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Vascular access:a guide to peripheral venous cannulation

Scales K (2005) Vascular access: a guide to peripheral venous cannulation. Nursing Standard. 19, 49, 48-52. Date of acceptance: June 13 2005.

Summary
This article provides an overview of the knowledge and skills required for peripheral venous cannulation, including anatomy and physiology, psychology, consent, vein selection, device selection, infection control, insertion technique, device securement, sharps disposal and the prevention and management of complications. A period of supervision and assessment of competency is required to consolidate this theoretical knowledge.

associated with an increased risk of venous thromboembolism (Scales 1999a). The wall of a vein is composed of three layers (Figure 1) (Scales 1999a): The tunica adventitia (the outer layer): a fibrous layer of connective tissue, collagen and nerve fibres which surrounds and supports the vessel. The tunica media (the middle layer): a muscular layer containing elastic tissue and smooth muscle fibres. The tunica intima (the inner layer): a thin layer of endothelium, which facilitates blood flow and prevents adherence of blood cells to the vessel wall. Trauma to the endothelium encourages platelet adherence and thrombus formation (Weinstein 1996). Skin is composed of two main layers: Epidermis (skin surface): approximately 1mm thick containing sensory nerve endings. Dermis (beneath the epidermis): thicker than the epidermis, composed of collagenous and elastic connective tissue and containing fat, blood and lymph vessels, nerves, hair follicles, sweat glands and sebaceous glands.

Author
Katie Scales is consultant nurse critical care, Hammersmith Hospitals NHS Trust, Charing Cross Hospital, London, and member of the Royal College of Nursing Intravenous Therapy Forum Committee. Email: kscales@hhnt.org

Keywords
Catheters; Drug therapy; Intravenous therapy; Peripheral venous cannulation These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit our online archive at www.nursing-standard.co.uk and search using the keywords.

CANNULATION IS increasingly being performed by nurses in a variety of clinical settings. To undertake this procedure successfully, a range of knowledge and skills is required. Nurses should Ageing alters the structure and appearance of the skin. The dermal layers become thinner and there know when to seek assistance if cannulation proves problematic. FIGURE 1 Cannulation, or insertion of a tube into a body duct or cavity, is performed to provide access to the Structure of blood vessel wall circulation for the administration of short-term, low-risk intravenous (IV) therapy. This includes Tunica the administration of blood and blood products, intima isotonic fluids and drugs whose pH and osmolarity are similar to that of blood. More complex IV Tunica therapy requires alternative vascular access media (Gabriel et al 2005).

Anatomy and physiology

Superficial veins of the upper limbs are usually selected for peripheral cannulation (Dougherty 1999). Cannulation of the lower limbs is 48 august 17 :: vol 19 no 49 :: 2005

Tunica adventitia

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is less subcutaneous tissue to support the blood vessels. The veins of older people are often easier to see because of the reduction in subcutaneous tissue, particularly on the dorsum of the hand. The vessels are also more mobile, more fragile and often tortuous and thrombosed (Dougherty 1999). The dorsum of the hand should be avoided in older people.

Psychology
Medicine produces fears and phobias, for example needle phobia, which Ost (1992) suggests is linked to a fear of pain. Pain during cannulation originates from nerve fibres in the skin rather than the blood vessel (Scales 1999b). Palpating and cleaning the skin trigger multiple sensory pathways to the brain and may also trigger memories of previous experiences (Melzack and Wall 1996), causing pain to be anticipated before cannulation. The experienced practitioner can reduce a patients anxiety by demonstrating confidence and acknowledging the patients previous experiences, as well as providing information and encouraging coping strategies, such as deep breathing and relaxation (Dougherty 1994). Topical anaesthetic agents can help to reduce the pain of cannulation and may lessen the anxiety associated with future cannulation.

arch are easily visualised and palpated. The radial end of the dorsal venous arch continues to form the cephalic vein while the ulnar end of the dorsal venous arch forms the basilic vein (Moore and Dalley 1999); all of these are suitable for cannulation (Figure 2). The cephalic and basilic veins continue into the forearm. The basilic vein is often overlooked (Dougherty 1999) because it is inconspicuous, not easy to stabilise and can be difficult to access due to its location. However, the cephalic vein is large, easily stabilised and accessible (Figure 3). The median cubital vein runs diagonally across the antecubital fossa connecting the basilic and the cephalic veins. There is great variation in the pattern of veins in this area. FIGURE 2 Veins of the hand Cephalic Dorsal venous arch

Basilic

Consent
Consent is necessary at every stage of a patients treatment. Written consent is considered good practice (Department of Health (DH) 2001) before invasive procedures and for procedures that involve risk, for example, operations and cytotoxic drug regimens. Verbal consent is considered adequate for procedures with a low level of risk, for example, cannulation. Implied consent describes compliant actions that lead one to believe that a patient is agreeing to an act, for example, holding his or her arm out for blood pressure measurement. Implied consent should be limited to minor interactions, such as recording observations. Consent is only valid if it is given voluntarily and accompanied by an adequate explanation, which allows the patient to make an informed choice to accept or reject a proposed treatment (DH 2001). Before peripheral cannulation it is important to provide an explanation of the reason for cannulation, duration of the intended therapy and associated risks, for example bruising.

Metacarpal

Digital

FIGURE 3 Superficial veins of the arm

Median nerve Cephalic vein Radial nerve

Basilic vein Brachial artery Median cubital vein

Radial artery Ulnar artery Ulnar nerve

Vein selection
Digital veins of the fingers are small and rarely used. The metacarpal veins and the dorsal venous NURSING STANDARD

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The median cubital vein is absent in 20 per cent of the population (Moore and Dalley 1999). The veins of the antecubital fossa are usually easily visualised, palpated and accessed because of their superficial nature and size. However, their position over the flexor surface of the elbow makes these veins prone to mechanical phlebitis, and the cannula prone to failure from kinking or dislodgement. History taking and assessment should alert nursing staff to specific patient issues that should be considered when identifying a site for cannulation. A cannula should not be placed in areas of localised oedema, dermatitis, cellulitis, arteriovenous fistulae, wounds, skin grafts, fractures, stroke, planned limb surgery and previous cannulation. Discussion with the patient is important. The patient may prefer the non-dominant limb to be selected for cannulation to promote independence and comfort (Dougherty 1999). Both upper limbs should be inspected to identify possible veins for cannulation. Potential veins can then be palpated to assess their condition. An ideal vein is soft and bouncy when palpated. Veins that are tender, thrombosed or hard should be avoided (Dougherty 1999). Veins contain valves, crescent shaped folds of endothelium, which assist blood flow back to the heart. Valves are most plentiful in the veins of the limbs and occur more frequently at junctions where veins converge. Careful observation may reveal valves (small bulges) within the peripheral veins, which should be confirmed by palpation. Valves may prevent blood withdrawal and cannula advancement and, therefore, should be avoided (Dougherty 1999). Palpation also allows the practitioner to differentiate between arteries and veins. Arteries are pulsatile and should be carefully avoided. New cannulae should be sited TABLE 1 Average flow rates based on gauge and length of cannula Gauge size 22 20 18 18 16 14 Catheter length (mm) 25 32 32 45 45 45 Catheter colour Blue Pink Green Green Grey Orange

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proximal to any previous sites to prevent drug or fluid infusion through damaged veins.

Device selection
It is important to select the correct vascular access device for the patients specific clinical situation (Gabriel et al 2005). Modern peripheral cannulae are usually made of polyurethane. Older cannulae are made of polyvinyl chloride (PVC) or Teflon. Older materials are more rigid, and some studies suggest that they are associated with a higher incidence of thrombophlebitis (Gaukroger et al 1988). Polyurethane cannulae are softer, cause less intimal damage and are kink resistant which reduces the incidence of cannula failure. Most peripheral cannulae contain a flashback chamber. This provides the practitioner with an immediate visual indication that the cannula has entered the vein. Generally, the smallest gauge of cannula should be selected for the prescribed therapy. This helps to prevent damage to the vessel intima and ensures that there is adequate blood flow past the cannula. Blood flow is slow in small peripheral vessels. If the cannula is too large, blood flow is impeded and drugs remain in prolonged contact with the vein wall resulting in chemical phlebitis (Crow 1996). Small gauge cannulae usually provide a sufficiently high flow rate to deliver most therapies, and reduce the risks of mechanical and chemical phlebitis (Table 1). It can be seen from Table 1 that a 22 gauge (blue) cannula can deliver 2.5 l/hr and should easily deliver a hydration regimen of three litres a day. Larger cannulae (18 gauge and above) are only required for acute emergency fluid resuscitation, for example, peri-operatively or to manage an acute gastrointestinal bleed. The following equipment for cannulation should be assembled and placed on a clean tray: cannula, antiseptic, sterile gauze, sterile saline flush, single or multiway adapter (primed with sterile saline) with integral needle-less device,

Flow rate ml/min (H20) 42 67 103 103 236 270

Flow rate l/hr (H20) 2.5 4.0 6.2 6.2 14.2 16.2

Flow rate ml/min (blood) 24 41 75 63 167 215 NURSING STANDARD

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BOX 1 Cannulation procedure Position the patient comfortably. It may be helpful to support his or her arm on a pillow. Wash hands and apply non-sterile gloves (Centers for Disease Control and Prevention (CDC) 2002). Apply a tourniquet to the upper limb to improve venous filling. This should not obstruct arterial blood flow and the radial pulse should still be palpable. Ask the patient to open and close the fist to promote venous filling. Clean the skin with a chlorhexidine-based solution (Pellowe et al 2004) and allow to dry. Do not re-palpate the skin. Open the cannula carefully and ensure the stylet within the cannula is positioned with the bevel uppermost. Hold the patients arm or hand and use your thumb to pull the skin taut below the intended puncture site. This will stabilise and anchor the vein before cannulation. Hold the cannula in line with the vein at a 10-30 angle to the skin and insert the cannula through the skin. As the cannula enters the vein blood will be seen in the flashback chamber. Lower the cannula slightly to ensure it enters the lumen of the vein and does not puncture the posterior wall of the vessel. Withdraw the stylet slightly and blood should be seen to enter the cannula: this confirms the position in the vein. The stylet must not be re-inserted as this can damage the cannula, resulting in catheter embolus. Slowly advance the cannula into the vein, ensuring the vein remains anchored throughout the procedure. Release the tourniquet. Dispose of the stylet in the sharps container at the bedside. Flush the cannula to check patency and to ensure easy administration without pain, resistance or localised swelling. Secure the cannula with a moisture-permeable transparent dressing (Royal College of Nursing (RCN) 2003). The dressing should allow viewing of the entry site while firmly stabilising the cannula to prevent mechanical phlebitis or cannula dislodgement. Record the cannulation procedure in the patients notes, including device, gauge, location, operator and number of insertion attempts.

sterile moisture-permeable transparent dressing, and a small sharps container. Cannulation procedure is outlined in Box 1.

Site preparation
Topical anaesthetic agents can reduce the pain of cannulation. Emla cream has to be applied two hours before cannulation, which is not always practical, and the associated vasoconstriction may complicate cannulation (Gunwardene and Davenport 1990). Ametop is a good alternative: it is effective after ten minutes and has mild vasodilatory effects. Local anaesthetic creams should be removed before cannulation because prolonged skin contact has been associated with skin damage (Hewitt and Scales 1998). As with all medications, the practitioner NURSING STANDARD

should check a patients allergy status before use. Hair removal, if needed, should be done by clipping with scissors, as shaving is associated with skin damage which increases infection risks (Weinstein 1996).

Complications
If the first flashback of blood does not occur, either the vein has not been punctured or the vein is already thrombosed and clotted. If the second flashback of blood does not occur, the cannula is no longer in the vein. Do not re-advance the stylet, select a new cannula, reaffirm consent with the patient and repeat the procedure. Dougherty (1998) suggests that only two cannulation attempts should be permitted before deferring to a more experienced practitioner. august 17 :: vol 19 no 49 :: 2005 51

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Cannula care
The cannula site should be inspected before use. To ensure patency the cannula should be flushed every 12 hours with normal saline (RCN 2003). Polyurethane cannulae may remain in situ for 96 hours provided there is no evidence of phlebitis (Centers for Disease Control and Prevention (CDC) 2002). A phlebitis scale should be used to assess the cannula site (RCN 2003). The cannula should be removed when it is no longer required or if there is evidence of complications. Remove the dressing and apply sterile gauze to the entry site, press firmly and remove the cannula. Continue to apply pressure for at least one minute after removal (Dougherty 1999), or until haemostasis is achieved, and cover the site with a sterile dressing.

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Conclusion
Cannulation is a valuable skill and has many advantages for the practitioner and the patient. Nurse-led cannulation allows timely management

of infusion therapy and may reduce the clinical risk associated with missed medications and delayed hydration. However, cannulation is another clinical task and nurses must be confident that their expanded practice role is not at the expense of patients essential nursing care. Cannulation requires a sound nursing knowledge of the theory underpinning the practice, however, this is a clinical skill and the clinical practice element is essential. Having studied the theory, nurses must complete a period of practice with an experienced supervisor who can help them to develop their skills and achieve competence. Once competence has been gained it is important to cannulate regularly to avoid deskilling. Regular cannulation helps nurses to develop their own portfolio of clinical experience. Cannulation can be complicated by preexisting disease, prolonged hospital admission and multiple vascular access attempts. Nurses must be aware of their own limitations in relation to experience and skill (Nursing and Midwifery Council 2004). There may be times when the nurse should decline to attempt cannulation if patient history or assessment suggests that cannulation is too complex (Jackson 2003) NS

References
Centers for Disease Control and Prevention (2002) Guidelines for the Prevention of Intravascular Catheterrelated Infections. MMWR Recommendations and Reports. August 9, 51, RR-10, 1-29. Crow S (1996) Prevention of intravascular infections ways and means. Journal of Intravenous Nursing. 19, 4, 175-181. Department of Health (2001) Reference Guide to Consent for Examination or Treatment. The Stationery Office, London. Dougherty L (1994) A Study to Discover how Cancer Patients Perceive the Intravenous Cannulation Experience. Unpublished MSc thesis. University of Surrey, Guildford. Dougherty L (1998) Intravenous cannulation. In A Guide to Intravenous Therapy. Continuing Education Reader, RCN Publishing, Middlesex, 11-16. Dougherty L (1999) Obtaining peripheral venous access. In Dougherty L, Lamb J (Eds) Intravenous Therapy in Nursing Practice. Churchill Livingstone, London, 223-259. Gabriel J, Bravery K, Dougherty L, Kayley J, Malster M, Scales K (2005) Vascular access: indications and implications for patient care. Nursing Standard. 19, 26, 45-52. Gaukroger PB, Roberts JG, Manners TA (1988) Infusion thrombophlebitis: a prospective comparison of 645 Vialon and Teflon cannulae in anaesthetic and postoperative use. Anaesthesia and Intensive Care. 16, 3, 265-271. Gunwardene RD, Davenport HT (1990) Local application of EMLA and glyceryl trinitrate ointment before venepuncture. Anaesthesia. 45, 6, 52-54. Hewitt T, Scales K (1998) Prolonged contact with topical anaesthetic cream: a case report. Paediatric Nursing. 10, 21, 22-23. Jackson A (2003) Reflecting on the nursing contribution to vascular access. British Journal of Nursing. 12, 11, 657665. Melzack R, Wall PD (1996) The Challenge of Pain. Penguin Books, Middlesex. Moore KL, Dalley AF (1999) Clinically Orientated Anatomy. Lippincott, Williams and Wilkins, Philadelphia PA. Nursing and Midwifery Council (2004) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. NMC, London. Ost LJ (1992) Blood and injection phobia: background and cognitive, psychological, and behavioural variables. Journal of Abnormal Psychology. 101, 1, 68-74. Pellowe CM, Pratt RJ, Loveday HP, Harper P, Robinson N, Jones SRLJ (2004) The epic project. Updating the evidencebase for national evidence-based guidelines for preventing healthcareassociated infections in NHS hospitals in England: a report with recommendations. Journal of Hospital Infection. 5, 6, 10-16. Royal College of Nursing (2003) Standards for Infusion Therapy. RCN, London. Scales K (1999a) Vascular access in the acute care setting. In Dougherty L, Lamb J (Eds) Intravenous Therapy in Nursing Practice. Churchill Livingstone, London, 261-299. Scales K (1999b) Anatomy and physiology related to intravenous therapy. In Dougherty L, Lamb J (Eds) Intravenous Therapy in Nursing Practice. Churchill Livingstone, London, 21-43. Weinstein SM (1996) Plumers Principles and Practice of Intravenous Therapy. Sixth edition. Lippincott, Williams and Wilkins, Philadelphia PA.

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