This is a very good article, describing how to take of patients with peripheral venous cannula.

1. 12 Nursing Times 21.08.12 / Vol 108 No 34/35 / www.nursingtimes.net
Keywords: Peripheral venous cannula/
Intravenous therapy/HCAIs
This article has been double-blind
peer reviewed
Nursing Practice
Practice educator
Venous cannulas
Author Louise McCallum is lecturer – adult
nursing, University of the West of Scotland,
Ayr; Dan Higgins is charge nurse critical
care, University Hospitals Birmingham
Foundation Trust and a freelance clinical
educator.
Abstract McCallum L, Higgins D (2012)
Care of peripheral venous cannula sites.
Nursing Times; 108: 34/35, 12-15.
Peripheral venous catheters are commonly
used in hospitals to deliver intravenous
therapy. They are associated with a range
of complications that can be damaging to
patients’ health and increase healthcare
costs. In order to minimise the risk of these
complications, thorough patient
assessment and careful catheter
management are essential.
I
t has been estimated that as many as
one in three hospital patients have a
peripheral venous catheter (PVC) in-
situ at any given time (Reilly et al,
2007). These small hollow catheters are
advanced over a needle into a peripheral
vein via the skin, and are used predomi-
nantly for the delivery of intravenous (IV)
therapy. However, PVCs are not without
complications. Infection and phlebitis are
of primary concern (Royal College of
Nursing, 2010), so registered nurses must
ensure their knowledge and skills related to
the management of PVCs are up to date and
evidence based (Nursing and Midwifery
Council, 2008) in order to reduce the com-
plications associated with these devices.
This article discusses some of the com-
plications associated with PVCs, focusing
specifically on phlebitis and infection, and
how they might be prevented through
careful observation and meticulous care of
the site.
5 key
points
1Peripheral
venous
catheters are
commonly used in
hospitals to deliver
intravenous therapy
2PVCs are
associated
with several
complications,
some of which can
have serious
consequences
3Careful
observation
and monitoring
are crucial to
identifying
complications at an
early stage
4Scrupulous
hygiene and
site management
will minimise the
risks of healthcare-
associated
infections
5PVCs should
be removed as
soon as they
become clinically
unnecessary
Indications and sites
Peripheral venous cannulation is indicated
for short-term use in many clinical situa-
tions. These mainly include administra-
tion of:
» IV fluids;
» Drugs;
» Blood and blood products;
» Dyes and contrast media.
Common sites of insertion are the
cephalic or basilic veins of the lower arm;
or the dorsal venous arch located on the
back of the hand (Lavery, 2007) (Fig 1). The
superficial veins of the lower limbs may
also be cannulated, but these tend to be
avoided as they are associated with a
higher risk of infection and embolism
(RCN, 2010).
Several factors must be considered
when selecting a site for peripheral venous
cannulation. The risk of infection or phle-
bitis can be minimised by considering the
following:
» The general condition of the veins;
» Avoidance of points of flexion;
» The type of drug to be administered
(determined by the osmolality or pH);
» Speed of drug delivery;
» Duration of intended therapy;
» The size of the cannula versus the size
of the vein.
Complications
Several complications are associated with
having a PVC in situ and the administra-
tion of IV therapy (Box 1). The most serious
are discussed below.
Phlebitis
Phlebitis is the inflammation of a vein, or
more specifically its inner lining, the
tunica intima (RCN, 2010). Clinical signs of
In this article...
Why peripheral venous catheters are used
Complications associated with peripheral venous catheters
Minimising the risk of complications
Use of peripheral venous catheters is common but infection can occur, and prove
fatal, if care is not taken to monitor the site and reduce the risk of complications
Care of peripheral venous
cannula sites
It is estimated one in three
inpatients have a peripheral
venous catheter in situ

2. 14 Nursing Times 21.08.12 / Vol 108 No 34/35 / www.nursingtimes.net
phlebitis are localised redness, heat and
swelling, which can track further along the
length of the vein, eventually leading to
induration and a “palpable venous cord”
(Jackson, 1998). The patient may complain
of pain, either continuously or during
infusion of drugs through the cannula.
Phlebitis is precipitated by mechanical,
chemical or infective causes (Higginson
and Parry, 2011).
Mechanical phlebitis
This is caused by the cannula rubbing and
irritating the tunica intima; the risk of this
complication may be reduced by using the
smallest gauge cannula capable of deliv-
ering the prescribed drug (Joanna Briggs
Institute, 2008).
Chemical phlebitis
This occurs as a consequence of irritation
to the tunica intima caused by properties
of the drug being infused. Strongly alka-
line, acidic or hypertonic drugs can
cause significant irritation if injected
into a small vein with an insufficient
blood flow (JBI, 2008). Drugs for IV admin-
istration should always be reconstituted
and delivered according to the manufac-
turer’s recommendations, and informed
by local policy.
Infective phlebitis
This occurs as a consequence of micro-
organisms entering the vein through the
puncture site. These can originate from
the patient’s own resident skin flora or
from cross-contamination of microorgan-
isms onto the PVC site and injection ports.
Infective phlebitis can be a consequence of
poor hygiene practices of healthcare pro-
viders (Health Protection Scotland, 2012).
Catheter-related bloodstream
infections
Catheter-related bloodstream infections
are caused by similar means as infective
phlebitis but microorganisms – including
Staphylococcus epidermidis, Staphylococcus
aureus, candida species and enterococci –
can also be introduced within
contaminated infusion fluid (Pratt et al,
2007). Once introduced into the PVC
tubing they combine to form a biofilm;
this is a collection of microorganisms
that grows on both living and inert sub-
stances in the presence of moisture. If
fragments of biofilm become dislodged
and enter the systemic circulation, they
can precipitate a bloodstream infection;
this can cause bacteraemia or sepsis,
which can have potentially fatal conse-
quences (HPS, 2012).
Alamy,CatherineHollick
BOX 1. COMPLICATIONS
OF PVC AND IV THERAPY
Catheter-related bloodstream infection
Microorganisms introduced into the
bloodstream via the cannula cause
bacteraemia
Extravasation Vesicant solution is
administered into surrounding tissue
Haemorrhage Bleeding occurs at
puncture site
Infiltration Non-vesicant solution is
administered into surrounding tissue
Phlebitis The tunica intima is inflamed
Source: RCN (2010); Pratt et al (2007)
FIG 1. VEINS COMMONLY USED FOR CANNULATION
The complications associated with
PVCsandIVtherapycanhaveadevastating
effect on patients’ health and quality of
life, and increase the costs of healthcare
through prolonged hospital stays and
treatment (Dychter et al, 2012).
Patient care
Observation and monitoring of the PVC
site and localised tissue are essential to
ensure any significant changes are identi-
fied and responded to appropriately, to
reduce the risk of complications. If two or
more signs indicative of phlebitis are
present (Jackson, 1998), or if the PVC is not
functioning, it should be removed imme-
diately; it should only be resited if the clin-
ical need for a PVC remains (HPS, 2012).
Phlebitis scales, such as the Visual Infu-
sion Phlebitis Scale (Jackson, 1998; Fig 2),
can assist nurses in assessing and man-
aging PVC sites (RCN, 2010).
The clinical necessity for a PVC should
be under constant review. Clinical require-
ment should be considered at least daily
and the PVC should be removed as soon as
it is deemed unnecessary. It has been sug-
gestedthatclinicalindicationaloneshould
drive the removal of PVCs (Webster et al,
2010). However, national guidelines state
that removal should be considered if the
PVC has been in situ for longer than 72
hours (HPS, 2012) or 72-96 hours (Depart-
ment of Health, 2011), as the risk of compli-
cations increases with time (Dougherty
and Lister, 2008). PVCs inserted in emer-
gency situations should be removed
within 24 hours (RCN, 2010).
The RCN (2010) and HPS (2012) recom-
mend that PVC sites are checked at least
on a daily basis. It is also recommended
that the site is assessed during injection of
drugs, when IV fluid bags are changed or
when drip flow rates are checked (RCN,
2010). To facilitate this, the PVC should be
dressed with a transparent dressing to
allow the site to be seen. The dressing
should be sterile and semi-permeable;
non-sterile tape should never be used.
Correct application of an adhesive
dressing will keep the PVC secure and
minimise the risk of mechanical phlebitis;
if the dressing becomes damp or loose it
must be changed.
PVC-site care must always be per-
formed using an aseptic non-touch tech-
nique (Rowley, 2001) to prevent cross-
infection (Pratt et al, 2007). Dressings
must not be secured with a bandage as this
causes them to retain moisture and makes
it impossible to see the insertion site
(Dougherty and Lister, 2008).
Handwashing has been indicated to be
the single most important step in breaking
the chain of infection. The World Health
Organization (2009) indicates that hands
should be decontaminated before clean
and aseptic procedures, and handwashing
Dorsal venous arch
Cephalic vein
Basilic vein
Nursing Practice
Practice educator

3. www.nursingtimes.net / Vol 108 No 34/35 / Nursing Times 21.08.12 15
is a key recommendation in national care
bundles that aim to reduce the risk of
healthcare-acquired infections associated
with PVCs (HPS, 2012; DH, 2011).
The high-impact PVC care bundle used
in England and Wales (DH, 2011) advocates
that PVC access ports, particularly needle-
less connections, are cleansed with 2%
chlorhexidine gluconate in 70% isopropyl
alcohol before drugs are administered.
These recommendations stem from
national epic2 guidelines for preventing
HCAIs in central venous catheters (Pratt et
al, 2007).
More recently it has been argued, based
on further microbiological research
studies and similar recommendations
within American national guidelines
(O’Grady et al, 2011), that the type of
cleansing solution might be less impor-
tant than the physical action of cleaning
the port (HPS, 2012). The Scottish PVC
care-quality improvement tool, therefore
recommends scrubbing the port with an
antiseptic solution containing 70% iso-
propyl alcohol for 15 seconds or more
before use (HPS, 2012). However, HPS
(2012) acknowledges that there are limita-
tions in the quality of research used to
inform the choice of antiseptic solution
for PVCs, so further studies are necessary
to improve the evidence base underpin-
ning these recommendations.
Nurses should ensure their clinical
practice adheres to local hospital policies
in relation to this issue. Regardless of the
cleansing solution selected, the DH (2011)
and HPS (2012) agree that the PVC port
must be allowed to dry before the device
is used.
Documentation
The date, time and reason for removal of
the PVC should be documented within the
patient’s notes with the corresponding
grade on the phlebitis scale (RCN, 2010).
The widespread acknowledgement that
PVCs are associated with HCAIs has
prompted many hospitals to adopt quality
assessment and monitoring tools in an
attempt to reduce these infections. Docu-
mentation plays an important role in the
audit process, facilitates the generation of
measurable real-time data (HPS, 2012; DH,
2011), and has been found to improve staff
compliance with care bundles. This should
help to improve the quality of care for
patients with a PVC in situ (Boyd et al, 2011;
Easterlow et al, 2010).
Conclusion
The complications associated with PVCs
can have potentially damaging or even fatal
consequences for patients. Infection and
phlebitis are avoidable if simple hygiene
andsafetyprinciplesareadheredtoforeach
patientateverypointofcontact.Nursescan
significantly influence the quality of care
provided by adopting the principles associ-
ated with the safe management and care of
patients who have these devices in situ
(HPS,2012;DH,2011).NT
References
Boyd S et al (2011) Peripheral intravenous catheters:
the road to quality improvement and safer patient
care. Journal of Hospital Infection; 77: 37-41.
Department of Health (2011) High Impact
Intervention No 2: Peripheral Intravenous Cannula
Care Bundle. tinyurl.com/DH-HIA2-cannula
Dougherty L, Lister S (2008) The Royal Marsden
Manual of Clinical Nursing Procedures. Oxford:
Wiley-Blackwell.
Dychter S et al (2012) Intravenous therapy: a
review of complications and economic
considerations of peripheral access. Journal of
Infusion Nursing; 35: 2, 84-91.
Easterlow D et al (2010) Implementing and
standardising the use of peripheral vascular access
devices. Journal of Clinical Nursing; 19: 721-727.
Health Protection Scotland (2012) Targeted
Literature Review: What are the Key Infection
Prevention and Control Recommendations to
Inform a Peripheral Vascular Catheter (PVC)
Maintenance Care Quality Improvement Tool?
tinyurl.com/HPS-PVC-rev
Higginson R, Parry A (2011) Phlebitis: treatment,
care and prevention. Nursing Times; 107: 36, 18-21.
Jackson A (1998) Infection control: a battle in vein
infusion phlebitis. Nursing Times; 94: 4, 68-71.
Joanna Briggs Institute (2008) Management of
peripheral intravascular devices. Best Practice; 12:
5, 1-4.
Lavery I (2007) Peripheral intravenous
cannulation: safe insertion and removal. Nursing
Standard; 22: 1, 44-48.
Nursing and Midwifery Council (2008) The Code:
Standards of Conduct, Performance and Ethics for
Nurses and Midwives. London: NMC. tinyurl.com/
NMC-Code-standards
O’Grady N et al (2011) Guidelines for the
prevention of intravascular catheter-related
infections. Clinical Infectious Diseases; 52:
e162-e193.
Pratt R et al (2007) epic2: National evidence-
based guidelines for preventing healthcare-
associated infections in NHS hospitals in England.
Journal of Hospital Infection; 65S: S1-S64.
Reilly J et al (2007) NHS Scotland National HAI
Prevalence Survey. Volume 1 of 2: Final Report.
Glasgow: Health Protection Scotland. tinyurl.com/
HPS-Prevalence-2007
Rowley S (2001) Theory to practice: aseptic
non-touch technique. Nursing Times; 97: 7, 7-8.
Royal College of Nursing (2010) Standards for
Infusion Therapy. London: RCN. tinyurl.com/
RCN-Infusion
Webster J et al (2010) Clinically indicated
replacement versus routine replacement of
peripheral venous catheters. Cochrane Database
Systematic Review. 3: CD007798.
World Health Organization (2009) WHO
Guidelines on Hand Hygiene in Health Care: First
Global Patient Safety Challenge. Clean Care is
Safer Care. Geneva: WHO. tinyurl.com/WHO-
hand-hygiene
FIG 2. VISUAL INFUSION PHLEBITIS SCORE
IV site appears healthy
No sign of phlebitis
Observe cannula
One of the following is evident:
Slight pain near IV site
Slight redness near IV site
Possible sign of phlebitis
Observe cannula
Two of the following are evident:
Pale near IV site Erythema Swelling
Early stage of phlebitis
Resite cannula
All of the following are evident:
Pain along path of cannula Erythema
Induration
Medium stage of phlebitis
Resite cannula Consider treatment
All of the following are evident and extensive:
Pain along path of cannula Erythema
Induration Palpable venous cord
Advanced stage of phlebitis or start of
thrombophlebitis
Resite cannula Consider treatment
All of the following are evident and extensive:
Pain along path of cannula Erythema
Induration Palpable venous cord Pyrexia
Advanced stage of thrombophlebitis
Initiate treatment Resite cannula
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