CANNULATION & VENESECTION

LEARNING OUTCOMES OF THE WORKSHOP To be able to assess the patient To be able to assess the patient To be able to take a blood sample using a vacutainer system To be able to take a blood sample using a vacutainer system To be able to site / change a cannula To be able to site / change a cannula To be able to name the complications of cannulation and venesection To be able to name the complications of cannulation and venesection

Patient Assessment & Vein Selection

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

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

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

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

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

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

WHICH VEIN?

Antecubital Fossa Brachial Artery Ulnar Artery Radial Artery Basillic Cephalic Median Cubital Vein VeinsArteriesNerves Radial 1st Intercostal Ulnar Median

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

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

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

CANNULA SELECTION

Selecting the right cannula Two key points to consider: What is the cannula going to used for? What is the cannula going to used for? The condition, location and size of the vein selected? 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.

ColourSizeFlowMl/minUses Brown14275 Rapid transfusions of whole blood. Emergency situations. Grey16173 Rapid transfusions of whole blood. Emergency situations / Obstetrics Green18100 Blood transfusions Pink2060 IV infusions. Bolus’ Blue2225 Bolus’. Maintenance infusions Yellow2413 Bolus medications. Short term infusions. Neonates Purple26Neonates

VENESECTION DEVICE SELECTION

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

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

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

ORDER OF DRAW No Additives ( Green, Red, Dark Blue) No Additives ( Green, Red, Dark Blue) Coagulation Screen (Light Blue) Coagulation Screen (Light Blue) Other Additives (Gold, Grey, Lavender & Pink) Other Additives (Gold, Grey, Lavender & Pink)EXCEPTION: Blood Cultures always FILL FIRST

Risks and Complications of Cannulation & Venesection

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

Transfixation Skin Vein wall Vein wall

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

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

Phlebitis TYPES OF: TYPES OF:

Infiltration “The inadvertent administration of non- vesicant solution/medication into surrounding tissues." “The inadvertent administration of non- vesicant 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. The cannula may still appear to be patent, so early recognition is vital to avoid tissue damage.

Extravasation “the inadvertent administration of a vesicant substance into the tissues surrounding a vein.” “the inadvertent administration of a vesicant substance into the tissues surrounding a vein.” (Royal Marsden Manual, 2004) (Royal Marsden Manual, 2004)

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 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 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 Allow vein to air dry DO NOT re-touch or palpate the vein once cleaned DO NOT re-touch or palpate the vein once cleaned Consider hair clipping if appropriate Consider hair clipping if appropriate

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