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Intravenous Cannulation

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For a list of staff with current IV certification, please follow this intranet link (ADHB staff only). You will also find the IV certification test and checklist on the intranet.

Preparation

Identify necessity for ongoing IV therapy:

  • The baby's size, age, and gestation.
  • The type and rate of infusion(s) and/ or medications infusing.
  • Why the baby needs an IV.
  • Is this the baby's last dose of antibiotics?
  • Could they be given I.M. instead?
  • Is the baby almost on full feeds?

Comfort measures

IV cannulation can be a painful procedure for the infant. The procedure should be approached in a developmentally supportive manner.

  • Swaddling provides containment and comfort.
  • Provide neutral thermal environment and prevent cold stress.
  • Infant's eyes should be shielded from bright light.
  • Non-nutritive sucking with use of a pacifier provides a calming effect.
  • Administer sucrose per unit protocol prior to procedure for all infants >31 wks & >1500 g for pain relief.

Catheter selection

  • Butterfly. Only used for scalp veins, sometimes used for obtaining blood samples. NS-ANP /Dr. procedure only. Discouraged due to shorter dwell time.
  • Surflow: Radiopaque Teflon. (current catheter used in newborn services is the Terumo Surflow in sizes 24 gauge, and 22 gauge).

Vein selection

  • The first choice of sites is the periphery to maximize available vein sites. In neonates, the veins of the anterior aspect of the hands and feet are the most visible.
  • Scalp IVs are to be avoided. If necessary, this is usually performed by an ANP or Registrar. Scalp IVs may be culturally inappropriate (in Maori and other cultures).
  • Veins used for long line insertion are not to be cannulated without permission of Senior Medical Staff. (Long saphenous and brachial veins- see diagrams below).

Select a site in where:

  • The vein is relatively straight.
  • The area is not bruised.
  • There is a vein that has not been infiltrated previously.
  • There is no difficulty immobilizing the joint of the extremity.

If there is difficulty finding an appropriate site, notify the medical staff to assist.

Differentiating between Veins and Arteries

See diagrams below

  1. When palpated, artery pulses (but not always).
  2. Artery blanches when flushed.
  3. Artery has bright red blood.
  4. Avoid ventral (flexor) surface of forearm near the wrist if possible.
  5. It is difficult to distinguish arteries and veins in an infant's scalp.
  6. Cannulating an artery can interfere with blood supply to an extremity or surrounding tissue and can cause necrosis of the tissue. Should an artery be inadvertently cannulated, remove the cannula immediately and apply direct pressure for 5 minutes.
  1. If the infant's parents are present inform them about the procedure, why it is required and what is involved. Encourage them to help comfort infant if feasible.
  2. Position infant appropriately. Use comfort measures as needed (See preparation).
  3. Visually assess condition of veins to ascertain suitability (ensure good lighting).
    Prepare cannula, tape prefilled syringe containing 0.9% normal saline and other equipment required.
    Twist cannula slightly around the stylet to loosen it. Do not pull straight off as this can cause pieces from the tip to shear off.
  4. Using an appropriate disinfectant, clean the skin thoroughly in a circular motion. Swab for at least 30 seconds. Allow to dry. Do not re-palpate.
  5. Stabilize vein below the site of insertion and pull the skin taut.
  6. Hold cannula at the sides to allow view of flashback chamber.
  7. Insert cannula smoothly through the skin at about a 10-degree angle with point of introducer down and bevel up. If cannula is completely removed through the skin, a new cannula MUST be used.
    Note: MAXIMUM three attempts allowed- then you must seek help. Use discretion with very small infants or infants with difficult access.
  8. Advance cannula until blood flashback appears. Press forefinger or thumb against the hub of the needle so it moves off the stylet. Observe for flash back. Remove stylet and place it in a proper container to discard appropriately.
  9. Gently inject 0.9% normal saline to distend the walls of the vein as you advance the cannula. Aim to insert the full length of catheter into the vein.
    Optional: Gently thread the cannula into the vein without fluid.
  10. Tape IV securely. (See below)
  11. Attach extension with luer plug and pall filter.
  12. Dispose of sharps and other IV equipment in a safe, appropriate manner.
  13. Document all insertions on observation chart. If IV is to be discontinued, state reason for discontinuation and state of IV site.

Taping peripheral IV Cannulae

It is expected that:

  • IVs are taped so the site directly over the tip of the cannula is visible for observing signs of infiltration.
  • Tape is not to be placed over pre-existing tapes. If an IV require re-taping, existing tape must be removed first.
  • Tape so that it will be easy to remove. Consider making tabs at the ends of each tape to help with easier removal. DO NOT use scissors to remove tapes.
  • Nailbeds must be visible for assessing peripheral circulation. Do not tape too tightly which could interfere with circulation of the extremity.
  • Tape in a way that is developmentally appropriate for the baby. If the IV is in the hand, ensure fingers are flexed over armboard and thumb is free. Feet are to be taped in an anatomical position with toes visible. Minimize restrictive movement as much as possible. Make sure baby will be comfortable after taping.
  • Tape in a way that is appropriate for that particular gestation. ELBW babies require Coban dressing (stretchy gauze) and minimal use of adhesive tape due to the fragility of their skin. Extra small armboards (handmade from gauze and cloth tape) are also useful.
  • Minimise the excessive amount of tape used directly on the skin.

Complications of IV Cannulation

  1. Local and systemic infections
  2. Phlebitis
  3. Thrombus
  4. Haematoma
  5. Embolism of clot by forceful flushing
  6. Air Embolism
  7. Accidental insertion into an artery
  8. Bleeding if disconnected
  9. Extravasation with blistering or tissue necrosis (may need clysis - see below)

Recognition and Prevention of IV Infiltration Injuries

Signs and symptoms of infiltration include:

  • An IV infiltration can be disastrous to a neonate's skin. Sloughing and tissue necrosis can occur, as well as full thickness skin and muscle necrosis is possible.
  • Plastic surgery may be necessary in extreme cases.
  • It is extremely important to observe IV sites closely, at least hourly, more often in cases of high infusion rates, caustic solutions, and small fragile veins.

Signs and symptoms of infiltration include:

  • Swelling
  • Pain
  • Coolness of skin
  • Leakage at site
  • Erythema
  • Blistering
  • Lack of blood return

Prevention measures

  • Avoid butterflies for infusion.
  • Avoid areas difficult to immobilize.
  • Avoid dorsum of foot in active babies, especially larger babies in cots. Always expose the IV site if the baby is in a cot.
  • Secure so site is clearly visible.
  • Tape loosely enough to maintain circulation.
  • Limit glucose concentrations to 12.5%. Amino acids > 25% require central line.
  • Dilute medications per drug protocol.
  • Assess catheter site and distal region hourly.
  • Stop infusion immediately if signs of infiltration are present. Follow RBP guidelines for IV infiltration. Refer intravascular catheter guidelines.
  1. Remove I.V. immediately at first sign of infiltration.
  2. If significant infiltration or necrosis occurs, notify CCN, NS-ANP, or Registrar immediately.
  3. Estimate the severity of the injury by Millam's 1988 Staging Guidelines.
  4. For Stage 1 and 2 injuries elevate limb, observe circulation, and document findings.
  5. For all Stage 3-4 injuries an incident report must be initiated. Photographs of the injury should be made for the medical notes and a digital copy made available for plastic surgeons. Parents to be notified and informed of actions taken.
  6. For Stage 3-4 injuries AND for extravasation injuries with potentially injurious solutions (caffeine, dopamine, dobutamine, blood, solutions containing ≥12.5% glucose, or IVN)
    Clysis treatment should be initiated as soon as possible following the discovery of a Stage 3-4 injury or extravasation of injurious solutions.
    After clysis has been carried out, plastic surgery referral may or may not be required. This should be determined over the next few days of careful observation.
    The plastic surgeon on call should be notified for all Stage 4 infiltrations if no improvement after clysis.

Staging Severity of IV Infiltration

Stage I Painful IV site
No erythema
No Swelling
Stage II Painful IV site
Slight swelling (0-20%)
No blanching
Good pulse below infiltration site
Brisk capillary refill below infiltration site
Stage III Painful IV site
Marked swelling (30-50%)
Blanching
Skin cool to touch
Good pulse below infiltration site
Brisk capillary refill below infiltration site
Stage IV Painful IV site
Very marked swelling (>50%)
Blanching
Skin cool to touch
Decreased or absent pulse*
Capillary refill > 4 seconds*
Skin breakdown or necrosis*

* The presence of any of these constitutes a stage IV infiltration

Clysis Therapy of Intravenous Fluid Extravasation

  1. Most infiltrations are able to be treated with local anaesthesia and analgesia such as paracetamol.
  2. If area is very large, general anaesthesia may be indicated. This should be discussed with specialist on call.
  3. Clysis is a sterile technique.
  4. Place large waterproof guard under affected limb before creating sterile field.
  5. Clean the affected area with a skin disinfectant appropriate for the infant's gestation and postnatal age. Allow to dry.
  6. Infiltrate affected region with local anaesthetic (usually 1% xylocaine, maximum dose 0.3ml/kg). This should be concentrated in area proximal to (above) the wound, and within the central area of wound. Wait several minutes until effective.
  7. Using size 15 scalpel blade, make several small (approximately 5mm long) stab wounds within affected region - these should be approximately 1-2 cm apart, and penetrate just below skin.
  8. Take large (Size 14 or 16) angiocath and remove sharp needle leaving white cannula only.
  9. Have 500 ml bag 0.9% NaCl ready on sterile field.
    Push Chemospike into fluid bag to provide access port for refilling syringe.
    Fill 20 ml syringe, attach to white cannula, and insert into stab wounds flushing with firm but gentle pressure in and around area of stab wound.
    Fluid should be seen to leak from stab wound sites
  10. Start in central part of affected area where the infusate is concentrated. Refill syringe and repeat as required.
  11. A large volume of saline should be used -depending on size of baby and of wound, it is suggested that 200-500 ml saline will be needed: Suggested volumes:
    <1000g        200ml
    1000-2000g 300ml
    >2000g        500ml
  12. When completed, cover area with sterile non-stick dressing (Mepitel or Intrasite Conformable gel dressing). Stab wounds should not be closed and may drain for some time. Elevate limb in comfortable position. Check wound 6-hourly over next 24 hours.
  13. One dose of intravenous antibiotic (Flucloxacillin 50mg/kg) should be given if the baby is not already receiving antibiotics.
  14. A clysis kit will be kept in the 'rarely - used stuff' cupboard in the storeroom.
    Blue waterproof sheet
    Dressing pack
    2 size 15 scalpel blades
    2x 16G angiocaths
    20ml syringe
    1 ml syringe and very fine 27G needle for local anaesthetic
    REM Chemospike

    You will also need to access 0.9%NaCl (500ml bag) and Mepitel dressing or Intrasite Conformable gel dressing

Diagrams of Vein and Artery Positions


Anatomy of veins over the hands and feet

Veins over hands and feet


Main Veins`of the Arm

Main veins of arm

Superficial veins of the legs

Leg veins

Main Arteries of the Arm

Main arteries of arm

Popliteal Artery and its Main Branches

Popliteal artery

References

  1. Millam DA. Managing complications of i.v. therapy. Nursing 1988;18(3):34-43.
  2. Gault DT. Extravasation injuries. Br J Plast Surg 1993;46:91-6.
  3. Casanova D, Bardot J, Magalon G. Emergency treatment of accidental infusion leakage in the newborn: report of 14 cases. Br J Plast Surg 2001;54:396-9.
  4. Harris PA; Bradley S,H.Moss A. Limiting the Damage of Iatrogenic Extravasation Injury in Neonates. Plastic & Reconstructive Surg 2001;107(3): 893-894
  5. Wilkins CE, Emmerson AJB. Extravasation Injuries on regional neonatal units. Arch Dis Child Fetal Neonatal Ed. 2004:89:F274-F275.
  6. Sawatzky-Dickson D., Bodnaryk K. Neonatal Intravenous Extravasation Injuries: Evaluation of a Wound Care Protocol. Neonatal Network 2006;25(1): 13-19.
  7. Duck, S., (1997). Neonatal Intravenous Therapy. Journal of Intravenous Nursing, 20(3), 121-128
  8. Blatz, S. & Paes, B.A., (1990) Intravenous Infusion by superficial vein in the Neonate. Journal of Infusion Nursing, 13(2), 122-128.
  9. MacQueen, S., (2005). The Special Needs of Children Receiving Intravenous Therapy. Nursing Times, 101(8), 59-64.
  10. 5 Pettit, J., (2003). Assessment of the Infant With a Peripheral Intravenous Device. Advances in Neonatal Care, 3(5), 230-240.
  11. Wilson, D., (2000). Starting Neonatal I.V.'s: Practical Tips. Mother Baby Journal, 5(1), 11-19.
  12. Thigpen, J.L., (2007). Peripheral Intravenous Extravasation: Nursing Procedure for Initial Treatment. Neonatal Network, 26(6), 379-384.

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Document Control

  • Date last published: 19 September 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years