Practice and Care Peripheral iv-line

Hasanul Arifin

The 4th Symposium on Critical Care

and Emergency Medicine,
Medan.
Fluid Therapy Course Skill Station
Kamis , 08 Mei 2008, 15.00-17.00 wib

Anatomy and physiology

Superficial veins of the upper limbs are usually
selected for peripheral cannulation
(Dougherty1999).
Cannulation of the lower limbs is associated with
an increased risk of venous thromboembolism
(Scales 1999).

Anatomy and physiology

Skin is composed of two main layers:
Epidermis (skin surface): approximately 1mm thick
containing sensory nerve endings.
Dermis (beneath the epidermis): thicker than the
epidermis, composed of collagenous and elastic
connective tissue and containing fat, blood and lymph
vessels, nerves, hair follicles, sweat glands and
sebaceous glands.

Anatomy and physiology

Ageing alters the structure and appearance of the skin.
The dermal layers become thinner and there is less
subcutaneous tissue to support the blood vessels.
The veins of older people are often easier to see
because of the reduction in subcutaneous tissue,
particularly on the dorsum of the hand.
The vessels are also more mobile, more fragile and often
tortuous and thrombosed (Dougherty 1999). The dorsum
of the hand should be avoided in older people

Psychology
Fears and phobias (needle phobia)
Pain during cannulation
Palpating and cleaning the skin (trigger
memories of previous experiences)
Reduce a patients anxiety by :
Deep breathing and relaxation
Topical anaesthetic agents

Consent
Consent is necessary at every stage of a
patients treatment.
Written consent is considered good practice
before invasive procedures and for procedures
that involve risk, for example, operations and
cytotoxic drug regimens.
Verbal consent is considered adequate for
procedures with a low level of risk, for example,
cannulation.

Consent
Consent is only valid if it is given voluntarily and
accompanied by an adequate explanation,
which allows the patient to make an informed
choice to accept or reject a proposed treatment
Before peripheral cannulation it is important to
provide an explanation of the reason for
cannulation, duration of the intended therapy
and associated risks, for example bruising.

Indication
Cannulation may be used

To administer drugs.
To maintain correct hydration (fluid infusion)
Transfusion of a blood component.
Parenteral nutrition

Vein Selection

Vein Selection
The veins of the antecubital fossa are
usually easily visualised, palpated and
accessed because of their superficial
nature and size.
However, their position over the flexor
surface of the elbow makes these veins
prone to mechanical phlebitis, and the
cannula prone to failure from kinking or
dislodgement.

Vein Selection
A cannula should not be placed in areas
of localised oedema, dermatitis, cellulitis,
arteriovenous fistulae, wounds, skin
grafts, fractures, stroke, planned limb
surgery and previous cannulation.
The patient may prefer the non-dominant
limb to be selected for cannulation to
promote independence and comfort

Vein Selection
Both upper limbs should be inspected to
identify possible veins for cannulation.
Potential veins can then be palpated to
assess their condition.
An ideal vein is soft and bouncy when
palpated.
Veins that are tender, thrombosed or hard
should be avoided

Device selection
It is important to select the correct
vascular access device for the patients
specific clinical situation
PUR (polyurethane), modern, softer,
cause less intimal damage and are kink
resistant which reduces the incidence of
cannula failure
PVC, Teflon, older materials are more
rigid, higher incidence of thrombophlebitis.

Device selection
Generally, the smallest gauge of cannula should
be selected for the prescribed therapy.
This helps to prevent damage to the vessel
intima and ensures that there is adequate blood
flow past the cannula.
Small gauge cannulae usually provide a
sufficiently high flow rate to deliver most
therapies, and reduce the risks of mechanical
and chemical phlebitis

equipment

Infusion standart
Fluid (RL, NaCl, etc)
Infusion tubing
The following equipment for cannulation should
be assembled and placed on a clean tray:
cannula, antiseptic, sterile gauze, sterile saline
flush, single or multiway adapter (primed with
sterile saline) with integral needle-less device,
sterile moisture-permeable transparent dressing,
tape, and a small sharps container.

Theoretical Maximum Flow Rates

Colour

Gauge

Flow

Yellow

24G

13 ml/min

Blue

22G

30 ml/min

Pink

20G

55 ml/min

Green

18G

80-100 ml/min

White

17G

135 ml/min

Grey

16G

180 ml/min

Orange or Brown

14G

270 ml/min

Site preparation
Topical anaesthetic agents can reduce the
pain of cannulation.
Emla cream has to be applied two hours
before cannulation, which is not always
practical, and the associated
vasoconstriction may complicate
cannulation
Ametop is a good alternative: it is
effective after ten minutes and has mild
vasodilatory effects.

Cannulation procedure

Cannulation procedure

COMPLICATIONS.
Haematoma.
Infiltration or tissueing.
Thromboembolism.
Air Embolism.
Phlebitis and Septicemia.

COMPLICATIONS.
Haematoma, is a collection of blood, it can be formed
following leakage of blood from the vein into the
tissues surrounding the insertion site. It can occur as
a result of failure to puncture the vein properly
during cannula insertion.
Infiltration or tissueing occurs when the infusate
enters the subcutaneous tissue rather than the vein.
Thromboembolism, occurs when a blood clot on the
catheter or vein wall becomes detached and is
carried by the venous flow to the heart and
pulmonary circulation.

COMPLICATIONS.
Air Embolism, is a possible hazard during all forms of
I.V. therapy. In peripheral cannulation, however, the risk
of air embolism is limited by the positive peripheral
pressure (3-5 cm H2O).
Phlebitis and Septicemia. Phlebitis is an inflammation of
the vein and can be due to chemical or mechanical
irritation, or infection. A thrombus can form in association
with the inflammation resulting in thrombophlebitis. Of all
the factors affecting the development of phlebitis such as
catheter size, Venepuncture site etc the duration of the
cannulation and the types of fluids administered are the
most important.

Replacement of Catheters
Peripheral Venous Catheters
Scheduled replacement of intravascular catheters has been
proposed as a method to prevent phlebitis and catheterrelated
infections. Studies of short peripheral venous catheters
indicate that the incidence of thrombophlebitis and bacterial
colonization of catheters increases when catheters are left in
place >72 hours. However, rates of phlebitis are
not substantially different in peripheral catheters left in place
72 hours compared with 96 hours. Because phlebitis
and catheter colonization have been associated with an
increased risk for catheter-related infection, short peripheral
catheter sites commonly are rotated at 7296-hour intervals to reduce
both the risk for infection and patient discomfort
associated with phlebitis.

Summary
This article provides an overview of the
knowledge and skills required for peripheral
venous cannulation, including anatomy and
physiology, psychology, consent, vein
selection, device selection, infection control,
insertion technique, device securement,
sharpsdisposal and the prevention and
management of complications.
A period of supervision and assessment of
competency is required to consolidate this
theoretical knowledge.

Thank you for listening