How can you verify that you have successfully entered the vein with the IV cannula?
Consider this in the IV cannulation procedure Show When the best vein available is identified and right size of catheter is chosen, the next step is insertion. First-stick success is always the goal. Any additional attempt of insertion increases pain and stress for the patient, adds workload to the caregiver and costs to the healthcare system. Consider using a heating pad, with caution, to increase venous distension and make the veins more visible and accessible. It is very important to observe the flashback of blood to know when the needle is in the vein. Flashback will be visible in the chamber connected to the needle as soon as the needle is in the vein. Always continue and insert an additional 1-2 millimetres to let the catheter, not only the needle tip, reach the inner lumen of the vein. Continue to insert only the catheter and carefully withdraw the needle at the same time. You will now see blood between the catheter and needle, the second flashback, which confirms that also the catheter is in the blood vessel. When working with small babies, neonates or patients with small and fragile veins, it’s important to have an instant blood response. For this reason, with our smaller sizes (24 and 26 G) the needle is notched in a very precise way and place to facilitate blood flashback. This speeds up visual feedback, because blood immediately appears between the catheter and the needle in front of the wing housing. As soon as the needle
is out, you immediately need to close off the luer end of the IV catheter, either with the white cap that comes with the product, or with an extension line or needle free connector of your choice. Before any infusion or injection, it’s always important to confirm correct placement of the IV catheter and good flow. Flush the catheter with saline and ask the patient if he or she feels the cold coming up the vein. If it’s not a communicative patient, place your fingertips of your non-dominant hand (the one not holding the syringe) at the level of the catheter tip and feel the cold yourself. Also look for any swelling in the tissue. After placing an IV catheter Always flush the IV catheter with saline after each usage, to prevent from clotting of blood and be able to use the catheter as long as possible. Attaching an extension line is a common recommendation in guidelines. The extension line could possibly increase the indwell time of the IV catheter as it enables the medical staff to operate away from the catheter, minimising the risk of contamination and movements. Avoid complications, follow our step-by-step guides: How to place an IV
catheter: CLiP Winged See also Procedural pain management guideline Key points
BackgroundMultiple attempts at IV insertion can cause significant distress for patients so alternatives to IV access should always be considered within the clinical context e.g. Oral or NG fluids/medication, IM or IO medications in emergencies. Cannulas inserted over joints, in areas of flexion or in the lower limb are more likely to fail than those inserted in the hand or forearm Selection of Intravenous (IV) accessThe following guidelines should be considered when referring patient for IV access
If available, ultrasound guidance should be considered if intravenous cannulation is predicted to be difficult or prolonged therapy is anticipated (see table below) Potential Complications
Equipment, Analgesia, Anaesthesia and Sedation
ProcedureExplain the procedure to the child and parents and obtain verbal consent. Sites
Transillumination
Ultrasound guided approach
Assess difficulty of intravenous cannulation
Score of 4 or more means >50% chance of failed initial attempt If difficult intravenous cannulation is predicted based on the above criteria, ultrasound guided insertion should be considered if the equipment and expertise is available. Some children are at higher risk of decompensation with multiple IV attempts, eg congenital heart disease with single ventricle physiology. If >2 attempts are required involve the senior clinician and consult the treating cardiology team. TechniqueHolding
Inserting the cannula
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Figure 3: passive blood collection for infants | Figure 4: aspirating blood for culture or gas |
Securement
- Remove tourniquet before strapping
- Connect the saline-primed 3-way connector to the end of the cannula by screwing it firmly on. Flush the connector tubing with more saline to confirm intravenous placement
- Use sterile tapes to secure the hub and a clear dressing over the cannula site such as Tegaderm™. Ensure that the proximal tip and area of skin around are always easily visible (Figure 5 below). Extravasation injuries can occur especially if the site is not readily accessible for regular nursing checks
- Consider placing a small piece of cotton wool ball or gauze underneath the hub of the cannula to prevent pressure areas
- Tapes and splint should secure the limb proximal and distal to the cannula (keeping thumb free) but not too tightly (Figure 6 below)
- Arm splints are not required for lines placed in the cephalic vein in the forearm (typically ultrasound guided). Cover the whole distal extremity in net bandage (eg surgifix tubular-fast). In very young children, consider bandaging the other hand as well to prevent them from removing the cannula
Post-Procedure Care
- Running a 'drug line' (3-5ml/hr of Sodium Chloride 0.9%) through the cannula may keep it patent for a longer period of time
- Regularly inspect insertion site for complications (tenderness, blockage, inflammation, discharge) - check the other hand if it has also been bandaged
- Unless complications develop, the peripheral IV should remain insitu until IV treatment complete
Difficulty with IV insertion
Each clinician should have a maximum of 2 attempts before escalating.
Strongly consider ultrasound assistance, if available, after 3-4 attempts
*Experienced Clinician – at least 2 years of acute paediatric experience
For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services
See video
RCH specific information
For assistance with difficult intravenous access
- 0730 - 1730 (Mon – Fri): Anaesthetics ASCOM 52000
- After hours / public holidays: PICU ASCOM 52327
Last updated September, 2019