Intravenous cannulation


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This slideshow introduces the basic concepts around intravenous cannulation. Whilst the context is midwifery this slideshow is also suitable for nurses and medical staff.

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Intravenous cannulation

  1. 1. Intravenous Cannulation Sarah Stewart 2012
  2. 2. Intravenous cannulation <ul><li>Looking at four key points: </li></ul><ul><li>Reasons why midwives need to </li></ul><ul><li>be able to cannulate </li></ul><ul><li>Preparation </li></ul><ul><li>Technique </li></ul><ul><li>Troubleshooting tips </li></ul>
  3. 3. Purposes of IV therapy <ul><li>Fluid replacement </li></ul><ul><li>Delivery of medicine </li></ul><ul><li>Delivery of blood </li></ul><ul><li>or blood products </li></ul><ul><li>Consider situations in midwifery practice when this would be necessary. </li></ul>
  4. 4. Reasons why midwives need to be able to cannulate PPH Epidural Drug treatment Blood transfusion Induction/augmentation Premature labour/PIH/diabetes LSCS/manual removal/repair of tear  Correct ketosis/?fetal tachycardia/distress
  5. 5. Preparation <ul><li>Choice of site </li></ul><ul><ul><li>choose veins in hand or lower arm </li></ul></ul><ul><ul><li>non-dominant side </li></ul></ul><ul><li>Avoid wrist or arm joints, small, visible veins, areas of recent inflammation or cannulation. </li></ul><ul><li>Selected vein should feel round, elastic, firm and engorged – not hardened, bumpy or flat </li></ul>
  6. 6. Preparation <ul><li>Choice of cannula </li></ul><ul><ul><li>Suitable for both the vein and the </li></ul></ul><ul><ul><li>fluid </li></ul></ul><ul><ul><li>16g -18g </li></ul></ul><ul><li>Communication – </li></ul><ul><ul><li>- explanation /informed consent </li></ul></ul><ul><li>L ocal anaesthetic </li></ul>
  7. 7. Technique <ul><li>Plenty of light </li></ul><ul><li>Make sure woman is comfortable – look at what she is wearing </li></ul><ul><li>Equipment at hand </li></ul><ul><li>Tourniquet - place around the limb 2 – 3 inches </li></ul><ul><li>below elbow joint </li></ul><ul><li>avoid pulling skin or hair </li></ul><ul><li>pull it tight enough to trap venous flow but not to occlude arterial flow </li></ul><ul><li>place “blue sheet” under arm and ? pillow </li></ul>
  8. 8. Cleaning <ul><li>Clean with alcohol swab and allow to dry naturally </li></ul><ul><li>Do not re-palpate after cleaning </li></ul><ul><li>Approaching vein </li></ul><ul><li>Ask woman to flex wrist </li></ul><ul><li>Bend thumb under fingers (if placing cannula in basilic vein) </li></ul><ul><li>Pull skin below site of insertion </li></ul>
  9. 9. Veins of the Hand 1. Digital Dorsal veins 2. Dorsal Metacarpal veins 3. Dorsal venous network 4. Cephalic vein 5. Basilic vein Veins of the Forearm 1. Cephalic vein 2. Median Cubital vein 3. Accessory Cephalic vein 4. Basilic vein 5. Cephalic vein 6. Median antebrachial vein
  10. 10. Inserting cannula <ul><li>Insert cannula at low angle (notice flash back of blood into chamber of cannula) </li></ul><ul><li>Reduce angle of cannula slightly and advance cannula along another 2 – 3 mm </li></ul><ul><li>Withdraw needle 5 – 10 mm so it does not go through wall of vein and then advance plastic cannula along </li></ul><ul><li>vein </li></ul><ul><li>Remove needle and dispose </li></ul><ul><li>Take blood samples for FBC and group </li></ul><ul><li>and hold </li></ul><ul><li>Release tourniquet </li></ul><ul><li>Press on vein above cannula to avoid blood spillage </li></ul><ul><li>Attach to IVI or flush with saline before screwing on injection cap(if needle-less system, attach rubber bung before connecting IVI or flush) </li></ul>
  11. 12. Applying dressing <ul><li>Apply transparent dressing so that cannula and infusion tubing is secure and insertion site can be observed </li></ul><ul><li>Tape tubing further up the arm so that it is secure and not pulling on cannula </li></ul><ul><li>Make sure tape is not interfering with transparent dressing or injection cap </li></ul><ul><li>Immobilize arm if insertion site is in wrist or elbow joint </li></ul><ul><li>Make sure woman is comfortable and can mobilise fingers and arm </li></ul>
  12. 13. Troubleshooting tips <ul><li>Backflow stops when you remove the stylet? </li></ul><ul><li>Oh dear! You may have pushed the stylet through the opposite wall of the vein. </li></ul><ul><li>In this case, retract the stylet slightly until blood flashback appears again, then advance the cannula into the vein and release the tourniquet. </li></ul><ul><li>Do not reintroduce the needle. </li></ul>
  13. 14. Troubleshooting tips <ul><li>Don’t panic if you are unable to withdraw blood for sample. The final test is whether the IVI runs properly. </li></ul><ul><li>If haematoma forms; insertion site is very painful; IVI doesn’t flow; cannulation has not been successful, so stop procedure. </li></ul>
  14. 15. Troubleshooting tips <ul><li>Have two attempts </li></ul><ul><li>then call for help . </li></ul>
  15. 16. <ul><li>Do not pass cannula through valve (which looks like a bump in the vein) as it is very painful. </li></ul><ul><li>Use bifurcated vein when possible (looks like inverted V). It is easier to cannulate than a single vein as it is more stable and less likely to roll. </li></ul><ul><li>Be positive. </li></ul><ul><li>Don’t forget to reassure woman. </li></ul>
  16. 17. Common problems during cannulation procedure <ul><li>Tourniquet too tight, too loose, too high, too low </li></ul><ul><li>Failure to release tourniquet promptly after vein is sufficiently cannulated </li></ul><ul><li>Stopping too soon after insertion of the stylet so that only the needle goes into the vein </li></ul><ul><li>Failure to recognise the cannula has gone through the vein wall </li></ul><ul><li>inserting the cannula too deep so that it is under the vein – very painful for woman and cannula won’t move freely </li></ul><ul><li>failing to penetrate the vein – angle of needle is too steep or not steep enough causing needle to ride along the vein or on top the vein </li></ul>
  17. 18. Local complications <ul><li>Thrombosis – obstruction to flow due to platelet formation at site if injury (by cannula) </li></ul><ul><li>Thrombophlebitis – thrombus plus accompanying inflammatory response </li></ul>
  18. 19. Local complications <ul><li>Phlebitis – inflammation of inner lining of vein usually due to mechanical or chemical trauma. More susceptible to infection. </li></ul><ul><li>- redness, swelling, pain, warm to touch, tender, palpable venous cord (if left too long), possible pulmonary embolism </li></ul><ul><li>- diagnosis : flow stops when apply pressure above cannula tip </li></ul>
  19. 20. Phlebitis
  20. 21. Local complications Treatment – stop infusion, remove cannula, resite, apply warm compress, elevate and rest arm Prevention – regular monitoring of IV site & cannula, appropriate choice of site, secure taping, ask woman to report any discomfort
  21. 22. Local complications <ul><li>Infiltration / Extravasation / Tissueing </li></ul><ul><li>- leakage of IV fluid into surrounding tissues </li></ul><ul><li>- signs - pain, tightness, skin cool to touch, oedema, IV rate slowed </li></ul><ul><li>Diagnosis – flow continues when apply pressure above cannula tip or halo appears when shine torch on oedema </li></ul><ul><li>Treatment – stop, remove, re-site, warm, elevate </li></ul>
  22. 23. Local complications <ul><li>Clotted cannula due to </li></ul><ul><li>--Inadequate flushing or </li></ul><ul><li>--fluids run dry or </li></ul><ul><li>--Increased venous pressure above site (BP cuff) </li></ul><ul><li>--Turning off to allow mobilisation </li></ul><ul><li>Noted by blood backing up tube or flow stopped </li></ul><ul><li>Intervention – first check height of bag, clamps, position </li></ul><ul><li>- aspirate, irrigate if no return, resite if need </li></ul>
  23. 24. Local complications <ul><li>Air embolism </li></ul><ul><li>Catheter embolism </li></ul><ul><li>– do not re-introduce needle </li></ul>
  24. 25. <ul><li>Women should have no more than 2 ½ litres in 24 hours </li></ul><ul><li>A pregnant woman already carries extra body fluid. Anti-diuretic hormone is increased in labour by fear and anxiety, as does oxytocin </li></ul><ul><li>Increased fluid volume cause water intoxication </li></ul><ul><li>Mother – oedema, headache, vomiting, convulsions </li></ul><ul><li>Baby – convulsions, apneoa, resp. distress, neonatal weight loss </li></ul><ul><li>Epidural – if hypotension persists, use ephidrine instead of large volumes of fluid </li></ul>
  25. 26. Sodium chloride 0.9% isotonic Most commonly used - administer drugs, eg syntocinin, magnesium sulphate. Replaces H20, Na, C in dehydration. Haemodilution can occur. Overload. Hartmann's (lactated Ringer's solution) isotonic Epidural - pre-loading dose to counter-act hypotension. Replaces H2O and electrolytes. If in doubt, use Hartmanns. Watch for overload. Ephedrine should be used if hypotension persists. Dextrose 5% isotonic Rarely used Increases maternal blood sugar - increases fetal insulin - fetal hypoglycaemia - jaundice. Haemaccel Synthetic polygeline colloid Plasma volume expander Not so commonly used as was. Whole blood Plasma volume replacement, replaces red blood cells (hb), replaces clotting factors, source of fresh blood. Increases O2-carrying capacity, administer through blood filter, do not infuse cold, risk of blood borne infections. Packed cells Treat anaemia, used with women with low hb but adequate blood volume. Increases O2-carrying capacity, replaces low hb without extra plasma volume preventing overload, administer through blood filter, risk of blood borne infections.
  26. 27. References <ul><li>Johnson R, & Taylor W. (2006). Skills for midwifery practice . Elsevier: Edinburgh. </li></ul><ul><li>Chapman V.(2003). The midwife’s labour and birth handbook . Blackwell Publishing: Oxford. </li></ul><ul><li>London, G. (1990). Nutrition and hydration in labour. In : Intrapartum care: a research-based approach. J. Alexander, V. Levy, S. Roch (Eds.). London: Macmillan. </li></ul>