PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL POLICIES
Section 3.12
CLINICAL POLICY FOR
PERIPHERAL VENOUS CANNULA INSERTION AND
MANAGEMENT (ADULTS)
TITLE
REFERENCE
NUMBER
MANAGER /
COMMITTEE
RESPONSIBLE
3.12
IV PROJECT LEAD
PARENTAL THERAPY GROUP
DATE ISSUED
18.09.2007
VERSION
REVIEW DATE
Equality Impact
Assessment has
been applied to this
policy
4
March 2008
Simon Freathy, Clinical Nurse Specialist Intravenous Therapy
B .BUCHANAN IV PROJECT LEAD/ SANDY KIRK CNS IV THERAPY
AUTHOR
RATIFIED BY
CHAIR OF PROFESSIONAL ADVISIORY COMMITTEE: 17.09.2007
AMENDMENTS RECORD:
The text of this policy is unchanged from issue 3, only the focus on the distal extremities is different.
See appendix III
CONTENTS:
1.
2.
3.
4.
5.
6.
7.
8.
INTRODUCTION
STATUS
PURPOSE
SCOPE/AUDIENCE
DEFINITIONS
CLINICAL PRACTICE
SUPPORTING EVIDENCE
DUTIES AND RESPONSIBILITIES
9. TRAINING
APPENDICES:
APPENDIX I: CANNULA INSERTION AND MANAGEMENT FORM
APPENDIX II: SUPPORTING WARD INFORMATION
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Section 3.12
CLINICAL POLICIES
1. INTRODUCTION
This policy will provide information about the correct technique for peripherally cannulating a vein aseptically and
the subsequent care of the peripheral venous cannulae. By using this policy the user will act to reduce the risks to
patients and staff associated with peripheral venous cannulation. These include thrombosis, pain, local or systemic
infection; occupational sharps injury and inappropriate cannula insertion.
Aseptic peripheral venous cannulation is undertaken to provide venous access for either diagnostic or therapeutic
purposes:
a)
Short-term intravenous fluid therapy of usually less than 3-4 days (if intravenous access is needed for
longer periods, other options should be considered).
b)
Administration of bolus injections in outpatients or in day case surgery
c)
Vascular access for fluids or drugs at time of particular procedure e.g. surgery, endoscopy
The implementation of this policy will be monitored using clinical audit. !0 cannula audits monthly. (appendix I)
2. STATUS
Clinical Policy
3.
PURPOSE
To inform best practice on the aseptic insertion of peripheral venous cannulation of adults. The implementation of this policy
will reduce the risks associated with this procedure including thrombosis, pain, local or systemic infection; occupational
sharps injury and inappropriate cannula insertion.
4.
SCOPE/AUDIENCE
This policy applies to all health care professionals performing cannulation in the Trust.
For cannulation in paediatric areas, please refer to Infection Control.
5.
DEFINITIONS
Aseptic Technique
Clinical practices used to protect the patient from micro-organisms by preventing contamination of wounds,
manipulated devices and other susceptible sites. Aseptic technique involves the use of appropriate hand hygiene,
use of sterile equipment, no touch technique and robust patient skin / site disinfection.
Venous Cannulation
Procedure for insertion of a hollow fine bore tube into the venous system
Health care professional
A registered or trained member of staff, including but not exclusively nurses, doctors and operating department
practitioners.
Infection
Entry of a harmful microbe into the body and its multiplication in the tissues
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Section 3.12
Peripheral cannula
A specifically-designed flexible tube designed for insertion into a blood vessel,
with a proximal connector to allow injection or infusion of liquids. Sizes range from blue 22g, pink 20g, green 18g,
grey 16g and orange 14g. 22-20g are optimal for administration of intermittent medications. 16- 14g are routinely
used to administer fluids in acute situations i.e. haemorrhage
Phlebitis
Inflammation of a vein
Thrombosis
Formation, development or existence of a blood clot within the vascular system
6.
CLINICAL PRACTICE
Action
Identify clinical need for cannula insertion
Identify patient by surname, first name and date of birth
Explain the procedure to the patient, discuss the need for
a cannula, obtaining verbal consent for procedure
establishing whether patient has any known allergies
Explain to the patient the importance of keeping the site
clean and dry and advise of risks of infection
Collect equipment needed including:
 Dressing trolley
 Sterile field with dressing pack or proprietary
cannulation pack
 Single use tourniquet
 Sterile gloves
 Sharps box
 2% Chlorhexidine and 70% alcohol (Deb) skin
preparation
 Local anaesthetic (1% lidocaine) orange needle
and 2ml syringe/ insulin syringe
 Cannulae - IV dressing
 Saline flush
Wash hands with soap and water as per the Trust Hand
Hygiene Policy
Place opened dressing / cannulation pack onto clean
dressing trolley. Open sterile packs and lay out equipment
within the sterile field.
Sanitise hands with alcohol gel or wash with soap and
water
Palpate potential sites these include:
 The hand - a lower risk of phlebitis
 The wrist or upper arm – increasing risk
 The lower limb has a higher risk than the upper
limb
When potential site is identified position patient
comfortably with appropriate limb below the level of the
heart. Removing excess hair (shaving is not
recommended – clippers are better)
Rationale
To prevent inappropriate insertion and exposure to associated
risks.
To ensure correct identification of the patient
To ensure patient is informed of procedure and the risk of
allergic reaction is minimised
To ensure patient compliance and reduce risk of infection
To ensure procedure is performed without disruption
Choice of cannula must be based on clinical need but the
smallest cannula should be chosen to reduce risk of
complications associated with larger bores.
To reduce the risk of infection
To reduce the risk of infection
To reduce risk of arterial rather than venous cannulation, and
reduce risk of infection.
To allow dependent veins to fill with blood
Local trauma can be caused by shaving, increasing risk of
infection
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CLINICAL POLICIES
Section 3.12
Action
Apply proximal single use tourniquet, without obstructing
arterial flow Optimal time for application is 3 to 5 mins – if
additional time is needed release tourniquet as vein will
tend to “disappear”.
Encourage patient to exercise limb muscles (e.g.
repeatedly making a fist and opening hand)
Sanitise hands with alcohol gel or wash with soap and
water and don sterile gloves
Clean insertion site using a spiral motion from the
proposed puncture site outwards with 2% chlorhexidine in
70% alcohol (from a bottle or pre-soaked wipe) for 30
seconds and then allow to dry
Administer local anaesthetic (1% lidocaine) which should
be encouraged in all but the most urgent of cases.
Alternatively apply prescribed topical local anaesthetic
cream 45mins prior to procedure
Inserting the cannula:
 Gently pull on skin, distal and lateral to insertion
site. Do not touch the cannula or the insertion
site.
 Insert cannula (bevel uppermost) through the
cleaned skin area at an angle of 20 degrees.
 Advance until just in the vein and then lower the
cannula until it is parallel with the skin (a
flashback of blood is usually but not always seen
at this point)
Rationale
To distend veins
Muscle pump forces blood into veins to distend them further
To reduce the risk of infection
To reduce risk of infection
To ensure patient comfort
To “fix” the skin and the superficial veins underlying it.
To use the sharpened needle to introduce the plastic cannula
into the vein.
Then, either;
a) Pull the needle back 1cm and push the
cannula/needle into the vein up to the hilt
Or;
b) Hold the needle still and advance the cannula over the
needle until the cannula is inserted up to the hilt
To introduce the cannula fully into the vein
In the event of unsuccessful cannulation of the vein
withdraw the cannula from the puncture site and apply
pressure with non woven swab
To minimise haematoma formation and /or excessive bruising
Prior to subsequent attempts at cannulation it is the
responsibility of the individual practitioner to risk assess
the difficulty of further attempts against their own
registered competence and experience. If the practitioner
anticipates the difficulty level to be beyond their scope of
practice, then referral to more experienced, competent
practitioners should be made
Remove the tourniquet and apply pressure on the
proximal vein, close to the tip of the cannula – a second
person may be required for this
Remove needle and dispose of immediately into sharps
container, cap off cannula with a sterile cap or attach
intravenous fluids as appropriate
To ensure cannulation is always undertaken by competent
practioners and minimise risks associated with failed attempts
at gaining venous access
To prevent excessive bleeding during needle-removal.
To reduce risk of needle stick injury and prevent blood spillage.
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CLINICAL POLICIES
Secure cannula with a recognised, sterile cannula
dressing, ensuring it is applied correctly (non-sterile,
sticky-tape fixation or bandage is NOT acceptable).
Place ‘date for cannula review’ sticker to outside of
dressing
Flush cannula with 1-2 ml saline if not being attached to
infusion.
Document cannula insertion and removal by completing a
Cannula insertion and management form for each
separate cannula inserted. Once cannula has been
removed this document is filed in the patients medical
notes.
DAY CASE patient’s cannula need only to be documented
fully in the notes. A cannula insertion and management
form is NOT required.
Section 3.12
To reduce risk of infection and secure cannula in position
To ensure timely review
To ensure cannula patency
To establish an audit trail and monitor management of cannula.
Cannula insitu for short period of time and then removed.
Ongoing cannula management:
Decontaminate hands before and after each patient
contact. Use correct hand hygiene procedure as per trust
policy.
Always access cannula by cleaning with 2% chlorhexidine
and 70% isopropyl alcohol, and allow to dry before
administering fluid or injections.
Swanlocks (bungs) should NOT be applied directly onto
the cannula; single or double lumen extensions should be
applied.
Cannula site should be inspected at least twice a day and
documented on the form.
Cannula dressing should be, intact, dry and adherent. A
date and time of insertion must be applied at point of
insertion.
Remove cannula if there is no continuing clinical
indication.
Replace cannula in a new site after 72-96 hours, earlier if
clinically indicated.
Administration sets should be replaced immediately after
blood and blood product administration, intermittent IV
antibiotics and medicines. Heparin infusion lines should be
replaced every 24 hours. All other fluid sets should be
replaced after 72 hours. ALL giving sets should be labelled
with date and time on commencement of use.
To reduce the risk of infection
To reduce the risk of infection
To prevent unwanted movement of cannula in the vein. Thus
causing phlebitis.
Observe for signs of infection or phlebitis.
To ensure that the cannula is replaced or removed on time, thus
reducing the risk of infection.
To reduce the risk of infection
To reduce the risk of infection
To reduce the risk of infection
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CLINICAL POLICIES
7.
Section 3.12
SUPPORTING EVIDENCE
 Department of Health (2001) The epic Project: Developing National Evidence – based Policys for
Preventing healthcare associated Infections Journal of Hospital Infection (2001) 47 (supplement)

Donaldson I. (1999) Intravenous therapy in critically ill adults: developing a clinically and costeffective approach Intensive and Critical Care Nursing No 15, 338-345


Dougherty L, Mallett J (2001) The Royal Marsden Hospital Manual of Clinical Nursing Procedures
Fifth edition. Blackwell Science

Fletcher SJ; Bodenham A (1999) Catheter related sepsis: an overview – Part 1 British Journal of
Intensive Care. March/April

Infection Control Nurses Association (2001) Policys for preventing intravascular catheter related
infection NICE (2003) (No. 4) Care of patients with central venous catheters Clinical policy 2 – Infection
control, June 2003

Polderman KH; Girbes AR (2002) Central venous catheter use. Part 2: infectious complications
Intensive Care medicine 2002, Jan; 28(1): 18-28

Portsmouth Hospitals NHS Trust Policys
 Infection Control Policys - Intravenous Cannulation and Infusion therapy
 Blood Transfusion Policy (Adult0

RCN (March 2004) Good practice in infection control – Guidance for nursing staff

RCN (Oct 2003) Standards for infusion therapy

DoH ( July 2006) winning ways high impact working together to reduce healthcare associated infection in
England-intervention 2b
8. DUTIES AND RESPONSIBILITIES
Supervisors of clinical practice will be responsible for monitoring compliance with the policys on an Ongoing basis.
The IV therapy Nurses will audit compliance as part of the infection control clinical practice audit process.
A snapshot audit to monitor clinical practice during cannula insertion and subsequent care will be undertaken
annually.
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Section 3.12
9. TRAINING
Prior to undertaking any cannulation procedure, all staff must be able to demonstrate clinical competence and a
clear understanding of the underlying principles of practice. This will be achieved by:
Nursing and other health care staff;
a)
b)
c)
complete the Trust venous cannulation competency pack
attend a cannulation study day
complete a period of supervised clinical practice
(Staff who have been trained and practised in a previous post may be allowed to demonstrate an equivalent level of
competence through a period of supervised practice only).
Medical staff;
Post registration house officer (PRHO) induction will include training by Trust trainers on local policys and principles
of practice.
Senior House Officer’s and Registrars will be assumed competent unless identified otherwise by their supervisor. If
problems are identified, the staff member will be required to:
a)
complete the Trust venous cannulation competency pack
b)
attend a cannulation study day
c)
complete a period of supervised clinical practice
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Section 3.12
CLINICAL POLICIES
APPENDIX I: CANNULA INSERTION AND MANAGEMENT FORM
FORM AVAILABLE FROM MEDICAL PHOTOGRAPHY (EXT3370). FORM NO: 08246
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CLINICAL POLICIES
Section 3.12
APPENDIX II: SUPPORTING INFORMATION FOR CLINICAL AREAS
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Section 3.12
Abbreviated guide to peripheral venous cannulation (adult.)
Clinical Practice Policy (abbreviated)
Action
Identify clinical need for cannula insertion
Identify patient by surname, first name and date of birth
Explain the procedure to the patient, discuss the need for a cannula, obtaining verbal consent for procedure
establishing whether patient has any known allergies
Explain to the patient the importance of keeping the site clean and dry and advise of risks of infection
Collect equipment needed including:
 Dressing trolley
 Sterile field with dressing pack or proprietary cannulation pack
 Single use tourniquet
 Sterile gloves
 Sharps box
 2% Chlorhexidine and 70% alcohol (Deb) skin preparation
 Local anaesthetic (1% lidocaine) orange needle and 2ml syringe
 Cannulae - IV dressing
 Saline flush
Wash hands with soap and water as per the Trust Hand Hygiene Policy
Place opened dressing / cannulation pack onto clean dressing trolley. Open sterile packs and lay out equipment
within the sterile field.
Sanitise hands with alcohol gel or wash with soap and water
Palpate potential sites these include:
 The hand - a lower risk of phlebitis
 The wrist or upper arm – increasing risk
 The lower limb has a higher risk than the upper limb
When potential site is identified position patient comfortably with appropriate limb below the level of the heart.
Removing excess hair (shaving is not recommended – clippers are better)
Apply proximal single use tourniquet, without obstructing arterial flow Optimal time for application is 3 to 5 mins – if
additional time is needed release tourniquet as vein will tend to “disappear”.
Encourage patient to exercise limb muscles (e.g. repeatedly making a fist and opening hand)
Sanitise hands with alcohol gel or wash with soap and water and don sterile gloves
Clean insertion site using a spiral motion from the proposed puncture site outwards with 2% chlorhexidine in 70%
alcohol (from a bottle or pre-soaked wipe) for 30 seconds and then allow to dry
Administer local anaesthetic (1% lidocaine) which should be encouraged in all but the most urgent of cases.
Alternatively apply prescribed topical local anaesthetic cream 45mins prior to procedure
Inserting the cannula:
 Gently pull on skin, distal and lateral to insertion site. Do not touch the cannula or the insertion site.
 Insert cannula (bevel uppermost) through the cleaned skin area at an angle of 20 degrees.
 Advance until just in the vein and then lower the cannula until it is parallel with the skin (a flashback of
blood is usually but not always seen at this point)
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Section 3.12
Then, either;
b) Pull the needle back 1cm and push the cannula/needle into the vein up to the hilt
Or;
b) Hold the needle still and advance the cannula over the needle until the cannula is inserted up to the hilt
In the event of unsuccessful cannulation of the vein withdraw the cannula from the puncture site and apply
pressure with non woven swab
Prior to subsequent attempts at cannulation it is the responsibility of the individual practitioner to risk assess the
difficulty of further attempts against their own registered competence and experience. If the practitioner anticipates
the difficulty level to be beyond their scope of practice, then referral to more experienced, competent practitioners
should be made
Remove the tourniquet and apply pressure on the proximal vein, close to the tip of the cannula – a second person
may be required for this
Remove needle and dispose of immediately into sharps container, cap off cannula with a sterile cap or attach
intravenous fluids as appropriate
Secure cannula with a recognised, sterile cannula dressing, ensuring it is applied correctly (non-sterile, sticky-tape
fixation or bandage is NOT acceptable).
Place ‘date for cannula review’ sticker to outside of dressing
Flush cannula with 1-2 ml saline if not being attached to infusion.
Document cannula insertion and removal by completing a Cannula insertion and management form for each
separate cannula inserted. Once cannula has been removed this document is filed in the patients medical notes.
DAY CASE patient’s cannula need only to be documented fully in the notes. A cannula insertion and management
form is NOT required.
Ongoing cannula management:
Decontaminate hands before and after each patient contact. Use correct hand hygiene procedure as per trust
policy.
Always access cannula by cleaning with 2% chlorhexidine and 70% isopropyl alcohol, and allow to dry before
administering fluid or injections.
Swanlocks (bungs) should NOT be applied directly; single or double lumen extensions should be applied.
Cannula site should be inspected at least twice a day and document on form
Cannula dressing should be, intact, dry and adherent. A date and time of insertion must be applied at point of
insertion.
Remove cannula if there is no continuing clinical indication.
Replace cannula in a new site after 72-96 hours, earlier if clinically indicated.
Administration sets should be replaced immediately after blood and blood product administration, intermittent IV
antibiotics and medicines. Heparin infusion lines should be replaced every 24 hours. All other fluid sets should be
replaced after 72 hours. ALL giving sets should be labelled with date and time on commencement of use.
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CLINICAL POLICIES
No needle free injectable
bungs should be applied
directly onto indwelling
cannulae; these
components are designed
for use in long dwell central
venous access devices only
For further information please contact the:
IV therapy team
Infection control department
Pathology Laboratory E Level
Queen Alexandra Hospital
Cosham
(02392) 286000
Ext.1744 / Clinical lead bleep 1494
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Section 3.12
Cannulae that are
anticipated to be
accessed intermittently
should have a single
access extension line
deployed to minimise
increased risks of
mechanical phlebitis
associated with direct
cannulae access
In cases of concurrent
therapy a double
lumen device should
be deployed thus
facilitating access to
the closed IV circuit
following appropriate
decontamination
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CLINICAL POLICIES
Section 3.12
1. Explain the procedure to the patient, discuss
the need for a cannula, obtaining verbal consent
for procedure. Establishing whether patient has
any known allergies. Collect equipment needed
2. Clean insertion site using a spiral motion
from the proposed puncture site outwards with
2% chlorhexidine in 70% alcohol (from a bottle
or pre-soaked wipe)
Apply tourniquet, perform hand hygiene and don latex
free sterile gloves, a sterile field can be deployed as
per individual practitioner preference
3. Administer intradermal local anaesthetic
( 1% lidocaine)
PHT Peripheral Venous Cannulation (Adults) Policy. Issue 4. 18.09.07
4.Gently pull on skin, distal and lateral to
insertion site. Do not touch the cannula or the
insertion site.
Insert cannula (bevel uppermost) through the
cleaned skin area at an angle of 20 degrees
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CLINICAL POLICIES
Section 3.12
a)
Pull the needle back 1cm and push the
cannula/needle into the vein up to the
hilt
Or;
b) Hold the needle still and advance the
cannula over the needle until the cannula is
inserted up to the hilt
6. Remove the tourniquet and apply pressure on
the proximal vein, close to the tip of the cannula
– a second person may be required for this
8. Flush cannula with 1-2 ml saline if not being
attached to infusion.
10. Place ‘date of insertion’ sticker to outside
of dressing
PHT Peripheral Venous Cannulation (Adults) Policy. Issue 4. 18.09.07
9. Secure cannula with a recognised, sterile
cannula dressing, ensuring it is applied
correctly (non-sterile, sticky-tape fixation or
bandage is NOT acceptable).
11. Cannulae that are anticipated to be accessed
intermittently should have a single access extension
line deployed to minimise increased risks of
mechanical phlebitis associated with direct cannulae
access
In cases of concurrent therapy a double lumen
device should be deployed thus facilitating access to
the closed IV circuit following appropriate
decontamination
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CLINICAL POLICIES
Section 3.12
order codes and product information
The nitrile lilac polyfield patient pack
Contents: 1 x pair nitrile sterile gloves
7 x 7cm x 7cm gauze swabs
1 x waterproof sheet
1 x sterile field
1 x sterile apron
1 x clinical waste bag
Order code : small : Code EVD055
Medium : Code EVD056
Large : Code EVD057
Smith and Nephew IV 3000 hand
Contents: 1 x semi-periable cannula dressing
Product specification
Order code: ELW032
Codan SWAN lock needle free adaptor
Contents: 1 x swan lock adaptor
Order code: FSW292
Codan SWAN lock single lumen needle free adaptor
Contents: 1 x swan lock single lumen adaptor
Order code: FSW286
Codan SWAN lock double lumen needle free adaptor
(with antireflux valves)
Contents: 1 x swan lock double lumen adaptor
(theatre equivilant wescott double lumen adaptor)
Order code 723162 (to be purchased non stock via IPROC)
BD “ stretch” disposable tourniquet
1 x Box : contents 25 items
order code: FWJ009
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Section 3.12
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