CANNULATION & VENESECTION AMANDA HARPER CLINICAL SKILLS COORDINATOR

LEARNING OUTCOMES OF THE WORKSHOP Assessment of patient Demonstrate the correct technique for performing cannulation & venesection as per SUHT policy & procedure Selection of the appropriate device Identify and recognise the complications that are associated with cannulation & venesection Correct documentation as per SUHT policy

Patient Assessment & Vein Selection

THE ASSESSMENT CONSIDER THE FOLLOWING POINTS: Age / size / history / condition / dependency of the patient History of previous cannulation / venesection Type / length of treatment required Number of tests ordered What medication is the patient on? Fluid status History of blood disorders

Conditions that affect the position of the device: - Amputation Stroke Mastectomy or other Breast / Lymph Surgery Renal Fistula Lymphoedema or Cellulitsis Diabetes / Vascular Disease / Arthritis Trauma / Fractures / Burns Social History

Questions to ask the patient OBTAIN CONSENT Have you had a cannula / blood test before? Were there any complications / adverse reactions? Do you have any allergies? Consider needle phobia Would you like a local topical anaesthetic before I insert the cannula or take blood? Which is your dominant arm?

Attributes of an ideal vein are: - Be engorged, bouncy & soft Refill after it has been depressed Be visible Feel round Be well supported by surrounding structures Be straight & ‘free of valves’

Veins to be avoided: - Thrombosed, fibrosed or sclerosed Inflamed or bruised or painful Thin or fragile Mobile Near bony prominences and joints Near sites of infection or oedema AVOID THE VALVES For venesection avoid the arm with an IV line running

Methods for improving venous access: Apply a disposable tourniquet Lower the level of the arm below the heart Ask the patient to open and close their fist Light tapping / rubbing of the veins Warm compresses over the selected vein Warm water Relax the patient / consider the environment

WHICH VEIN?

Antecubital Fossa Cephalic 1st Intercostal Brachial Artery Radial Basillic Median Cubital Vein Radial Artery Median Ulnar Artery Ulnar Veins Arteries Nerves

DIGITAL DORSAL VEIN DORSAL METACARPAL VEINS DORSAL VENOUS NETWORK CEPHALIC VEIN BASILLIC VEIN

VEINS TO BE USED ARE: METACARPAL VEINS CEPHALIC VEIN BASILIC VEIN MEDIAN CUBITAL VEIN

GROUP EXERCISE In pairs, use a tourniquet to identify each others: Veins Arteries Valves Ligaments

CANNULA SELECTION

Selecting the right cannula Two key points to consider: What is the cannula going to used for? The condition, location and size of the vein selected? You should try to select the smallest gauge possible that will accommodate the intravenous therapy that is prescribed.

Colour Size Flow Ml/min Uses Brown 14 275 Grey 16 173 Green 18 100 Rapid transfusions of whole blood. Emergency situations. Grey 16 173 Rapid transfusions of whole blood. Emergency situations Green 18 100 Blood transfusions Pink 20 60 IV infusions. Bolus’ Blue 22 25 Bolus’. Maintenance infusions Yellow 24 13 Bolus medications. Short term infusions. Neonates Purple 26 Neonates

SGH, exceptions to this rule: - Patients Condition Cannula Size All obstetric patients Grey Active gastrointestinal (GI bleed) Brown or Grey At risk of GI bleed At risk of epileptic fit Green At risk of cardiac event At risk of neurological event

VENESECTION DEVICE SELECTION

VACUTAINER Quicker collection than other methods Closed system Exact amount of blood obtained Reduces the risk of haemolysis of the sample Reduces the risk of needlestick injury

BOTTLES & BLOOD FORMS E-QUEST SYSTEM for blood requests & results within SUHT ALWAYS ensure that the GROUP & SAVE or CROSSMATCH request has been correctly completed & signed for by the requesting MEDICAL PRACTIONER

Serum AB Levels E.D.T.A. FBC & ESR Cross Match Group & Save Coagulation INR / APTR Glucose Lithium Heparin, PST, U&E’s, Bone & Liver Trace Elements

ORDER OF DRAW NO ADDITIVES (Green, Red, Dark Blue) COAGULATION (Light Blue) OTHER ADDITIVES (Gold, Lilac, Pink & Grey) EXCEPTION to this is when Blood Cultures have been requested, these MUST BE filled first – aerobic (Blue) followed by anaerobic (Pink)

Risks and Complications of Cannulation & Venesection

Risks - During Insertion Transfixation Pain Nerve damage Arterial puncture Allergies Needlestick injury Infection Haemorrhage Haematoma Vaso-vagal episode Needle phobias Catheter embolism (cannulation)

Transfixation Skin Vein wall Vein wall

Haematoma/Bruising Transfixation Tourniquet too tight / left on too long / use of RUBBER GLOVE! Arterial puncture Repeated insertion sites

Future Complications of Cannulation Phlebitis — septic / mechanical / chemical Infection Drug reaction / Allergy Infiltration Extravasation Thrombosis / Embolism Speed shock Fluid overload

Phlebitis TYPES OF:

Infiltration “The inadvertent administration of non-vesicant (non-toxic) solution/medication into surrounding tissues." (Royal Marsden Manual, 2004) The cannula may still appear to be patent, so early recognition is vital to avoid tissue damage. Examples of fluid include: Normal Saline & 5% Dextrose

Extravasation “the inadvertent administration of a vesicant substance (toxic) into the tissues surrounding a vein.” (Royal Marsden Manual, 2004) Examples of fluid include: 10% Dextrose, Chemotherapy & Potassium

Thrombus Formation Correct flushing technique - pulsated push-pause & positive pressure, prevents blood being left in the cannula & removes debris from the internal catheter wall (use 5mls of Normal Saline). Flushing blocked cannula can lead to pulmonary embolus (30% PMs show undiagnosed PE).

Signs of Cannula Related Infection Phlebitis Pyrexia Feeling unwell Raised white blood cell count

Site preparation As cannulation / venesection is performed using an aseptic non-touch technique it is imperative that the vein is cleaned PRIOR TO THE PROCEDURE, wearing clean non-latex gloves Clean the vein for 30 seconds with 2% chlorhexidine in 70% alcohol solution, cleaning the vein in a criss-cross motion Allow vein to air dry DO NOT re-touch or palpate the vein once cleaned Consider hair clipping if appropriate

DOCUMENTATION SEE CANNULA CARE PLAN includes: Time & date of blood sample / cannula insertion Site of insertion Gauge and batch number of the cannula What blood samples have been taken Number of attempts (MAX 2 per person) Any complications noted (e.g. haematoma) Print & sign your name Evidence verbal consent has been obtained