Peripheral Intravenous

Cannulation
Introduction
Obtaining peripheral intravenous access is an essential
skill for all physicians. Although it is considered one of
the simplest invasive procedures, mastering this
potentially lifesaving intervention requires refined skills
and experience.
 Vascular access is the most common invasive procedure
undergone by patients in secondary care.
It is often poorly undertaken and is the source of considerable
patient discomfort and inconvenience, as well as morbidity and
mortality.
Vascular access is essentially a single, often repetitive, task but
providing a quality service requires more; this includes all aspects
of human factors as well as education, training, audit and technical
proficiency.
New technology such as ultrasound and other imaging has
increased the number of tools available.
 Peripheral venous cannulation is the commonest, and probably
the most important invasive procedure practised in hospitals.

Guide to peripheral cannulation

1. The smallest practical size of cannula should be used.
2. Needle guards to reduce needle stick injury are
recommended in all procedures.
3. Peripheral insertion is inappropriate for infusion of
fluid with high osmolality (> 500 mOsm.l1) or low (<
5) or high pH (> 9) or intravenous access for more
than 2 weeks.
4. The relative safety of peripheral administration of
vasopressors/inotropes is contentious, but likely to be
dependent on vein size and its blood flow, infusion rate,
individual drug effect and dilution. This is a good area
for future studies.
5. Insertion in a limb with lymphoedema should be
avoided, except in acute situations due to increased
risks of local infection.
6. Transillumination, ultrasound and infra-red devices may
be useful.
7. Routine changes of peripheral cannulae at 7296 h is
not advocated.
8. All cannulae must be flushed after use.
 Indications

Peripheral intravenous catheterization

1. required in a broad range of clinical applications
2. including intravenous drug administration
3. intravenous hydration, and
4. transfusions of blood or blood components
5. as well as during surgery
6. during emergency care, and
7. in other situations in which direct access to the
bloodstream is needed.
 Contraindication of intravenous cannulation

No absolute contraindications to IV cannulation exist.

A. Peripheral venous access
1. injured,
2. infected, or
3. burned extremity should be avoided if possible.
B. Some vesicant and irritant solutions (pH < 5, pH >9, or
osmolarity >600 mOsm/L)
1. blistering and tissue necrosis if they leak into the tissue,
2. including sclerosing solutions,
3. some chemotherapeutic agents, and vasopressors. These solutions
are more safely infused into a central vein. They should only be
Anatomy

A detailed understanding of
the venous systems of the
upper and lower extremities
will facilitate successful
cannulation.
The upper extremities have
two primary venous
systems: the cephalic and
the basilic veins (Fig. 1). The
venous system of the lower
extremities consists of the
 Equipment
Gather the equipment and have it ready at the bedside before beginning the procedure.
Gloves
eye protection
tourniquet
chlorhexidinebased
antiseptic solution
sterile 2-by-2 gauze
a saline flush

a transparent occlusive dressing

tape
a catheter of an appropriate size, ranging from 14- to24-gauge, an intravenous fluid bag with
tubing, and a sharps container. A local or topical anesthetic may be required if the catheter is
20-gauge or greater.
 Catheter Type
and Size
There are many catheters, varying in style, length,
and safety mechanisms (Fig. 2).
The smallest effective catheter should be used,
because small catheters allow for less resistance to
blood flow around the cannula and are associated
with fewer complications.
Large catheters, such as 14- and 16-gauge catheters,
are used in acute situations for fluid resuscitation.
Other variables that may influence the size of the
catheter used include age-related vessel size, the
need for pressurized boluses for administration of
contrast material or medication, and the viscosity of
the fluid to be infused.
Procedure

1. Wash hands prepare the equipment

2. Remove the cannula from the packaging and check all
parts are operational
3. Loosen the cap and gently replace it
4. Apply tourniquet
5. Identify vein
6. Clean the site over the vein with alcohol wipe, allow to
dry
7. Remove tourniquet if not able to proceed
8. Put on non-sterile gloves
9. Re-apply the tourniquet, 7-10 cm above site
10.Remove the protective sleeve from the needle
taking care not to touch it at any time
11.Hold the cannula in your dominant hand,
stretch the skin over the vein to anchor the
vein with your non-dominant hand (Do not re
palpate the vein)
Cannulation
Insert the needle (bevel side up) at an angle of
5-30o to the skin (this will depend on vein depth.)
Observe for blood in the flashback chamber

13
 Lower the cannula slightly to ensure it enters the lumen
and does not puncture exterior wall of the vessel

Gently advance the cannula over the needle whilst

withdrawing the guide, noting secondary flashback
along the cannula

Release the tourniquet

Cannulation
Apply gentle pressure over the vein
(beyond the cannula tip) remove the white
cap from the needle

15
 Remove the needle from the cannula and dispose of it
into a sharps container

Attach the white lock cap

Secure the cannula with an appropriate dressing

Cannulation
Flush the cannula with 2-5 mls 0.9%
Sodium Chloride or attach an IV giving set
and fluid

17
 POST PROCEDURE

Document the procedure including

Date & time

Site and size of cannula
Any problems encountered
Review date (cannula should be in situ no longer than 72 hours without
appropriate risk assessment.)
Note: some hospitals have pre-printed forms to record cannula events

Thank the patient

Clean up, dispose of rubbish

Complications of intravenous cannulation

Periprocedural and postprocedural complications may

include the following:
Pain
Failure to access the vein
Blood stops flowing into the flashback chamber
Difficulty advancing the catheter over the needle and
into the vein
Refrence
The New England Journal of Medicine. Downloaded from nejm.org
at UNIV OF NORTH TEXAS HLTH SCIENCE CTR on November 29,
2014.
Benumof JL, ed. Clinical procedures in anesthesia and intensive
care. Philadelphia: J.B. Lippincott, 1991.
Costantino TG, Parikh AK, Satz WA, Fojtik JP. Ultrasonography-
guided peripheral intravenous access versus traditional
approaches in patients with difficult intravenous access. Ann
Emerg Med 2005; 46:456-61.
Tagalakis V, Kahn SR, Libman M,Blostein M. The epidemiology of
peripheral vein infusion thrombophlebitis: a criticalreview. Am J
Med 2002;113:146-51.
 Mayang Indah Lestari, Sp.An
Jason Liando, S,Ked
Cahaya Intan, S.Ked
Endy Averoselly, S.Ked

DEPARTMENT OF ANESTHESIOLOGY AND INTENSIVE CARE

SRIWIJAYA UNIVERSITY
PALEMBANG 2017