Intramuscular, intravenous, and intra-arterial cannulation techniques are described. Intramuscular injections deliver medication into large muscles and became popular after World War II. Intravenous cannulation involves inserting a cannula into a vein to deliver fluids or medications and potential complications include extravasation, hematoma, and infection. Intra-arterial cannulation is used for invasive arterial blood pressure monitoring and involves inserting a catheter into an artery like the radial artery. Potential complications of intra-arterial cannulation include thrombosis and pseudoaneurysm.

1. Intramuscular injection , intravenous
and intra arterial cannulation
By-Dr Varun B R & Dr Prashant
Moderators:-
Dr. Vaibhav tiwari
Dr. Sweta
Dr. Sudheer dhama

2. INTRAMUSCULAR
INJECTION

3. HISTORY
The first injection was given in 1920,
but became popular only after second world war.
Now injections are probably the most common
percutaneous procedure practiced worldwide

4. DEFINITION
Intramuscular injections are a common yet complex
technique used to deliver medication deep into the
large muscles of the body
It may be for curative, diagnostic or recreational
purpose

5. Site Selection
• The most common injection site is anterolateral
thigh into Vastus Lateralis muscle
• Never use gluteal muscle in children
• The other site in adult and in older children is deltoid
muscle
5

6. Anterolateral Thigh

7. Deltoid

8. Selecting Gluteus Muscle

9. Skin preparation
• Avoid site with oozing dermatitis or infection
• If the skin is clean than no use of disinfection
• Clean the site with single use spirit or alcohol swab
in a circular motion in an area 5-8 cms
• Pre wetted cotton swabs are better to be avoided
• If spirit is not available normal saline can be used
• Never use Savlon or Dettol
• Let the site be dry before injection
9

10. Preparing Syringe
• The area for preparing injection should be clean
• Clean your hands with alcohol based hand wash
• If you have cut or injury on fingers, cover it with
water proof adhesive
• No need to use gloves routinely
10

11. Preparing syringe
• Remember to use new equipment
• Observe aseptic precautions
• No need to change the needle after withdrawing
medication
• Do not ever wipe the needle with swab
• Do not keep the air bubble inside the syringe
11

12. Giving injection
• We have found giving injection necessary
• We have selected the site
• We have prepared the syringe
So now comes giving injection
12

13. Giving injection
• Make the patient comfortable and give him a
proper position so as to identify the proper
site for injection
• Properly hold the child
• Hold the syringe in your hand as if holding a
pen
• Remove needle cap immediately before giving
injection…not earlier
13

14. Giving injection
• Ensure smooth and steady insertion of the
needle at 90 degree with a dart technique
• No need to aspirate
• Slowly push the medication allowing muscle
fiber to stretch and accommodate the injected
volume
• Wait for a while and remove the needle in the
same direction as it was pushed
• Apply gentle pressure with a dry gauze
14

15. Z technique
15

16. Preventing Needle Stick Injury
• Anticipate abrupt movement of the patient and
take care
• More the used needle is handled or carried, the
greater is the risk of sharp injury
• Never try to recap, bend or manually remove
needle from syringe
• Do not move around with used equipment in hand
• Keep needle destroyer near by only
• Properly dispose it
16

17. Multiple injections
• Some times multiple injections are to be given
in a single visit especially for vaccines
• Any no of injections can be given in a single
visit
• Use different anatomical site
• If same limb is to be used than separate two
injections by 1-2”
17

18. COMPLICATIONS
• The most common one is transmission of
blood borne infections mainly Hepatitis B,
Hepatitis C and HIV
• Abscess
• Muscle or fat necrosis
• Muscle fibrosis and contracture
• Gangrene
• Nerve Injury

19. Post Injection Syncope
– This is known side effect especially in adolescents.
So it is better to observe the patient for 10-15
minutes
19

20. • According to WHO
Use injections only when necessary – oral
medicines are effective in most cases.
20

22. INTRAVENOUS CANNULATION

23. Objectives
Having completed the IV cannulation workshop you will beable to:
• Describe the basic anatomy and physiology of the superficial veins of the arms and
hands
• Locate and assemble required equipment for IV cannulation or venepuncture
• Perform a successful IV cannulation on the training arm
• Demonstrate awareness of Infection Control guidelines and O H & S practices as
per organisation policy
• Be aware of documentation requirements in relation to cannulation
• Demonstrate critical thinking relevant to managing the risks and complications of IV
cannulation
• Identify patient education requirements

24. Anatomy and physiology
• Approximately 2/3 of total blood volume is in the veins which
transport deoxygenated blood to the heart from the tissues
• Veins are thin-walled, fibrous, have a large diameter and low
pressure
• Veins contract to propel the blood through the vein towards the
heart
• Some veins contain valves to regulate the one way flow to the
heart (usually lower limbs)
• The skeletal muscle pump influences venous return
• Superficial and deep veins

25. Anatomy and physiologycont
Blood vessel walls have three layers
• Tunic Intima
innermost, epithelial lining
• Tunic Media
Elastic and Smooth muscle fibres and nerve supply
• Tunic Externa
Outer coat

26. Anatomy and physiologycont
Major veins of the arm
• Dorsal
• Cephalic
• Basilic
• Cubital Fossa

27. Anatomy and
physiologycont

28. Anatomy and physiologycont

29. Cannulae
• 14G
• 16G
• 18G
• 20G
• 22G
• 24G
• Large volume replacement
• Rapid transfusion of whole blood or blood components
• IV maintenance, NBM patients
• IV analgesia
• Paediatrics, elderly, chemotherapy patients
• Paediatrics, neonates

31. Equipment
• Dressing/IV trolley with sharps container and waste bag
• Dressing pack
• Gloves (sterile)
• Alcoholic chlorhexidine
• Transparent semi permeable dressing
• Cannula (size depending on need)
• Giving and Extension set (and prescribed IV fluids)
• Water proof protective cover
• Syringe 10ml with 0.9% Normal saline
• Tourniquet
• Fluid balance sheet

32. Assessing & preparing the patient
• Check patient for baseline vital signs, diagnosis
and allergies to medications, cleansing fluids &
dressings
• Provide a clear explanation of the procedure
including potential adverse and side effects
• A relaxed patient is generally easier to cannulate
• Assess the dominant/non-dominant side and
check the veins for status and suitability

33. Preparing equipment
• Equipment should be gathered on trolley in
treatment room with sharps container
• IV fluids should be prepared by priming the giving
set
• The equipment should not be opened until in the
patient’s room and patient education, assessment of
vein and appropriate positioning has been attended

34. Positioning the patient
• If possible use the non dominant arm
• Raise bed prior to procedure
• Place the arm in a supported comfortable
position
• Use a tourniquet to find vein but release it while
you are getting equipment ready
• Position patient with pillows or towels
• Have IV trolley close by

35. Preparing vein
Warm veins by
• Rubbing
• Washing client’s hands under warm water
• Apply warmed towel
• If limb is warm ask the patient to gently clench and
unclench their hand
• Or gently rub up and down the vein

36. Before inserting cannula
• The tourniquet is applied above the
IV insertion site and should not be
left on for more than 2-3 minutes
• Don gloves and clean site with
appropriate solution using a
circular outward movement
• Allow site to air dry or dry with sterile
swab

37. Inserting the cannula
• Hold cannula and rotate the barrel 360
degrees
• Apply skin traction to immobilise the vein
• Ensure cannula has bevel side
UP and insert at approximately
30 degree angle
• You will see a flashback of blood in
the chamber once you have pierced
the vein
• Then advance the cannula a few more
millimetres and then flatten the cannula,
stabilise the device and advance the
cannula until at skin level
• Remove the stylet and apply pressure
just beyond the catheter tip

38. Inserting the cannulacont
• Gently stabilise the cannula hub
• Release the tourniquet
• Attach the extension line
• Apply dressing and secure cannula
• Flush cannula with 5-10ml 0.9% sodium
chloride to ensure patency
• Connect to IV fluid
• Dispose of sharps and waste
• Document in patient notes

39. Dressing
• A transparent sterile occlusive
dressing is the optimal dressing
to use
• Before applying dressing, ensure
site is clean of
blood and moisture
• Check with patient re allergies to
dressings

40. Documentation
• Site of insertion-vein and arm/hand
• Type and gauge of cannula
• Date and time of insertion
• Type and amount of IV solution
• Reason for IV therapy
“Because of the invasive nature of I.V. therapy, patients may
experience unexpected problems, even with diligent nursing
care. Your careful documentation helps prove that the care
you provided met the standard of care…” (Rosenthal, 2005,
p.28)

41. Potential complications
• Extravasation
• Haematoma
• Phlebitis
• Venous Spasm
• Occlusion
• Thrombophlebitis
• Infection

42. Extravasation
The infiltration of a drug from an I.V. line into surrounding tissue.
Causes
• Catheter erodes through the vessel wall at a second point,
• Increased venous pressure causes leakage around the venepuncture site
• When a needle pulls out of the vein.
• Vesicant drugs/solutions may cause severe tissue injury
Signs & Symptoms
• Oedema and changes in the site's appearance
• Coolness of the skin.
• Slowing of infusion
• Pain or a feeling of tightness around the site.
• Possible consequences include necrotic ulcers, infection, disfigurement, and loss
of function.
Intervention
• Remove cannula
• Elevate affected arm
• Apply ice pack (early) or warm compress (late)

43. Haematoma
Localised collection of extravasated blood, usually
clotted, in an organ or tissue.
Cause
• Blood leaking out of the vein into the tissue due to
puncture or trauma
Signs & Symptoms
• Swelling, tenderness and discolouration
Prevention
• Proper device insertion
•Pressure over site on removal of cannula
Intervention
• Apply appropriate pressure bandage, monitor the site

44. Phlebitis
Inflammation of the vein
Cause
• Poor aseptic technique
• High osmolarity I.V. infusions or
drugs
• Trauma to the vein during
insertion/incorrect cannula gauge
• Prolonged use of the same site
Signs & Symptoms
• Tenderness, redness,
heat and oedema
• Advanced-induration, palpable
venous cord
Intervention
• Remove cannula
• Apply warm compress
• Observe for signs of
infection
• If phlebitis is advanced
antibiotics may be required

45. Venous spasm
Spasm of the vein wall
Cause
• Patient anxiety
• Cold I.V. fluids
• Drug irritation
• Trauma to the vein during cannula
insertion
Signs & Symptoms
• Pain
• Slowing of the I.V. infusion
• Blanching at the insertion site
• Vein difficult to palpate
Intervention
• Apply warm compress
• Slow the infusion rate
• Reassure the patient

46. Occlusion
• Slowing orcessation of fluid infusion due to:
• Fibrin formation in or around the tip of the cannula
• Mechanical occlusion (kink) of the cannula
Cause
• Cannula not flushed
• Kinking of the cannula
• Back flow or interrupted flow
Signs & Symptoms
• I.V. not running
• Blood in the line
• Discomfort
Intervention
• Check for kinks in cannula
• Raise IV higher
• Remove cannula

47. Thrombophlebitis
Formation of a thrombus and inflammation in the vein,
usually occurs after phlebitis.
Cause
• Injury to the vein
• Infection
• Chemical irritation
•Prolonged use of the same vein
Signs & Symptoms
• Tenderness/redness
• Heat/oedema
• Cordlike appearance of the vein
• Slowing of the IV infusion
Intervention
• Remove cannula
• Observe for signs of
infection
• Change cannula
frequently (48-72hrs)

48. Infection
Pathogen in the surrounding tissue of the I.V. site.
Cause
• Lack of asepsis
•Prolonged use of the same site
Signs & Symptoms
• Tenderness and swelling
• Erythema/purulent drainage
Intervention
• Remove cannula
• Antibiotics may be
required
• Documentation

49. STOP!
CHECK.
FAIL!

50. Preventing complications
• Know your organisation’s policy on IV therapy
• Check and inspect the IV site regularly as per
your facility policy
• Ask the patient how the IV site feels
• Document
• Troubleshoot at first sign
• Report any problems

51. Hints
Successful peripheral intravenous cannulation
increases with
•Meticulous attention to proper technique
•The use of proper equipment
•Familiarity with anatomy
•Knowledge of a variety of approaches to
accessing peripheral veins
•Knowledge of the latest evidence in the area
(this should drive your organisation’s policies
around cannulation and IV management)

52. IV access decision tree
Edwards,A., Muir,Y.,Grieves,L.,& Willis, K 2010.

53. INTRA ARTERIAL CANNULATION

54. INVASIVE ARTERIAL BLOOD PRESSURE
MONITORING
INDICATIONS :
• Induced current / Anticipated hypotension
• Wide BP fluctuations
• End organ disease necessitating precise beat to beat pressure
regulation
• The need for multiple arterial blood gas or other blood
analyses.
CONTRAINDICATIONS :
If possible , catheterization should be avoided in smaller end
arteries lacking collateral blood flow or in extremities where
there is a suspicion of pre existing vascular insufficiency

55. SELECTION OF ARTERY FOR CANULATON :
RADIAL ARTERY :
commonly used -- superficial location and substantial collateral
flow(in most patients the ulnar artery is larger than the radial
artery and there are connections between the two via the palmar
arches ).
• Allen’s test is simple but not reliable , method for assessing
the safety of radial artery cannulation.

56. ULNAR ARTERY : Difficult to cannulate as it is deep and tortuous, and
usually not considered because of the risk of compromising blood flow
to the hand.
BRACHIAL ARTERY :Large and easily identifiable in antecubital fossa. Its
proximity to the aorta provides less wave form distortion. However ,
being near the elbow predisposes brachial artery catheters to kinking.
FEMORAL ARTERY :Prone to atheroma formation and pseudoaneurysm
but often provides excellent access. Femoral site has been associated
with increased incidence of infectious complications and arterial
thrombosis.

57. DORSALIS PEDIS AND POSTERIOR TIBIAL arteries are some
distance from the aorta and therefore have the most distorted
waveforms.
AXILLARY ARTERY :surrounded by axillary plexus, nerve damage
can result from a hematoma or traumatic cannulation. Air and
thrombi can quickly gain access to the cerebral circulation during
vigorous retrograde flushing of axillary artery catheters

58. NORMAL WAVEFORM OF ARTERIAL BP :

59. Normal Arterial Pressure Waveform
• Waveform result from ejection of blood from the left ventrical
during systole followed by peripheral run of during dyastole
• Systolic wave follow ECG R wave
• Steep pressure upstroke, peak ensure decline down slope
interrupted by dicrotic knotch
• Decline during diastole after ECG T wave reach nadir at end
diastole

60. Abnormal Arterial Pressure Waveform
• Aortic Stenosis – Pulsus Parvus (Narrow pulse pressure), Pulsus
tardus (delayed upstroke)
• Aortic Regurgitation – Bisferience Pulse (Double Peak) Wide
Pulse Pressure.
• Hypertrophic Cardiomyopathy – Spike and dome (Mid systolic
Obstruction
• Systolic Left Ventricular Failure – Pulses alterans (Alternate
Pulse pressure amplitude
• Cardiac Tamponade – Pulsus paradoxus (Exaggerated decrease
in systolic BP during spontaneous inspiration more than 10 to
12 mmhg

61. Arterial Pressure Monitoring and Waveform Analysis for
Prediction of Volume Responsiveness
Inspiratory
Phase
Increase
Intrathorac
ic
Pressure
and
Decrease
left
ventricle
after load
Increase
Total Lung
Volume
and
Displays
Blood from
Pulmonary
Venus
Reservoir
to Left
Side
Increase
Left
Ventricle
preload
Increase
Stroke
Volume

62. • During Expiration – Situation reverse – Stroke
Volume Decrease - Systemic Arterial BP decrease
• This Cycle of increase and decrease in BP and stroke
volume in response to inspiration and expiration is
known as systolic pressure variation (SPV)
• In mechanically ventilated patient normal SPV – 7 to
10 mmhg with up change 2 to 4 mmhg and down
change 5 to 6 mmhg values greater than this indicate
hypovolemia
• Preload Reserve –physiological state in which volume
expansion or fluid challenge shift the patient
upward on the frank starling curve ,which lead to
increase in stroke volume and increase in CO

63. • PULSE PRESSURE VARIATION- normally less then 13 -17 %
• values more then 10-13% positive response to volume
expansion

64. Technical Aspect of Direct BP Measure
• Factor Including Extension Tubing, Stop Cock, Flush Device,
Recorder, Amplifier and Transducer may confound the measured
way form
• Mostly invasive BP monitoring system are underdamped second
order dynamic system that demonstrate simple harmonic motion
dependent upon elasticity, friction and mass. These properties
determine frequency response or dynamic response
• Natural Frequency – How rapidly system oscillate after a
pertubation
• Damping Coefficient – How rapidly it return to its prior resting state
• Original Pressure Wave is charactersied by its fundamental
frequency clinical as a pulse rate and expressed as cycle per second (
Example – If pulse rate 120/minute, frequency = 2hz)

65. • 6 to 10 harmonics of fundamental frequency (Pulse rate) are
required to provide distortion free reproduction of most
arterial pressure waveform
• If natural frequency is to low pressure
Wave form recorded on the monitor will
Be exaggerated or amplified

66. • Overdamped Waveform - Slurred upstroke absent dicrotic
notch and loss of fine details
• Lower the natural frequency narrower the range of
acceptable damping coefficient
• Adding bubble to the monitoring system increase damping
and decrease its natural frequency

67. Transducer Setup – Zeroing & Leveling
• Transducer zeroing and leveling are distinct and separate
• Zeroing establishes the zero reference point as ambient
atmospheric pressure while leveling align this reference
point relative to the patient body
• Transducer should be placed best to estimate aortic root
pressure, it is 5 cm posterior to the sternal border.
• However Conventional Location – Mid thoracic level, which
correspond most closely to mid left atreal position
• During sitting neurosurgical procedure, It is more
informative to place it at level of ear which approximate to
circle of willis

68. Complications :
Complications of intra aterial monitoring include :
Hematoma ,bleeding (particularly with catheter tubing
disconnections ) , vasospasm , arterial thrombosis , embolization of
air bubbles or thrombi , pseudoaneurysm formation , necrosis of
skin overlying the catheter , nerve damage , infection ,necrosis of
extremities or digits and un intentional intra arterial drug injection.
Factors associated with an increased rate of complications include
prolonged cannulation , hyperlipidemia , repeated insertion
attempts , female gender , extra corporeal circulation, the use of
larger catheters in small vessels and use of vasopressors .
RISK is reduced with good aseptic techniques , when the ratio of
catheter to artery size is small , when saline is continously infused
through the catheter at a rate of 2-3 mL/hr and when flushing of
the catheter is limited.

69. THANK YOU