toruous
Sites to avoid include:

Evidence of venous fibrosis;


Evidence of haematoma/oedema formation;
Evidence of localised infection/inflammation;
Any vascular access device;
Fistulae or vascular grafts.
Limbs with fractures
Small, visible but impalpable veins
The affected side in patients post mastectomy or post-cardiovascular
accident.

Factors to consider when choosing a vein

Patient's medical history


Patient's age, size and general condition
Condition of the patient's veins
Veins commonly used for venepuncture and cannulation
Your skill at Venepuncture and Cannulation
Patient input as to quality and accessibility of veins from the perspective
of past experience

To palpate a vein

Place two fingertips over the vein and press lightly. Release pressure to
assess for elasticity and rebound filling. When you depress and release an
engorged vein, it should spring back to a rounded full state. Palpate the
position where the cannula tip will rest, not just the point of insertion. If the vein
is not straight then it will be difficult to advance the cannula.

To acquire a developed sense of touch, palpate veins prior to each


Venepuncture or cannulation. Through this practice you will gain valuable
experience, as well as an increased confidence in the assessment and
Cannulation/ venepunture of more difficult veins later on in your practice.

Veins that may appear suitable on inspection, can prove otherwise upon
palpation.

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What questions will you ask your patient that will help you decide on which
vein to use?

Accurate vein assessment is essential in matching your skill level with the
patients condition. It is not appropriate for the novice to attempt
venepuncture on patients with fragile or difficult veins. It is expected that the
novice would become confident and competent before attempting to access
more difficult veins. Discuss vein and patient assessment with your assessor.

Anatomy and physiology Summary

Only perform venepuncture and cannulation on healthy tissue


Be aware of the artery at the Antecubital Fossa
Be aware of the nerves at the Antecubital Fossa
In some individuals the artery lies over the vein so remember to check if there
is a pulse.

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Section 3. Infection Prevention and Control

IV cannulation is an invasive procedure involving a breach in the skins


integrity. Furthermore, the breach extends from the skin surface to the
bloodstream, so the potential for infection is always there and skilled and
conscientious care are required to prevent its occurrence.

The Royal College of Nursing (RCN) Standards for Infusion Therapy specify
that Use of aseptic technique, observation of universal precautions, and
product sterility are required in infusion procedures (Royal College of Nursing,
2003).

Objectives

Reducing health care associated infections


Aseptic Non-Touch Technique (ANTT)
Safe disposal of sharps & waste
What to do in the event of a sharps injuries

Why is Infection, Prevention and Control so important in the practice of venepunture


and Cannulation?

National Institute for Clinical Excellence (2003) states that: Gloves must be
worn for invasive procedures, contact with sterile sites and non-intact skin or
mucous membranes, and all activities that have been assessed as carrying a
risk of exposure to blood, body fluids, secretions or excretions or sharp or
contaminated instruments.

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How will you prevent infection and cross infection in your own Practice?

NICE (2003) also states that Disposable plastic aprons should be worn when
there is a risk that clothing may become exposed to blood, body fluids,
secretions or excretions, with the exception of sweat. Therefore ensure you
take adequate precautions when cannulating or for venepuncture.

Good hand hygiene is the single most important way of preventing the spread
of infection (Josephson, 2004). Please familiarise yourself with the 7 stages of
handwashing. For more information from the World Health Organisation for
hand washing please following the below link.

http://webserver/clinical_directory/infection_control/links.asp?menu_id=4

Centres for Disease Control and Prevention (2002b) states that:

Wearing clean gloves rather than sterile gloves is acceptable for the insertion
of peripheral intravascular catheters if the access site is not touched after the
application of skin antiseptics.

What systems and or care plans are in place to reduce the risk from
Cannulation and Venepuncture? What do you have in your areas?

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During invasive clinical procedures including the use of invasive medical
devices, patients depend upon healthcare workers to protect them from
harmful microorganisms. This critical clinical competency is termed:

ASEPTIC TECHNIQUE

This is the most commonly performed critical infection prevention skill in health
care. The aseptic non touch technique is an initiative aimed at ensuring the
essential actions of aseptic technique occur every time. Cannulation and
Venepuncture are skills that require this technique in order to protect the
patient from harmful microorganisms.

The 3 main sources of microbiological contamination during aseptic


technique

Sources of Routes of
contamination Contamination

The air environment Airborne


Contamination
The Health Care Hand touch
Worker contamination

The proceeding Direct and indirect


workplace contamination

Be Clear what do we mean by aseptic?

Sterile Clean Asepsis

Free from all Free from marks and Free from pathogens
microorganisms stains and organisms, in
sufficient numbers to
cause infection
This is not achievable This is not a This is achievable in
in the health care satisfactory standard typical health care
setting for invasive clinical settings
procedures or
maintenance of clinical
devices

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A lack of respect for microorganisms transference via equipment
utilization. Examples within Venepuncture and Cannulation Include;

The ANNT Approach

1.Key-Part / Key-Site Risk Assessment



2. Environmental Management

3. Decontamination & Protection

4. Aseptic Field Selection & Management

5. Non-Touch Technique

6. Decontamination

Please complete the ANNT competency: Further reading includes the


ANNT workbook; available from the Infection Prevention and Control
Team

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Section 4. Venepunture

Learning to perform Venepuncture for the purpose of obtaining blood samples


involves acquiring challenging skills that require knowledge, perseverance,
patience and practise. Good preparation and practice is essential and will
ensure that you become efficient. Your confidence will then soon grow.
Confidence and proficiency come with performing real procedures on real
patients with different and varied types and qualities of veins. Be patient, you
will get it.

You may perform this skill a number of times before you are signed off by
your assessor. There is no set number of successful attempts prior to sign
off. Skill development will differ with experience, exposure and manual
dexterity.

Please access the Royal Marsden on the RUH Desktop for a detailed
description of how to perform Venepunture. This will be expanded upon in your
skills teach.

Refer to section 3 with regards to choosing the most appropriate vein.

How will you position your patient?

Tourniquets are single patient use only and are latex free. Do not use your
own material tourniquet. This is not acceptable. Remember 3 minutes is
maximum time for tourniquet application. Organization is the key to
being successful within the given time frame.

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Blood bottles have specific solutions in each tube to enable the blood to be
analised in the laboratories. It is therefore important to take the blood in a
specific order to reduce any cross contamination of solutions. The RUH use
the BD Vacutainer System with the following order of draw.

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In your preparation for venepuncture, check the requisition for specific test(s)
required. Be certain that you understand what type of blood specimen is
required, what tube is needed and the amount of specimen required. If in
doubt, call the appropriate lab.

Blood Cultures should be taken first - Then most commonly:

Blue Top (clotting screen)


Yellow Top (biochemistry profile)
Purple Top (full blood count)

All tubes must be mixed to allow accurate testing in the laboratory. Blue and
mauve tops should be gently rotated 3-4 times. All other tubes should be
rotated 6-8 times.

How to Label...
1. Use ICE label if available otherwise a black pen
2. Include full name, D.O.B, Ward, date and time
3. Write the time of collection on the request form and initial the form
4. Place the tubes in the bag and attach the blood form and seal

Venepunture Checklist:

Have you confirmed the identity of the patient?


Have you obtained informed consent?
Have you considered local anaesthesia?
Does the patient have an IV infusion in progress in the limb you propose
to use?
Do you have all the equipment required?
Do you have a sharps bin?
Do you know how to document the procedure?
What will you do if you are unsuccessful?

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Venepuncture Key Points and Summary

Always gain consent

Always wear gloves when carrying out venepuncture

Always use vacutainer equipment when taking blood, never a needle and
syringe.

Always label blood bottles immediately after taken, ideally by the the
bedside of the patient.

Always follow the Trusts policies and guidelines

Always perform the skill under direct supervision by a trained member of


staff competent in the skill and who uses them regularly, until such time that
you are signed off as competent

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Section 5. Cannulation

Peripheral Cannulation is the procedure of inserting a cannula into the


peripheral veins, usually the veins of the hand or forearm although veins in the
feet or lower leg may also be used in exceptional circumstances (Finlay, 2004)
Peripheral IV cannulation is not suitable for patients who require long-term IV
therapy or for the infusion of markedly irritant or vesicant substances (e.g.
Cytotoxic drugs).

Summarise the indications and reasons for intravenous canulation

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Your answers to the above could have included some or all of the following;

maintaining hydration
restoring fluid and electrolyte balance
providing fluids for resuscitation
administering blood or blood components
administering drugs such as antibiotics.

Nurses, midwives and radiographers must be signed as competent in the


administration of a 5ml normal saline flush (in accordance with the Trust
administration of intravenous drugs policy section 3) prior to carrying out
peripheral venous cannulation. The flushing of cannula will be covered on the
skills teach.

Non-registered practitioners must only carry out peripheral venous cannulation


for a named patient on the verbal or written instructions of a Doctor, Nurse or
Radiographer. Other staff cannot give such authorisation.

Non-registered practitioners includes:

Doctors assistants
Radiology Department Assistants
Health Care Assistants

The cannula chosen should be the smallest to meet the clinical need. The
larger the lumen of the catheter the faster the flow rate. The indication for
cannulation should be considered and the cannula chosen accordingly. For
example, emergency colloid or blood replacement after a post-partum
haemorrhage will require a 16gage grey cannula whereas a line for
intermittent intravenous bolus injections of antibiotics could be 18g green or
20g pink. The larger the amount and type of fluid over a given time will
highlight to you as to the size of cannulae.

It is important to choose the correct size cannula. The options are:


16 gauge (grey) for surgical emergencies (170mls/min);
18 gauge (green) for blood transfusions or larger volumes (80mls/min);
20 gauge (pink) for maintenance of intravenous fluids; and

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22 gauge (blue) for difficult veins, slow intravenous fluids, or intravenous drugs
in a patient who can take oral fluids (31mls/min)

THINK;
Purpose of infusion,
Type of infusate and
length of treatment

Refer to section 3 Anatomy and Physiology for the appropriate vein


assessment and choice for cannulation. NB. Start your assessment
for a vein distally and work proximally. In an emergency any available
large peripheral vein may be used e.g. median cubital vein in the anti-
cubital fossa.

The site should be inspected daily (Hart, 1999) for signs of complications,
such as infection or phlebitis and also to check that the cannula is still firmly
secured and the dressings intact. VIP scores and care plans should be
completed every shift. Refer to section 5 for detailed complications.

What are the cannulation aftercare considerations?

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Royal College of Nursing (2003) provides detailed information about
documentation required in relation to infusion therapy. Here are some of the
main points applied to peripheral IV cannulation:

documented evidence of informed consent


Insertion: type, length and gauge of cannula; date and time of insertion;
number and location of attempts; any complications; name of person placing
the cannula.
Site care and appearance/condition using standardised assessment scales
for phlebitis and/or extravasation/infiltration.

Once sited the cannula should be flushed with 0.9% normal saline. The site
should be regularly inspected for signs of phlebitis.

VIP Care plans.

Peripheral cannulae should be re-sited every 48-72 hours to reduce the risk of
phlebitis, but this may be difficult in patients with difficult veins.

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Section 6. Potential Complications

Objectives

To understand the potential complications of Venepuncture and Cannulation

To understand how to deal with such complications if they should occur.

Complications

Haematoma (Bruising)
If a haematoma begins to
form, release the tourniquet,
remove the needle from the
vein and apply firm pressure
to the site.

The incidence of haematoma


after venepuncture can be
decreased by applying
pressure to the site after the
needle is removed.

A petechiae is a small red or


purple spot on the body,
caused by a minor
haemorrhage (broken
capillary blood vessel).
This often occurs in patients
with a coagulopathy but can
also occur if the tourniquet is
left tightened for prolonged
periods of time

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Infection
Local cellulitis or
septicaemia are
complications of
venepuncture. Strict aseptic
technique will reduce the
risk of patients developing a
bacteraemia. Inform medical
staff Immediately if infection
is suspected.

Bacteraemia and septicaemia:


An IV device provides the opportunity for bacteria to enter the
bloodstream. The presence of bacteria in the blood is termed
bacteraemia. If bacteraemia is accompanied by the symptoms of
infection (e.g. fever and rigors) the condition is termed septicaemia.
Bacteraemia and septicaemia are extremely serious, life-threatening
complications (Wilson, 1994). Local infections at the cannula site (e.g.
bacterial phlebitis) can lead on to systemic infection.

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Phlebitis (irritation)
All iv cannulae must be
checked daily for signs of
infusion phlebitis & a VIP
score documented.
Two of the most common
causes of infusion phlebitis
are chemical (due to fluid or
drug) & mechanical (due to
cannula). Consider removing
the cannula & inform medical
staff.

Phlebitis has been defined as

"inflammation of the vein wall." (Angeles & Barbone (1994) in Campbell


(1998))

Fuller & Winn (1998) have provided evidence to suggest that the risk of
phlebitis is increased for:

Cannulae in situ for more than 48 hours.


Veins that have been repeatedly cannulated.
Cannulae inserted in older people.

Clinical Signs:
Pain
Erythema (Redness)
Swelling
Infection

Extravasation
This has been defined as

the inadvertent administration of a vesicant or irritant solution into the


surrounding tissue.
Lamb (1999)

Clinical signs:

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Burning sensation
Pain
Some resistance to giving of a bolus injection or slowing of an infusion.
Tissue sloughing but this often takes a few days or a few weeks to become
apparent.
Necrosis

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Treatment of extravasation is difficult so it is essential that every measure is
taken to ensure its prevention.

Extravasation can be reduced by taking the following precautions:

Ensure that the cannula has been sited correctly using the smallest gauge
possible.
If the cannula has been in situ for more than 72 hours make sure that it is
replaced and preferably on a different limb.
Administer vesicant medicines first, after testing for placement by flushing.
If in doubt stop and resite cannula.
Lamb (1999)

Inform medical staff as soon as possible if extravasation is suspected.


Complete nursing documentation and refer to the RUH NHS Trust Care Plan
for the use of intravenous cannulae and intravenous infusions.

Embolism

The emboli most likely to occur in IV therapy are:


dislodged blood clot (thromboembolism).
fragment of cannula (cannula embolism).
air (air embolism).

Other embolisms include particulate matter such as hair or glass (Josephson,


2004). All of these can result in life-threatening pulmonary embolism.

Careful insertion technique will reduce the incidence of an embolism occuring

Causes

Thromboembolism: with IV therapy the usual cause is trauma to the intima of


the vein (Josephson, 2004).

Air embolism: causes include accidental severance of IV lines, infusion tubing


not being primed with infusate, disconnected or loose tubing junctions or
vented infusion containers being allowed to run dry (Josephson, 2004).
Cannula embolism: The most likely cause is through the reinsertion of the
needle into the stylet. This is bad practice and strongly discouraged.

36
Clinical features

Thromboembolism: a clot may travel to the lungs (pulmonary embolism). The


clinical features of pulmonary embolism include dyspnoea, pleuritic discomfort
or pain, apprehension, cough, sweats, tachypnoea, unexplained haemoptysis,
cyanosis and low grade fever.

Air embolism: the clinical features of air embolism are associated with
vascular collapse: dyspnoea, hypotension and tachypnoea (Josephson, 2004).

Cannula embolism: the patient may complain of severe, sudden pain at the
IV site. There will be absent or reduced blood return when checking for
placement. If the fragment lodges in the lungs or heart there will be
hypotension, chest pain, tachycardia, cyanosis and possible loss of
consciousness (Josephson, 2004).

Infiltration
Infiltration is the inadvertent administration of non-vesicant medication or
solution into the surrounding tissue instead of into the intended vascular
pathway (Royal College of Nursing, 2003).

Causes
These include:
cannula too large for diameter of vein.
puncture of distal wall of vein during cannulation.
poorly secured cannula e.g. too loose and mechanical friction from cannula
causes vein puncture; taping that is too tight above the cannula tip can act as
a tourniquet, disrupting flow and rupturing the vessel wall.
over-manipulation of the cannula.
delivery of fluid at high rate or pressure. (Josephson, 2004)

Clinical features

These include skin blanching, oedema, skin cool to touch, possibly pain
(Infusion Nurses Society, 2000, cited in Royal College of Nursing, 2003).

37
Key Points to remember

Remember to plan & never rush.


Careful technique will reduce the incidents of Complications.
Document all attempts as per trust policy.
Only two attempts for the same patient episode.
Always ask someone if you are not sure.

38
Section 7. Flushing of Peripheral Venous Cannulae

The cannula once successfully in situ must then be flushed with a 0.9%
Normal Saline 5-10ml, to ensure that all the blood products are flushed out of
the cannula to prevent occlusion. Flushing peripheral venous cannula is an
integral part of its insertion and therefor the competency.

The flushing of cannula should be immediately after insertion of that cannula.

NB Blood samples may be taken from the cannula immediately after


insertion of the cannula and before the administration of a flush.
Once flushed the cannula should never be used to remove blood
samples. Remember to Flush after you have taken the blood samples
and concluded the care episode.

This section should be read in conjunction with the medicines Code:


Administration of Intravenous Drugs policy and procedure.

A 0.9% saline flush must be prescribed. A verbal order must never be taken
under any circumstances for this.

Non-registered practitioners can administer one 5ml 0.9% sodium chloride


flush post-cannula insertion with a 10ml syringe. This can only be done
once they have successfully completed the approved Trust Peripheral
Cannulation Training Competencies and have completed the required
Qualification Credit Framework (QCF) unit.

All intravenous medicines must be double checked and this must be done
rigorously prior to administration. Two persons will carry out the check one of
whom will be a Registered Nurse or Doctor. (See sections 3.1, 4.3, 4.4 and 4.5
and Appendix 4 of the Trust Administration of Intravenous Medicines policy.)

Obtain informed consent from the patient. If in doubt refer to a Registered


member of staff. (If not already done so with cannula procedure)

The identity of the patient must be checked by the authorised non-registered


staff with the Registered Nurse or Doctor. This must be done by checking the

39
wristband of the patient against the drug prescription chart. A verbal
confirmation must also be made as per Trust peripheral cannulation policy.

The authorised non-registered staff must check that there are no faults in the
ampoules and equipment prior to use.

Use aseptic non touch technique (ANTT) and refer to the Infection
Prevention and Control Policy.

The Medicines chart must be signed by the person administering the flush and
countersigned by the checking practitioner

Dispose of all sharps and equipment in accordance with Trust infection


control policy.

List the essential Information required on a complete prescription?

40
Section 8. References

Collins, M. Phillips, S. Dougherty, L. (2006) A structured learning programme for


venepuncture and cannulation. Nursing Standard. 20 (26). 34-40.2.

Dimond, B. (2002) Legal aspects of nursing (2nd edition), Harlow: Longman.

Department of Health (2003) Winning Ways, Working together to reduce Health Care
Associated Infection in England

Department of Health(2006) Saving Lives: High Impact Interventions No.1.


Preventing the risk of microbial contamination

Department of Health(2006) Saving Lives: High Impact Interventions No.2 a/b.


Peripheral Intravenous Cannula Care Bundle.

Department of Health (2007) Saving Lives: reducing infection, delivering clean safe
care. (available on the Department of Health website at: www.dh.gov.uk).

Dougherty, L. (1999) Obtaining peripheral venous access, in Dougherty, L. and Lamb,


J. (editors) Intravenous therapy in nursing practice, Edinburgh: Churchill Livingstone,
pp.223-259.

Finlay, T. (2004) Intravenous therapy, Oxford: Blackwell Science.

Fuller, A. & Winn, C. (1998) The management of peripheral IV lines. Professional


Nurse 13(10) 675-8.

Hart, S. (2007) Using an aseptic technique to reduce the risk of infection. Nursing
Standard. 21,47, 43-48

Josephson, D.L. (2004) Intravenous infusion therapy for nurses. Principles and
practice (2nd edition), Clifton Park: Thomson Delmar Learning.

Lavery, I. Igram, p (2005) Venepuncture: best practice. Nursing Standard. 19,49. 55-
65.

41
Lamb, J. (1999) Local and systemic complications of intravenous therapy, in
Dougherty, L. & Lamb, J. (1999) (Eds) Intravenous Therapy in Nursing Practice,
Churchill Livingstone, Edinburgh

Mayberry, M. and Mayberry, J. (2003) Consent in clinical practice, Abingdon: Radcliffe


Medical.

National Audit Office (2009) Reducing Healthcare Associated Infections in Hospitals in


England. The Stationary Office, London. Available on
www.nao.org.uk/publications/0809/reducing_healthcare_associated.aspx

National Institute for Clinical Excellence (2003) Infection control. Prevention of


healthcare-associated infections in primary and community care. Information on
website: http://www.nice.org.uk/pdf/Infection_control_fullguideline. pdf (Accessed
05 Nov 2012).

Nursing Standard, (1999) Quick reference guide 5 Venepuncture. Vol 13 Number 36

Pratt et al (2007) EPIC 2 National Evidence-Based Guidelines for Preventing


Healthcare Associated infections in NHS Hospitals in England. The Journal of Hospital
Infection.

Pratt RJ, PelloweCM, Wilson JA et al (2007) epic2: National Evidence Based


Guidelines for preventing healthcare associated infections in NHS hospitalsin
England. Journal of Hospital Infection. 65, supplement. Elsevier, Oxford3.

RobergeRJ. (2004) Venodilatation techniques to enhance venepuncture and


intravenous cannulation. Journal of Emergency Medicine 27(1) 69-73

The Royal Marsden(2006) Clinical Nursing Procedures. Intranet Version,


(6thedition). Blackwell Publishing Ltd.

Wilson, J.A. (1994) Preventing infection during IV therapy, Professional Nurse, 9(6),
pp.388-390, 392.

42
Appendix 1: Questions

The following questions should be completed prior to attending the


skills teach and brought with you on the day. Failure to do so may
result in you being asked to rebook another session. It is essential
that all modules are completed as your knowledge will be assessed
during the course.

Canulation and Venepunture Work book questions


The answers to the questions can be found in the workbook and the reference list provided.

Please tick True or false to each Question True False

A pulse is always present on palpation of a vein

Only Nurses can be held responsible

Two attempts are acceptable in one patient episode per


person

The antecubital Fossa is easily accessible

It is possible to cannulate an artery

Ignorance is not a defence

It is acceptable to perform a procedure that you have not


been trained to do

It is your responsibility to keep up to date with practice

The antecubital fossa is located at the medial aspect of the


elbow

Veins and arteries consist of 5 layers

Veins include valves that aid the return of blood to the

43
heart
Questions continued

Veins take deoxygenated blood from the tissues to the


heart

The radial nerve gives feeling to the skin on the outside of


the thumb

The Median Nerve passes down the inside of the arm and
crosses behind of the elbow

Veins should be soft, palpable and bouncy

When possible only perform venepuncture and cannulation


on healthy tissue

Gloves must be worn for invasive procedures

Always label blood bottles immediately after taken

It does not matter which order you fill blood bottles

The bigger the gage of the cannula the better

Peripheral cannulae should be re-sited every 30-60 hours


to reduce the risk of phlebitis

A petechiae is a small red or purple spot on the body,

The incidence of haematoma after venepuncture can be


decreased by applying pressure to the site after the needle
is removed.

Extravasation can cause necrosis

Over-manipulation of the cannula can cause Infiltration

A 0.9% saline flush must be prescribed

Non-registered practitioners can administer one 5ml 0.9%


sodium chloride flush post-cannula insertion
44
20 attempts must be completed prior to competency
assessment

Careful technique will reduce the incidence of


complications

Topical local anaesthesia may be of benelfit when patients


are needle phobic

Royal United Competencys need to be completed before


you can practice the skills alone

45
Appendix 2: Student Note Page

46
Appendix 3: Record of Supervised Practice

Practice to be carried out after completion of Trust approved training, and until
member of staff feels competent.

Name of nurse:

Date Assessors name Comments, nurse or assessor

47
Appendix 4: Competency Assessment for Peripheral Venous
Cannulation

Name of staff member being assessed Date

Role / Band Ward / Department

1. Knowledge Assessor
Can the staff member:- to initial
and date
1.1 Identify local policies and national Yes / No
guidelines regarding peripheral venous
cannulation.
Yes / No

1.2 Describe the anatomy and physiology of


the venous and arterial circulatory systems. Yes / No

Yes / No
1.3 Differentiate between a vein and an
artery Yes / No

1.4 Identify the physiological need for


performing the procedure Yes / No
Yes / No
Yes / No
1.5 Where appropriate, identify the normal Yes / No
dosage, range and possible side effects of Yes / No
local anaesthesia. Yes / No
Yes / No
Yes / No
1.6 Identify and describe the following
potential hazards relating to peripheral
venous cannulation:

48
i. Air embolism
ii. Infection
iii. Haematoma
iv. Extravasation
v. Infiltration
vi. Phlebitis
vii. Faulty equipment
viii. Incorrect cannula fixation

49
2. Procedure Assessor
to initial
Did the staff member:- and date

2.1 Check the name of the patient against the Yes / No


patients wristband.
Confirm the name of the patient verbally.
If verbal identification of identity is not
possible, check patients identity with a second
practitioner.
Yes / No
2.2 Assess individual needs of the patient.
Yes / No
2.3 Select where appropriate a suitable person
for assisting with the procedure.
Yes / No
2.4 Prepare and demonstrate correct and
appropriate use of equipment.
Yes / No
2.3 Identify a suitable vein and position the
patient appropriately. Yes / No

2.4 Where appropriate, use of local Yes / No


anaesthesia as prescribed.
Yes / No
2.5 Insert a peripheral cannula correctly

2.6 Flush the cannula with 0.9% saline using Yes / No


at least a 10ml syringe.
Yes / No
2.7 Fixate the cannula using the appropriate
dressing. Yes / No

2.8 Safely dispose of all equipment according


to Trust policies.

2.9 Document the procedure correctly

50
Assessors name: Assessors signature:

Staff members name: Staff members signature

Pass Yes / No If No, reassessment date:

Competence can be defined as: The state of having the knowledge,


judgement, skills, energy, experience and motivation required to respond
adequately to the demands of ones professional responsibilities (Roach,
1992).

51
Appendix 5: Peripheral Venous Cannulation Procedure Guidelines

All staff have a responsibility for ensuring that the principles outlined within this
document are universally applied. This policy applies to all members of staff
who are involved in any aspect of the development and use of procedure
development.

1. Preparation

Equipment required
i. Sharps bin container tray.

ii. Sharps bin appropriate to tray (Not 5 litre size)*

iii. Non-sterile gloves

iv. Plastic apron

v. Alcohol-based hand rub

vi. Cannula appropriate to the purpose of insertion - The cannula chosen


should be the smallest to meet the clinical need.

vii. Chloraprep

viii. Sterile luer lock cap

ix. Sterile gauze

x. Sterile hypoallergenic adhesive plaster

xi. 10 ml syringe

xii. 21g Needle

xiii. 5ml vial 0.9% saline

*Patients in nursed in isolation rooms should have a sharps bin inside their
room as per Isolation policy.

52
2. Procedure prior to cannulation

Cannulation must only be carried out on the direction of a member of medical


staff or where a locally agreed protocol exists.

Put on apron and Wash hands with soap and water or alcohol gel as per Trust
hand hygiene policy.

Wipe plastic tray with soap and water or a detergent wipe if not socially clean
and dry.

Gather equipment as per list above.

Ensure correct patient identification as per the Trust Patient identification


policy.

Check the name of the patient against the patients wristband.

Ask the patient to confirm their name and date of birth. Do not ask, Are you?

If verbal confirmation of the identity is not possible, check patients identity with
a second practitioner.

Explain procedure to patient and obtain verbal consent in accordance with the
Trust policy on obtaining consent.

If the patient requires topical local anaesthetic this must be prescribed and
applied as directed. If administered non-registered practitioner this must be
supervised by a doctor or nurse.

3. During Cannulation

Prepare equipment and arrange in the plastic tray, checking all packaging for
expiry date, tears and other damage.

Ensure correct positioning of the patient under adequate lighting and that the
limb which is to be cannulated is well supported. Avoid unbalanced bending

53
and unsure you are in a comfortable and safe position. As per Trust Back care
when carrying out cannulation and venepuncture information

Clean hands with alcohol gel and allow to dry.

If required, apply a single use tourniquet six to eight inches above the insertion
site (Campbell 1995).

Assess suitability of chosen vein i.e. palpable, non-pulsatile, straight and


healthy. Veins must be palpated to assess suitability (Millam 2000)
Be aware of possible valves.

The hemiplegic limb of a patient having suffered a cerebrovascular


accident (CVA) must be avoided.

Bony prominences such as at a joint and the inner arm must be avoided.

Anywhere other than the hand of a patient in renal failure must not be
cannulated because of an existing fistula or potential future need for
one.

Limbs with lymphoedema, or arm on the side of an axillary node


dissection must be avoided. Patients with a Superior Vena Cava
Obstruction (SVCO) must not have their upper limbs used for peripheral
access.

Avoid the use of antecubital veins unless in a critical emergency


situation or for the administration of contrast media.

If the patient is cold to the touch, use measures for increasing venous
dilation such as the soaking of arms in warm water (which must then be
dried before cannulation is carried out), or by wrapping the arm/hand in a
blanket.

54
Nurses, radiographers, Doctors Assistants, radiology department
assistants, health care assistants, and other non-registered authorized
practitioners must not cannulate the lower limbs. However, exceptionally
some nurses who have undertaken extra training and assessment of
competence may carry out cannulation of lower limbs where a local
protocol exists to allow them to do so.

Feet should always be soaked prior to cannulation the patient should


be sitting upright to encourage blood flow.

If used, release the tourniquet.

Open the sterile dressing towel and place it under the patients arm except
where the patient is going to have the cannula inserted for a period of less
than 30 minutes.

Open all equipment and arrange it on an injection tray ensuring protection of


all key parts by using the Aseptic Non-Touch Technique.
Re-apply the tourniquet if used.

Clean the patients skin along and around the selected vein for at least 30
seconds using Chlorhexidine 2% w/v and Isopropyl in 70% alcohol
(Chloraprep Sepp). Allow to dry for at least 30 seconds.

Do not re-palpate the vein or touch the skin.

Apply alcohol hand rub.

Put on non-sterile gloves (Wynnejones & Pether 1993)

Take hold of the cannula and remove the needle guard, visually checking the
cannula for any faults.

Anchor the vein to be accessed by applying manual traction to the skin a few
centimetres below the proposed insertion site.

Ensuring that the cannula and bevel of the stylet/introducer are both facing
upwards, insert the cannula at the correct angle according to the depth of vein.

Wait for flashback of blood into the flashback chamber of the stylet/introducer.
55
Level the device by decreasing the angle between the cannula and the skin
and advance the cannula a few millimetres to ensure entry into the lumen of
the vein.

Withdraw the stylet slightly and a second flashback of blood should be seen
along the shaft of the cannula.

Maintaining skin traction with the non-dominant hand and using the dominant
hand, slowly advance the cannula off the stylet/introducer and into the vein

Release the tourniquet.

Apply digital pressure to the vein above the cannula tip and remove the stylet.
NB. Never reintroduce a stylet/introducer into a cannula.

Immediately dispose of the stylet/introducer into an appropriate sharps


container in accordance with the RUH Trust policy concerning disposal of
clinical waste.

Seal cannula with extension or administration set; or sterile luer lock cap.

Where an extension set, or administration set is used, it should be primed with


0.9% saline immediately prior to cannulation. Following successful cannulation
of the patient, it should be attached to the cannula in accordance with the RUH
Trust Administration of intravenous drugs policy and procedures.

When using a needle-less connector or extension or administration set with an


integral connector, always do so in accordance with the manufacturers
instructions.

Observe the site for signs of swelling or leakage, and ask the patient if any
discomfort or pain is felt.

Apply the appropriate dressing to secure the cannula. Remove gloves, wash
hands with soap and water or alcohol hand rub as appropriate.

Flush the cannula with 5-10mls of sodium chloride 0.9% for intravenous use.

Discard any other waste according to Trust policies.

56
Document the procedure using the appropriate trust documentation, at time of
publishing this is the Adult Peripheral Venous Cannula (PVC) Care Record.
Any failed attempts should be documented in the patients care records.

The only exception to this is where a cannula is in situ for 30 minutes or less
(E.g. CT/MRI).

Cannulae should be removed as soon as no longer required, or after 72 hours


(except where a local protocol exists) and this must be documented except
where the cannula is inserted for less than 30 minutes.

57
Appendix 6 : Equipment Alerts

It is essential that as a practitioner that you make yourself aware of any


potential alerts concerning equipment that could affect cannulation and
venepuncture and patient safety. Examples include;

Medical Device Alerts:

Ref: MDA/2012/069 Issued: 09 October 2012 at 14:00 Device


Intravenous (IV) connectors: one-way valves (examples are: non-return,
check, anti-reflux or anti-siphon/anti free-flow valves).
All manufacturers and brands.

Problem: These devices have been confused with needle-free IV connectors


(with an integral membrane) leading to instances of air emboli.
If the IV connector with one-way valve is left un-capped, air may enter the
uncapped connector.
Valves that have a lower activation pressure (e.g. anti-reflux, check, non-
return) are more susceptible to air entrainment if left uncapped than higher
activation pressure valves (anti-siphon/anti free-flow).

N.B Always ensure that you understand the equipment that you are
using and its risks to patients.

58