Peripheral Venous Cannulae in Neonates on the Neonatal Unit - Standard Operating Procedure for the Insertion and Maintenance of

Publication: 20/03/2013  
Next review: 01/03/2024  
Standard Operating Procedure
CURRENT 
ID: 3274 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Standard Operating Procedure 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.

Please check the patients allergy status, as they may be allergic to Chlorhexidine, and alternative ( Providine iodine) solution will be required.
Be aware: Chlorhexidine is considered an environmental allergen.
Refer to the asepsis guidance.

Standard Operating Procedure for the Insertion and Maintenance of Peripheral Venous Cannulae in Neonates on the Neonatal Unit

Introduction

Peripheral cannulation is a common invasive procedure carried out within the Neonatal Unit. It is the preferred method of vascular access in most non-emergent situations. Peripheral venous access is indicated for the administration of fluids and medication.

Vascular catheter related infection is an important cause of mortality and morbidity in hospitalised patients. The most common responsible organisms are Staphylococcus aureus  and Staphylococcus epidermis. Most catheter related infections occur shortly after insertion. The strict application of appropriate aseptic techniques and subsequent care of the catheter are the most important factors in the reduction in the incidence of sepsis.

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Indications for peripheral venous cannulae

  • To maintain fluid/electrolyte balance in infants unable to take enteral fluids
  • To achieve predictable drug levels e.g. antibiotics for infection
  • Emergency situations
  • Prior to a surgical procedure
  • For infants whose gastrointestinal tract has to be rested e.g. patients with non-functioning or inadequately functioning gastrointestinal tracts, or following gastrointestinal surgery
  • When the medicine is not broken down in, or not absorbed from the gastrointestinal tract
  • When an injection is required but injection into the skin or muscle would cause pain or trauma
  • When the medicine is not available in alternative formulation

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Preparation

  • Patient identification: Practitioners must identify that they have the correct patient in accordance with LTHT Policy for Positive Patient Identification and they should try to obtain verbal consent prior to undertaking the procedure from the infant’s carers.
  • Infection Prevention and Control
    • Insertion should take place in an appropriate clinical area.
    • Strict hand hygiene must be followed (LTHT Hand Hygiene in Practice Policy).
    • An aseptic technique must be used (LTHT Asepsis Policy). 
    • All cannulation equipment must be sterile prior to use and sterile examination gloves and an IV cannulation pack must be used to undertake the procedure.

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Competence
Cannulation should only be performed by a practitioner who has the relevant knowledge and skills to do so .

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Attempts
An insertion attempt is defined as one needle puncture of the skin. Peripheral venous cannula attempts must be limited to two attempts (two needle punctures) by each health care professional. If a baby is deemed to have difficult venous access, the first attempt should be made by an experienced operator. For each separate attempt, the skin must be cleaned again with fresh ChloraPrep® and a new cannulation pack and new cannula used.

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Equipment
Metal trolleys should be used, and must be decontaminated with Sani-cloth before use (see Trust IPC asepsis video http://lthweb.leedsth.nhs.uk/content/aseptic/v6/ch3.php ). The operator and/or assistant should prepare all necessary equipment on the clean trolley. Once the operator is sterile, if further equipment is required, the observer must fetch and open packs.

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Site Selection
The preferred sites for neonatal cannulation are

  • The dorsum of the hand
  • The dorsum of the foot
  • The cephalic vein on the radial border of the wrist

Cannulation should be avoided on bruised, painful or infected sites.

Peripheral venous cannulation should not be attempted in the areas preferred for peripherally inserted central venous catheters (Long lines) i.e. antecubital fossa and medial aspect of the ankle and lower leg.

Pain Management
Intravenous cannulation is a painful procedure for the Neonate. The procedure should be carried out in a developmentally supportive manner.

  • Swaddling (providing containment and support)
  • Provide neutral thermal environment and prevent cold stress
  • Administer sucrose in accordance with the Neonatal Pain Management guideline Procedural Pain in the Newborn

Skin preparation
The site should be cleaned with 2% chlorhexidine/70% alcohol (ChloraPrep® and allowed to air dry for 30 seconds. In babies under 30 weeks gestation, use a dabbing rather than rubbing motion to maintain skin integrity. In babies < 28 weeks gestation and < 1 week old, clean skin again with sterile 0.9% sodium chloride, to minimise risk of skin burns due to pooling.

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Line insertion
Refer to the neonatal procedures handbook for insertion technique. Handling of the cannula should be kept to the minimum.

Blood samples may be taken immediately from the line according to the SOP for neonatal blood cultures Blood Culture Sampling in Neonates

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Dressing
The entry site is an open wound. In order to prevent migration and infection of the cannula it should be dressed appropriately with a transparent semi-permeable dressing this will prevent bacterial access while still allowing visual inspection. The device should be secured with steri strips and dressed in a manner that should not impair the visual assessment of the insertion site or obstruct delivery of the prescribed  therapy.

An insertion date label should be applied to the dressing.

A cannula dressing which becomes loose, or where moisture is seen beneath the dressing must be replaced. Following removal of the dressing the cannula site should be cleaned with 2% Chlorhexidine in 70% alcohol and allowed to dry for 30 seconds.  The dressing should be changed using an aseptic non touch technique.

Bandages are not recommended for the additional securing of the peripheral cannula as they make observation of the insertion site difficult. Single use splints may be used.

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Flushing
Cannulae should be flushed with 1-2mL of 0.9% Sodium Chloride for injection in a 2ml syringe. All flushing solutions should be prescribed and recorded once administered.

Cannulae should be flushed using a pulsatile ‘push-pause’ technique.  This creates turbulence, removing debris from the internal wall ensuring clearance of drugs.

If resistance is met when attempting to flush a cannula excessive pressure should not be exerted. This may damage the vein or expel thrombus from the cannula.

Cannula should be flushed (using appropriate flush as per IV drug monographs guidelines):-

  • Following device placement
  • To check patency
  • Before drug/solution administration
  • Before connection of infusions
  • Between multiple drug administration
  • Following drug/solution administration
  • Following sampling (blood samples can only be taken from peripheral cannulae immediately following insertion and before they have been flushed).

Documentation
All attempts at cannulation (successful and unsuccessful) should be documented using the Infection prevention booklet (IPC). The following information must be recorded as a minimum standard

  • Date and time
  • Site of cannula (successful and unsuccessful)
  • Reason for insertion
  • Operators name and signature

The cannulation record should be placed in nursing kardex. IPC booklet in orange folder.

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Maintenance
All infants with a cannula must have the site checked at least twice daily for signs of phlebitis. The Visual Infusion Phlebitis VIP score (appendix 1) must be documented on the LTHT insertion and ongoing care record (see appendix 3).

If there is any redness, tenderness or swelling around the insertion site action should be taken. Refer to VIP score.

Cannula sites should also be observed:

  • Hourly when IV fluids are infusing
  • When bolus injections are administered
  • When IV flow rates are checked or altered
  • When solution containers are changed
  • When vesicant or irritant medication is administered

For recommendations on management of VIP score see appendix 2.

The continuing need for IV access must be considered daily and documented in the patient’s notes. A cannula that is no longer required should be removed immediately.
If a patient’s cannula site has a phlebitis score of 2 or more, the cannula should be removed immediately and replaced if venous access is still required at another distant site.

Cannula removal

  • Maintain asepsis and universal precautions throughout procedure
  • Stop the infusion and disconnect tubing ensuring device is clamped
  • Release the transparent dressing from the skin.
  • Withdraw the catheter outside the vein and apply pressure using gauze for at least 5 minutes. Observe site for bleeding. Do not apply dressing.
  • Inspect the catheter for fragmentation.
  • Document removal on the Paediatric and Neonatal Cannulation documentation record including the following information
    • Date and time of removal
    • Reason for removal

Management of complications

Complication

Recommendation

Puncturing Artery

Remove device immediately

Apply pressure until bleeding stops

Document in patient’s notes

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

Risk  reduced by:

  • Good cannulation skill
  • Monitoring of site
  • Location of device
  • Sequencing of drugs administered

If extravasation does occur follow the Management of Extravasation: Treatment summary

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

Apply pressure until bleeding stops
If  appropriate, elevate the limb
Document in the patients notes
Seek surgical advice very large or tissue compromised

Local site Infection

Infection at or near cannula insertion site.

See VIP score

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 as per LTHT microbiology guidelines

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Provenance

Record: 3274
Objective:

Aims

To promote and standardise best practice in the insertion, ongoing care and removal of peripheral venous cannulae on the neonatal unit.

Objectives

  • To standardise evidence based clinical practice and ensure the incidence of peripheral venous cannula-related complications are kept to a minimum.
  • All clinical professionals responsible for the insertion of the cannula, have undertaken theoretical education, a period of supervised practice and understand the significance of the associated complications in technique and ongoing care.
  • To ensure that all clinical professionals understand their roles and responsibilities associated with cannula insertion, ongoing care and removal.
  • To ensure all clinical professionals know how to prevent associated complications of peripheral cannulation.
  • To ensure that cannula insertion, ongoing care and removal is clearly documented using the Paediatric and Neonatal Cannulation documentation record (Appendix)
Clinical condition:

Neonates requiring cannulation

Target patient group: Newborn infants
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

  1. Campbell H & Carrington M. (1999) peripheral Intravenous Cannulation Dressings-Advantages and disadvantages. British Journal of Nursing vol. 8, part 21: pp1420-1427  
  2. Castledine, G (1996) Nurses Roles in Peripheral Venous Cannulation. British Journal of Nursing. vol. 5, part 20: pp1274.
  3. Davies, S. (1998) ‘The Role of Nurses in Intravenous Cannulation.’ Nursing Standard. Vol. 12, part 17. pp43-46
  4. Department of Health. Reference Guide to Consent for Examination or Treatment.
  5. Department of Health, the Essence of Care (2001)
  6. Department of Health. '12 key points on consent: the law in England' (2001)
  7. Going Further Faster: implementing saving lives delivery programme. (DH2006)
  8. Department of Health. (2000) Developing Key Roles for Nurses and Midwives – A Guide for Managers, London: DOH.
  9. Department of Health (2001) ‘Standard principles for preventing hospital acquired infections.’ Journal of Hospital Acquired Infection   vol. 47: ppS47-S67.
  10. Department of Health (2001) ‘Standard principles for preventing hospital acquired infections.’ Journal of Hospital Acquired Infection   vol. 47: ppS47- S67.
  11. Dougherty L (1996) ‘Intravenous Cannulation.’ Nursing Standard vol.11, part 2: pp47-51
  12. Dougherty, L. (1999) Intravenous Therapy in nursing practice Edinburgh: Churchill: Livingstone.
  13. Dougherty, L & Lamb, J. (1999) Intravenous Therapy in Nursing Practice. Edinburgh: Churchill Livingstone.
  14. Dougherty, L. (2000) ‘Care of a peripheral Intravenous cannula.’ Nursing Times. Vol. 96, part 2: pp675-678.
  15. Finlay, T. (2004) Intravenous Therapy. Oxford: Blackwell publishers.
  16. Fox N (2000) Managing the Risk Posed by Intravenous Therapy.  Nursing Times vol. 96, part 30: pp66-70.
  17. Fuller, A & Winn, C. (1998) ‘The Management of Peripheral IV Lines.’ Professional Nurse, vol. 13, part 10: pp675-678.     
  18. Gabriel, J. (2004) ‘Needlestick and Sharps Injuries: Avoiding the Risk in Clinical Practice.’ Professional nurse, vol. 20 part 1: pp25-28.
  19. Gabriel, J, Bravery, K, Dougherty, L, Kayley, J, Malster, M & Scales, K. (2005) ‘Vascular Access: Indications and Implications for Patient Care.’ Nursing Standard, Vol. 19 part 26: pp45-52
  20. Gupta, P, Ruchi, R, Basu, S & Fandi, M. (2003) Life Span of Peripheral Venous Cannulas in a Neonatal Intensive Care Unit of a Developing Country. Journal of Paediatric Nursing.  Vol. 18, part 4: pp287-292.
  21. High impact intervention No b: peripheral line care in saving lives. (2007)
  22. Jackson, A. (1998) ‘A Battle in Vein: Infusion Phlebitis.’ Nursing Times, vol. 94, part 4: pp68-71.
  23. Manual of Clinical Nursing Procedures – Royal Marsden Hospital 7th Edition (2008)
  24. Millam D.A. and Hadaway L.C. 2003. On the road to successful I.V. starts.
  25. Nursing: May, Supplement.Vol 33 No 5, Pages 1 – 14
  26. Mitchie, MM (1996) A Delicate concern-Caring For Neonatal Skin.   
  27. British Journal of Midwifery. Vol. 4, part 3: pp159-163.  
  28. NMC Standards for Medicines Management (2008)
  29. National Health Service Management Executive. (1991) Junior Doctors –The New Deal. London: NHSME.
  30. Nursing & Midwifery Council (2002) Code of Professional Conduct. London: NMC.   
  31. Royal College of Nursing. (2003) Standards for Infusion Therapy. London:   RCN
  32. RCN Standards for Infusion Therapy (2010)
  33. RCN competences: An education and training competence framework for peripheral venous cannulation in children and young people (2010)
  34. The EPIC Project. epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospital in England; The Journal of Hospital Infection Volume 63, supplement 1, Feb 2007, Elselvier.
  35. United Kingdom Central Council. (1992) The Scope of Professional Practice. London: UKCC.
  36. Workman, B. (1999) ‘Peripheral Intravenous Therapy Management’. Nursing Standard  vol. 14, part 4: pp53-60

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Appendix 1

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