IV cannulation

Intravenous (IV) cannulation is a technique in which a cannula is placed inside a vein to provide venous access. Venous access allows sampling of blood, as well as administration of fluids, medications, parenteral nutrition, chemotherapy, and blood products.

14G	Orange	In massive trauma situations.
16G	Gray	Trauma, surgeries, or multiple large-volume infusions
18G	Green	Blood transfusion, or large volume infusions.
20G	Pink	Multi-purpose IV; for medications, hydration, and routine therapies.
22G	Blue	Most chemo infusions; patients with small veins; elderly or pediatric patients
24G	Yellow	Very fragile veins; elderly or pediatric patients

Vein Selection

Start with distal veins and work proximally. Start choosing from the lowest veins first then work upward. Starting at the most proximal point can potentially lose several sites you could have below it.

Use a BP cuff rather than a tourniquet. If the patient has low BP, it would be best to use a BP cuff inflated to appropriate pressure to make the veins dilate. This technique can also be useful for older patients and those with veins that are too difficult to access. 

 Apply the tourniquet correctly. The tourniquet should be placed tightly enough to hinder venous flow, but not too tight to impede arterial flow — that way, blood continuously flows into the extremity, but it meets resistance as it tries to leave, thus distending the veins. Apply the tourniquet snugly, about 20 to 25 cm above the needle insertion site. Feel for the radial pulse with the tourniquet in place, if you can’t palpate it, your tourniquet is too tight.

Puncture without a tourniquet. If the patient has adequately filled but fragile veins, proceed with the insertion without using a tourniquet. Pressure from the placement of the tourniquet may cause the client’s delicate vein blow out upon puncture.

COMPLICATIONS OF IV INSERTION OR ADMINISTRATION

Insertion of an IV cannula or administration of IV fluids/medication sometimes comes with complications. This is usually due to choosing an inappropriate cannula size, insertion/administration site or not observing best practices during IV administration. Below are some of the complications that can arise:

1. INFILTRATION: Leaking of non-irritant IV solution into surrounding tissue. It occurs when an IV cannula dislodges or perforates the wall of the vein.

Symptoms: Swelling at insertion site or entire limb, pain, sluggish flow rate, discomfort, blanching of surrounding skin.

Treatment: Stop infusion, discontinue IV cannula, apply sterile dressing, elevate extremity if possible. Start IV infusion in new site or proximal to the infiltration site if the same extremity must be used again.

Prevention: Inspecting infusion site hourly and using the appropriate size of cannula for the vein.

2. EXTRAVASATION: Leakage of irritant solution or medication into surrounding tisue as a result of cannula dislodgement or leakage through brittle veins. Irritant solutions include Vasopressors, K+ and Ca2+ preparations and chemotherapeutic agents.

Symptoms:  Swelling, Blanching, Stretched skin, Necrosis, Blistering and subsequent peeling of skin

Treatment: Stop infusion immediately. Initiate treatment protocol including specific antidotes to the extravasated medication. Thorough neurovascular assessment of the affected extremity.  Do not use affected extremity for further cannula placement.

Prevention:  Avoid inserting IV lines in areas of flexion, secure IV lines, use appropriate sizes of IV cannulas.

3. PHLEBITIS: Inflammation of the vein wall.

Chemical: irritating medication or solution (↑pH), rapid infusion rates. Mechanical: long periods of cannulation, cannulas in flexed areas, gauges larger than vein lumen, poorly secured cannulas. Bacterial: poor hand hygiene, lack of aseptic technique.

Symptoms: Reddened, warm area around insertion site or along the path of the vein, swelling +/- fever.

Treatment: Discontinue the IV line and restart it in another site, consider antibiotic therapy according to the CBC.

Prevention: Aseptic technique, appropriate size cannula,  monitoring site hourly for any complications.

4. THROMBOPHLEBITIS: Presence of a clot plus inflammation in the vein. 

Symptoms: Localized pain, redness, warmth, swelling and immobility of the limb, sluggish flow rate, fever, malaise, and leucocytosis.

Treatment: Discontinue the IV infusion, apply a cold compress to decrease flow of blood, elevate the exteremity, restart the IV line in the opposite extremity.

Prevention: Avoiding trauma to the vein at the time of IV insertion, observing site every hour.

5. HEMATOMA: Results when blood leaks into tissues surrounding the IV insertion site. Due to perforation of the opposite vein wall, needle slipping out of the vein, applying insufficient pressure after removal of the cannula.

Symptoms: Ecchymosis, immediate swelling at the site, leakage of blood at the insertion site.

Treatment: Remove the needle and apply light pressure with a sterile dry dressing, elevate the extremity to maximize venous return, restart the line in the other extremity.

Prevention: Carefully inserting cannula, extra care for patients with bleeding disorders, liver disease or those on anticoagulants.

Equipment for IV cannulation

• Inspect administration set
• Choose the appropriate set: vented or nonvented
• Gather venipuncture and dressing supplies
• Catheter (22 g, 20 g, or 28 g most common)
• Dressing (gauze or TSM)
• Tape: 1-inch paper
• Prepping solution
• sterile Gloves 2×2 gauze

Patient Education

Patient must receive information on all aspects of their care. After catheter is stabilized, dressing is applied, and labeling complete:

• Inform regarding any limitations of movement or mobility
• Explain all alarms if EID is used
• Instruct to call for assistance if venipuncture site becomes tender or sore or if redness or swelling develops
• Advise that site will be checked every shift by the nurse

Documentation

Document the relevant data, including assessments.

• Record the start of the infusion on the client’s chart.
• Include the date and time of the venipuncture
• The gauge and length of the device
• Specific name and location of the accessed vein
• Amount of solution used, including any additives
• Container number
• Flow rate
• Type, length and gauge of the needle or catheter
• Venipuncture site, how many attempts were made and location of each attempt
• The type of dressing applied
• The client’s general response
• Your signature

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