Peripheral Venous Cannula (PVC, Insertion and Management of in Adults and Children)

Publication: 30/03/2011  --
Last review: 17/10/2018  
Next review: 17/10/2021  
Clinical Guideline
CURRENT 
ID: 1778 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Peripheral Venous Cannula (PVC, Insertion and Management of in Adults and Children)

 

Summary of Guideline
Definitions
Background
Insertion- Considerations prior to PVC insertion
Guide to PVC selection
Training requirements

Appendix 1: Insertion of PVC
Appendix 2: Care and management of PVC
Appendix 3: Removal of PVC
Appendix 4: Visual Infusion Phlebitis Score for Adults and Children
Appendix 5: PVC Documentation
Appendix 6: Complications and Recommendations

Summary of Guideline

These guidelines set out the principles of care required to reduce the risk of infection and other complications when delivering intravenous therapy via a peripheral venous cannula.

Only staff that has received appropriate training can carry out this clinical procedure in LTHT.  Staff are personally responsible to ensure that they have the required knowledge and skill to undertake procedures that require asepsis if their role profile requires this.

Latest evidence recommends a PVC no longer requires routine change at 72 hours, rather a PVC can remain for as long as clinically indicated and where the VIP score is 1 or below (EPIC3, 2014)

PVC inserted by Yorkshire Ambulance Service can remain insitu provided the VIP remains 1 or below and they do not have the yellow label to signify the insert was not under optimal conditions.

Back to top

Definitions

Phlebitis: the inflammation of a vein.

Bacteraemia: is the presence of bacteria in the blood and is associated with increased morbidity and mortality.

Extravasation : the leakage of intravenous drugs from the vein into the surrounding tissue.

Extravasation Injury: damage caused by leakage of solutions from the vein to the surrounding tissue spaces during intravenous administration.

Vesicant drug: vesicant drugs or solutions can cause severe tissue injury or destruction when they extravasate. Possible consequences include necrotic ulcers, infection, disfigurement, reflex sympathetic dystrophy syndrome, and loss of function.

Venous Access Devices: devices such as Hickman line, Peripherally Inserted Central Catheter and Central Venous Catheter. The tip of these devices generally sits in the lower 3rd of the superior vena cava.

Back to top

Background

Peripheral venous catheters (PVC) are now an essential part of medical care and their management has an important effect on the incidence of catheter associated infections.

Although the incidence of local blood stream infections associated with PVC is low, serious complications can occur because of the frequency in which the PVC is used ( Wilson 2006). Through the application of best practice, complications and infections can be reduced. Safety cannulae have been introduced following a European directive to promote sharp safety awareness and practice.

To minimise the risk to the patient: use the correct size PVC for the fluid which has to be infused. Using the smallest size PVC possible, will adequately deliver the required fluid, allow a higher blood flow around the cannula (Doughter & Lister 2008). This should improve haemodilution, and lower risk of clots developing. This also reduces the effects of irritant solutions on the inside of the vein, the degree of mechanical irritation and insertion trauma.

Back to top

Insertion- Considerations  prior to PVC insertion

Back to top

Guide to PVC selection

Cannula gauge size and colour

Length (mm)

Applicable use

Suitable anatomical location for insertion

14G Orange

42

For rapid transfusion o, blood components or viscous fluids

Often used in Theatres or emergency interventions

Antecubital fossa
Median cephalic (radial side)
Median basilic (ulnar side)
Median cubital (in front of elbow joint)

16G Grey

42

For rapid transfusion of blood components or viscous fluids

Often used in Theatres or emergency interventions

Antecubital fossa
Median cephalic (radial side)
Median basilic (ulnar side)
Median cubital (in front of elbow joint)

18G Green

40

For infusing blood components quickly

Parenteral nutrition

Stem cell harvesting & cell separation

Large volumes of fluids

Median cubital (radial aspect of forearm)
Median basilic (ulnar aspect of forearm)
Median antebrachial

20G Pink

32

For routine infusion therapies & infusing blood components or large volumes of fluids

Patients on long term medication

Patients receiving up to 2-3 litres of fluid per day

Accessory cephalic (branches off the cephalic vein along the ulnar bone)

Basilic (ulnar aspect of lower arm along ulnar bone)

Metacarpal (on dorsum of hand)

22G Blue

25

Appropriate for most infusion therapies

Standard for paediatrics

For infusing blood components

Patients with fragile small veins

Oncology patients undergoing chemotherapy

Accessory cephalic (branches off the cephalic vein along the ulnar bone)

Basilic (ulnar aspect of lower arm along ulnar bone)

Metacarpal (on dorsum of hand)

24G Yellow

18

For elderly, paediatric and neonatal patients

Oncology patients undergoing chemotherapy

Medications, short tem infusions

Patients with fragile veins

Metacarpal (on dorsum of hand)

Accessory cephalic (branches off the cephalic vein along the ulnar bone)

Basilic (ulnar aspect of lower arm along ulnar bone)

Digital veins (along lateral-distal portion of fingers)

Cephalic  (radial aspect of lower arm along radius bone of forearm

Consider:

  • The purpose of the infusion.
  • What is being infused/ given?
  • The size and condition of the patients veins.
  • The required flow rate for the intended therapy.
  • Would a Central Venous Access Device  (CVAD) be more appropriate?

Complications of PVC usage:

  • Phlebitis
  • Infitration
  • Extravasation
  • Blood stream Infection
  • Local infection ( entry site)
  • Thrombosis
  • Haematoma
  • Cannulation of Artery

Back to top

Insertion of PVC -Appendix 1

Check patients allergy status prior to insertion of PVC. If Patient  has an allergy to Chlorhexidine , use alternative solution

Avoid (if possible) the antecubital fossa site as these veins can increase the possibility of dislodgement, infiltration, extravasation or mechanical phlebitis, accidental arterial cannulation and puncture of arteries.

It is recommended that only two attempts to cannulate a patient by any one practitioner be made. If unsuccessful, contact a more experienced practitioner for advice. Please consider alternative access such as a CVAD.

ON-GOING CARE AND MANAGEMENT -Appendix 2

REMOVAL OF PVC- Appendix 3

Visual Infusion Score-Appendix 4

Documentation- Appendix 5

Trouble shooting- Appendix 6

Back to top

Training requirements

Cannulation should only be performed by a practitioner who has the relevant knowledge and skills to do so. They must be aware of and follow LTHT guidelines. 

Cannulation must not be undertaken by practitioners who have not satisfied the following requirements unless they are in training and under the supervision of a suitably qualified mentor:

  • Non registered and registered practitioners need to complete the LTHT Cannulation Theory Practice training programme.
  • Medical practitioners should obtain competency in the skill of peripheral venous cannulation through their own education and training curriculum.
  • Whilst all Health Care Professionals (HCPs) are accountable for their own practice and therefore their competence, any HCP who has not undertaken IV Cannulation in the last 6 months should establish their competence by being observed by a competent practitioner.
  • All practitioners are required to complete an asepsis assessment as described in the LTHT asepsis policy. This assessment can be achieved by demonstrating IV cannulation using an aseptic technique, or by demonstrating another aseptic procedure (LTHT Asepsis Policy).
  • Non medical staff who cannulate should discuss the skill during their annual appraisal.

Back to top

Related information

Appendix 1: Insertion of PVC 

Equipment:

  • Clean Trolley
  • Apron
  • IV cannulation pack
  • Appropriate size PVC
  • 10ml syringe and drawing up needle ( unless have prefilled syringe)
  • 10mls of Sodium Chloride 0.9%
  • Needle free device

Procedure:

  • Introduce self and correctly identify patient prior to gathering equipment. Gain patient’s consent by informing patient of the procedure and rationale. If patient appears agitated, seek assistance.
  • Clean hands as per LTHT Hand Hygiene in practice  policy
  • Clean Trolley from top to bottom, with Sani-Cloth detergent wipes and allow trolley to dry.
  • Ensure all equipment is gathered, ensuring equipment is intact and within expiry date and place on bottom shelf of trolley
  • Take trolley to the patient ensuring there is enough space to undertake procedure.
  • Assist patient into a comfortable position whilst maintaining their dignity.
  • Apply disposable tourniquet, and select vein for puncture.
  • Once vein selected, loosen tourniquet while preparing equipment
  • Clean hands as per LTHT Hand Hygiene in practice  policy
  • Open cannulation pack ensuring that only the corners of the paper are touched.
  • Open other supplementary packs, including the cannula, 10ml syringe, drawing up needle, needle free device, and tip contents gently onto the centre of the sterile field. Place sterile towel under patient’s arm, careful to touch the corner of the towel only.
  • If an assistant is not available, the ampoule of 0.9% sodium chloride should be checked with a second person (expiry date and solution) and opened. It should then be placed on the top of trolley, outside of outside of the sterile field.
  • Carefully remove waste bag from pack and place on the side of the dressing trolley, below the level of the sterile field.
  • Open the sterile gloves near to the edge of the sterile field. 
  • Re-apply tourniquet if being used.
  • Put on the sterile gloves, taking care not to contaminate any sterile area.
  • Decontaminate the patient’s skin using the SEPP device from pack (containing 2% chlorhexidine in 70% alcohol or equilevant solution if patient is allergic to Chloehexidine), using a cross-hatch technique for 30 seconds, and then allow to dry for 30 seconds.  Be careful not to contaminate sterile gloves.
  • If an assistant is not available, the previously opened saline ampoule should be drawn up using a sterile needle and syringe without contaminating gloves.
  • If a second person is assisting with the cannulation procedure, they can hold the sodium chloride flush solution whilst the expiry date is checked, and the saline is drawn up.
  • Prime the needle free device and leave syringe attached
  • Place the sterile towel under the patient’s arm.
  • Insert the cannula using the appropriate technique. Once flash back is seen loosen tourniquet with non-dominant hand.
  • Attach the needle free device using an aseptic non touch technique (ANTT). 
  • Apply the semi-permeable transparent dressing from the cannulation pack.  Ensure insertion site is not obscured and that cannula and needle free device is secure.
  • Flush the needle free device with the prepared saline solution, using ANTT.
  • Dispose of sharps in point of use sharps bin and remove sterile towel and place  clinical waste into yellow/orange clinical waste bin.
  • Take off apron and then gloves, and decontaminate hands as per LTHT Hand Hygiene in Practice Policy
  • Complete and date label and apply to the dressing, ensuring the cannula and insertion site are not obscured.
  • Complete cannula Insertion record and place in appropriate patient records.
  • Clean the trolley with a Sani-Cloth detergent wipes

NB- If patient is anxious about cannulation consider use of topical anaesthesia.

Summary of special considerations for paediatric patients

For this patient group further clinical guidance is required.

There may be clinical circumstances where minimal shaving may be required in the neonatal and paediatric patient to safely secure a scalp vein cannula.

Tourniquets may not be required and the limb should be gently supported and squeezed by a healthcare worker.

It is recommended that topical anaesthetic is used especially for paediatric patients. If used these must be prescribed or used under a Patient Group Directive (PGD)

Bandages should be used with extreme care in  young children. Circumferential adhesive dressings around a limb must never be used as they may cause limb ischemia

Smaller volumes of flushing solution may be required in paediatrics or patients with fluid restrictions.

Back to top

Appendix 2: Care and management of PVC

  • PVC should be reviewed daily and if not accessed within the prior 48 hours, should be removed immediately.
  • An aseptic non touch technique (ANTT) should always be maintained whilst dealing with PVC
  • Hands must be decontaminated prior to and after accessing PVC
  • Personal Protective Equipment should be used when dealing with PVC
  • Needle free access device should be either single or double extensions depending on clinical indications.
  • A guide to when the  IV administration sets should be changed as follows:

Clear fluids

96hours

Lipids

24hrs

Blood products

After 2nd unit, after transfusion episode or 12hrs whichever is occurs first (EPIC3 2013.  Marsden Manual 2008).

Intermittent infusion

Administration sets to be discarded after each use.

  •  
    • PVC site must be visible in order to ascertain Visual Infusion Phlebitis score (VIP).
    • PVC site should be inspected at least daily, and every time the PVC is accessed, or infusion rates are altered. The observation should be documented daily on appropriate document (RCN 2005, DoH 2007).
    • If the VIP is greater or equal to 2 the PVC should be removed. If the site appears infected, a swab should be taken and a datix form completed.
    • If bandages are used as extra support to secure PVC, they should be removed at least daily and every time the PVC is accessed or infusion rates are altered in order to inspect the insertion site.
    • Injection ports/hubs- Scrub the hub with 2% Chlorhexidine in 70% Isopropyl alcohol wipe, or alternative if patient is allergic to Chlorhexidine for 15 secs before and after accessing the system.
    • The PVC should be flushed pre and post drug administration with 5-10mls of Sodium Chloride (0.9%) in a 10ml syringe.
    • All IV bolus including flushes should be labelled in accordance with Leeds Teaching Hospitals injectable Medicines Code.
    • The dressing should be changed immediately when it becomes loose, damp or soiled. An aseptic non-touch technique should be used when changing the dressing. The area should be cleaned with 2% chlorhexidine in 70% Isopropyl alcohol, moving from the catheter site outwards, providing it is compatible with the device (For children under 3 months use Alcohol /Sterile Sodium Chloride 0.9%). The area should be allowed to dry and a sterile peripheral dressing applied (use alternative if patient has a history of chlorhexidine sensitivity) (EPIC 3 2014).
    • A PVC should not be used for routine blood sampling. However, it is recognised  there may be situations ( paediatrics, patient resuscitation) where it may be necessary, it is recommended blood should only be drawn once immediately following insertion. Slowly draw blood, as excess force may haemolyse the sample and cause thrombophlebitis of the vein. (Dougherty& Lamb 2008, RCN 2005).
    •  
      1. No longer required.
      2. Patient has pain when fluids are infused or on flushing
      3. Signs of phlebitis, infection or thrombophlebitis, VIP score of 2 or greater.
      4. PVC should be re- sited immediately if complications occur.
    •  
      • Removal of the intravenous cannula should be an aseptic procedure
      • Explain procedure to the patient and gain consent
      • Decontaminate hands as per LTHT Hand Hygiene in Practice Policy.
      • Apply clean examination gloves and disposable apron.
      • Remove dressing.
      • Gently withdraw cannula using a slow, steady movement and keeping hub parallel with skin.
      • Check integrity of cannula before disposing into sharps bin.
      • Apply pressure for 2-3 minutes with gauze.
      • When bleeding has stopped apply gauze dressing or plaster.
      • Document the date and time of removal in the patients notes including the name of the person removing the device.
      • If there is a suspicion of an infected insertion site (VIP score of 2 or more), Practitioners should ensure that this is accurately documented in the patient’s notes and any treatment and advice acted upon. Please complete Datix form.
      • Cannula removal must be documented on the patient’s LTHT cannula documentation.

      Complication

      Recommendation

      Puncturing Artery 
      When the needle has entered an artery rather than a vein.

      Release tourniquet
      Remove device immediately
      Apply pressure until bleeding stops
      Explain what has happened to the patient
      Document in patient’s notes
      Do not reapply a tourniquet to the limb
      Seek urgent medical help if bleeding persists; large hematoma develops or signs of limb ischemia.
      Vascular surgery if bleeding persists

      Extravasation 
      The leakage of intravenous drugs from the vein into the surrounding tissue

      The risk of Extravasation can be reduced by:
      Good cannulation skill
      Location of device
      Sequencing of drugs administered
      Monitoring of site
      If Extravasation does occur follow the Management of Extravasation: Treatment summary

      Extravasation Injury 
      Damage caused by leakage of solutions from the vein to the surrounding tissue spaces during intravenous administration

      The risk of extravasation injury can be prevented (see above).
      Subsequent management depends on the drug involved and the degree of damage. Refer to local extravasation guidelines if available and/or seek medical/pharmacy advice.  Further information can be found:
      Management of Extravasation: treatment summary
      The National Extravastion Information Service
      Adult Chemotherapy Extravasation Policy.

      Haematoma 
      When blood has leaked from a vein/artery into the surrounding tissue.

      Apply pressure until bleeding stops
      Give the patient an explanation
      If appropriate, elevate the limb
      Apply a suitable topical cream with pressure dressing
      Do not reapply tourniquet to affected limb
      Document in the patients notes
      Seek surgical advise if haematoma is large or if tissue is compromised advice

      Vasovagal Reaction 
      Syncope or fainting.
      When a patient experiences dizziness and can lose consciousness.

      Call for assistance
      If conscious and feeling faint, ask the patient to put their head between their legs or
      Lie the patient down, elevate legs or place in recovery position. Maintain airway, consider oxygen therapy Document in the patients notes

      Local site Infection 
      Infection at or near cannula insertion site.

      See VIP score (Appendix 4)

      Peripheral Venous Cannula Associated Bacteraemia 
      An infection of the blood stream (bacteraemia) caused by a cannula. May develop following a local site infection.

      Remove cannula if still insitu
      Treat Patients infection as per LTHT microbiology guidelines

  • Back to top

    Appendix  3:  Removal of PVC

    Ongoing Care Action/Hand Hygiene.

    • Decontaminate hands before and after each patient contact.
    • Use the correct hand hygiene procedures.

    Personal Protective Equipment

    • Wear personal protective equipment when indicated in accordance with local policy.
      Gloves and apron should not compromise hand hygiene

    Continuing Clinical Indication.

    • All intravenous cannulae and associated devices are clinically indicated.
    • If there is no indication for the cannula it should be removed. 
    • Vascular access devices to be removed if there are any signs of phlebitis or infection
    • Indication of ongoing need for device should be documented at least daily.

    Site Inspection.

    • The insertion site should be visibly inspected on accessing the device and the visual infusion phlebitis score recorded (VIP) daily at a minimum.

    Dressing.

    • An intact, dry, adherent, transparent dressing should cover the cannula site. 
    • Sterile transparent dressing should be changed at a minimum every 7 days or sooner if the integrity of the dressing is compromised. 
    • Dressing must be changed using an aseptic technique
    • Cleaning of the access site should be carried out with 2% chlorohexidine gluconate  in 70% isopropyl alcohol solution  and allowed to air dry. (If the patient has a sensitivity povidine- iodine in 70% alcohol application is used) 

    Catheter Injection Ports

    • Injection ports should be covered by smart sites or caps.

    Cannula Access.

    • Use aseptic non touch technique. 
    • Decontaminate needle free device with 2% chlorhexidine in 70% isopropyl alcohol for 15 seconds and allow to dry before and after accessing the cannula for the administration of fluids or drugs  

    Administration Set Replacement.

    • Immediately after blood or blood products.
    • Lipids at 24 hours  
    • All other fluid sets at 96hrs.  
    • Smart sites to be changed every 7 days or after 200 uses.
    • Giving sets are labelled with the date and time to ensure they are changed at correct intervals

    Routine Cannula Replacement.

    • Routine replacement is not indicated in neonates paediatrics.
    • Replace site when clinically indicated.
    • If venous access is limited, the cannula can remain in situ if there are no signs of infection.

    Remove PVC if;

    Removal:

    Back to top

    Appendix  4: Visual Infusion Phlebitis Score for Adults and Children

    All patients with a peripheral vascular catheter (PVC) device should have the IV site checked every time it is accessed for signs of infusion phlebitis.

    Back to top

    Appendix 5:  PVC  Documentation

     

     

    Back to top

    Appendix 6:  Complications and Recommendations

Provenance

Record: 1778
Objective:

Aims
To provide a framework for the insertion, management and safe removal of Peripheral Venous Cannula (PVC) in line with best practice, in order to reduce the risk of infection and other complications to our patients.

Objectives

  • To standardise clinical practice for the insertion, daily management and removal of a PVC.
  • To prevent infection.
  • To ensure it is the right device, for the right patient, at the right time.
  • To maintain a closed intravenous system.
  • For staff to understand the risk associated with the on-going care of the PVC.
  • To provide the knowledge and skills in preventing associated complications.
  • To maintain a patent device.
Clinical condition:
Target patient group: All requiring a PVC
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Allied Health Professionals
Adapted from:

Evidence base

Dougherty L, Lamb J (Eds.) (2008): 2nd Edition: INTRAVENOUS THERAPY IN NURSING PRACTICE: Blackwell Publishing, Oxford.

Dougherty L, Lister S (Eds) (2011): 8th Edition: THE ROYAL MARSDEN HOSPITAL MANUAL OF CLINICAL NURSING PROCEDURES: Blackwell Publishing, Oxford

EPIC 3 (2013): National Evidence- Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. JOURNAL OF HOSPITAL INFECTION

General Medical Council (2006). Good medical practice. www.gmc-uk.org/guidance/good_medical.../index.asp

Infection Control Nurses Association (2001): Guidelines for Preventing Intravascular Catheter related infections. London:ICNA/3M

Infusion Nurses Society (2000):Standards for Infusion Therapy. Infusion Nurses Society

Nursing and Midwifery Council (2009): Standards for medicine management. Nursing and Midwifery Council. London.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.