Peripheral venous cannulation of children

This guideline provides guidance on peripheral venous cannulation of children at Great Ormond Street Hospital (GOSH).

NOTE: We review our guidelines regularly and this guideline is now past its review date. The content of the guideline below may not reflect the most recent evidence based practice. Please use with caution.

Note: While this guideline refers to the ‘child’ throughout, all activities are applicable to young people. 

Cannulation is a procedure commonly performed on children in hospital. It may be part of a planned sequence of events and investigations or it may have to be carried out speedily in an emergency situation (Rationale 1).

Peripheral cannulation provides access for the purpose of intravenous hydration, feeding, and administration of medication and blood products.

A cannula is a flexible tube containing a needle (stylet), which may be inserted into a peripheral vein (Weller 2005).

While the insertion of a cannula is a routine event for health care professionals (HCP), many children and families associate it with dramatic events and serious illness. Cannulation can be both traumatic and painful for the child and stressful for the family. They will require support and encouragement to deal with the procedure (Eland 1988).

The implications of cannulation should not be underestimated. The introduction of a foreign body into the vein is an extraordinary intervention and carries infection risks. An aseptic non-touch technique should be employed throughout the procedure (Rationale 2).

Training

Only a HCP that has been trained in the skill should undertake the cannulation of a child (Appendix 1 (PDF)).

Training is undertaken Trust-wide through the Training and Development department. This study day is structured classroom-based training with both practical and theoretical elements (Nursing and Midwifery Council (NMC) 2008a), covering all aspects of intravenous access (Rationale 3). All attendees are given a competency workbook to complete within a three-month period after attending the study day.

Supervised practice will be undertaken with the support of an experienced HCP, who will mentor the trainee in the clinical setting.

Any training should include the opportunity to practise the skill on a manikin before the trainee attempts the cannulation of a child (Rationale 4).

The trainee should read appropriate literature and research around the subject of cannulation (Rationale 5). HCPs who take on this role should be responsible for ensuring that they work within the guidelines contained in their Codes of Professional Conduct (General Medical Council (GMC) 2003, Health Professions Council (HPC) 2003, NMC 2008a) and that they identify their own moral and legal accountability.

With supervision by a qualified HCP who is skilled in this procedure, the trainee may wish to take the opportunity to practise on a consenting, qualified colleague. Any such volunteer must be aware of benefits and potential risks to themselves, and the procedure must adhere to the sequence of events and precautions contained in this clinical procedure guideline (Rationale 6).

Any training should acknowledge that the physical act of inserting a cannula into the child’s vein is only a part of this procedure. Training should incorporate the sequence of events and psychological considerations (Claar 2002)(Rationale 7).

Once the essential skills have been taught, the trainee must have opportunities to practise cannulation as soon and as frequently as possible (Frey 1988)(Rationale 8).

The newly trained HCP should continue to make themselves aware of developments in practice, research and available products.

Every HCP must undertake a yearly update to demonstrate competency and fulfill professional development requirements. This is assessed through an e-learning pack and practical assessment.

Medical staff should have their competency assessed and documented during their general paediatric training. If no assessment was undertaken or they feel an update is required the practice educator in their clinical area can arrange this.

Planning and preparation – child and family

Explain the entire procedure to the child and family including the reason for the cannulation, avoiding medical jargon and language. Information must be given according to the child’s age and developmental understanding (Frederick 1991)(Rationale 9).

Previous experience needs to be considered, together with preferred methods of coping, timing of the preparation and readiness of parent/carer(s) to take an active role (Rationale 10).

There is evidence that tolerance to pain increases with age and maturity when the child no longer perceives medical interventions as punitive (Haslam 1969Sclare 1995)(Rationale 11).

For communication to be effective, the non-verbal aspects of the practitioner-parent-child relationship must be understood (Rationale 12).

Obtain verbal consent from the child and family for the procedure (United Nations (UN) General Assembly 1989Orr 1999; Department of Health (DH) 2001a; DH 2001bDH 1997)(Rationale 13).

The procedure should be explained to the patient and they should have the opportunity to ask questions and raise concerns (NMC 2008b).

Provide play preparation, for example venepuncture role-play dolls if appropriate, involving the play specialist if possible (Rationale 14).

Consider involvement of a clinical psychologist if appropriate, particularly if previous procedures have been very stressful for the child or if they are known to have, or exhibit signs of, anticipatory anxiety and distress, eg procedural phobia (Claar 2002, Duff 2003).

Prepare appropriate methods of distraction for the child to use during the procedure itself. Attempt to discover from the child and family what techniques are most likely to consume their attention. For example, pop-up books, musical books, blowing bubbles and guided imagery where the child is encouraged to imagine something pleasant, like a favourite holiday (Rationale 15).

Consult the child and family on previous successes and failures and the best veins to use (Rationale 16). Limbs should be inspected to select the most appropriate site (Rationale 17).

Consider which hand the child favours and avoid using if possible. Establish whether the child sucks their thumb and to which they show a preference (Van Cleve 1996)(Rationale 18). However, do not make promises to use sites that are not accessible (Rationale 19).

Avoid selecting veins adjacent to joints if possible (Rationale 20). The veins should be straight and feel soft and bouncy when lightly pressed. Avoid veins that are sclerosed, fribrosed or hard. A suitable vein will be palpable or visible, of good width and length with a brisk refill capacity. Straight, non-tortuous veins, without valves, are preferable.

Consult the child and family on their preferred choice of pain relief. These could be sucrose, Ametop® cream, Emla® and Ethyl Chloride spray (if over five years old). If Emla® is used, ensure that it remains in situ for the appropriate time (Rationale 21).

Always check for previous allergic reactions and ascertain the severity of previous reactions. Enquire as to the length of exposure on such occasions, the dressing used and consider a test patch, eg on the forearm. 

Special precautions may need to be taken with known atopic children with eczema. This test patch should be closely monitored, the result recorded in the child’s health record and reported to medical staff (NMC 2010)(Rationale 22). Ensure that a detailed account of the event and materials used is entered should a reaction occur.

Apply the cream to two suitable veins and leave in situ for the recommended time to prevent any adverse reactions (Hewitt 1998)(Rationale 23).

Sterile polyurethane dressings are the method of choice for securing local anaesthetic creams (Strehle 2008). Alternatively, a cling film dressing can be applied if preferred. It may be useful to also cover the dressing with a bandage if the child is likely to fiddle with the dressing or lick the cream (Rationale 24 and 25).

Remove the cream within the recommended time (Rationale 26). 

Sucrose teaching and information.
The sucrose protocol.

Planning and preparation – equipment and environment

Use a clinical room if possible. Avoid using the child’s own bed space or room (Rationales 27, 28, 29).

If it is impossible to use a clinical room, arrange equipment and furniture, as far as possible, as they would be found in the treatment room (Rationale 30).

Perform a 'social hand wash' (see 'Hand Hygiene').

Gather all the required equipment (see Appendix 2 ). Check the expiry dates and sterility of all products and equipment selected (Rationale 31).

Prepare equipment protecting key-parts using ANTT (aseptic non-touch technique) on a clean tray that has been disinfected with a 70% isopropyl alcohol wipe (eg Sani-Cloth 70®)

Select the correct size and type of cannula for the child. Selection should be based upon the needs of the patient and the intended use and position of the cannula (Arrowsmith 2000)(Rationale 32).

Prepare personal protective clothing, ie clean gloves and apron (Rationale 33).

Gloves should be of a comfortable fit but tight to the skin, particularly at the fingertips (Rationale 34).

Positively identify the patient prior to the procedure with the use of an identification band. Verbally ask their full name and date of birth and check these against the patient records. 

If blood sampling is requested, the completed request form must also be checked by the HCP with the child and family.

Cannulation – staff provision and roles

Seek the assistance of a colleague to hold the child’s limb, assist with the securing of the device and to provide distraction if appropriate (Rationale 35).

Allow the child’s parents to be as involved as they wish, but also give them the option of being absent if they prefer (Shaw 1982; Dearmun 1992; Kumar 1995Gilboy & Hollywood 2009)(Rationale 36).

If the parents choose not to be present or are unavailable, it is advisable to recruit another colleague to assist with the procedure (Rationale 36).

However, older children, particularly those familiar and relatively confident with cannulation may not wish to have a parent present. The child should be allowed to choose whenever practicable (UN General Assembly 1989; Orr 1999; DH 2001a; DH 2001b).

All HCPs involved should be aware of the level of restrictive physical intervention and therapeutic holding that will be required for the individual child (Peach 2005; Jeffery 2008)(Rationale 37).

The age of the child and their possible competence to assent or consent to the procedure must also be considered. 

Cannulation – procedure

There should be adequate lighting of the environment and the room warm enough to encourage vasodilation. Position the child on a chair, on a treatment couch or on their parent’s lap as appropriate. Whenever possible, allow the child the freedom to select their chosen position.

Ensure that the chosen position will be comfortable for the child, parents and HCPs for the duration of the procedure. You may need to adjust the height or position of the couch/chair to avoid unnecessary twisting and bending (Rationale 38).

Perform a 'social handwash' (Rationale 2).

Put on personal protective clothing and ensure that HCPs assisting are similarly attired. The HCP must wear properly fitting gloves to protect them from contamination from potential blood spillage (Rationale 33).

Place yourself in a comfortable position, sitting facing the child and family (Rationale 39).

Remove the local anaesthetic cream if used and wipe dry with a tissue or gauze.

If an Opsite®, IV3000® or Tegaderm IV® dressing was used, remove by stretching parallel with the skin (Rationale 40).

Confirm with the child if appropriate that the cream has caused numbness of the skin effectively (Rationale 41).

Apply an appropriate size tourniquet 7–8cm above the intended vein to allow compression, but not so tight to occlude arterial supply to the limb. Indications of occluded arterial supply include: loss of colour, compromised pulse and pain. Loosen and remove the tourniquet immediately if any indication of occluded arterial supply is observed. Lightly tapping the vein or instructing the child to clench or pump the fist can encourage further venous filling (Rationale 42).

Palpate the intended vein by placing one or two fingers over the vein and pressing lightly (Rationale 43).

Disinfect the skin at the site at which it is intended to insert the needle, with 2% chlorhexidine gluconate/70% iso propyl alcohol swab (eg Chloraprep SEPP®) with back and forth and left to right strokes for 30 seconds (Rationale 44)(Scales 2009).

Allow the site to dry completely (Rationale 45).

Do not re-palpate the vein once the skin has been cleaned (Rationale 46).

Select the appropriate size cannula to ensure the correct flow rates required for the procedure (Scales 2005)(Rationale 47).

Unsheath the cannula and hold it firmly so that the two component parts cannot become separated. Examine the cannula for faults. If any are found, reject but retain for inspection by the clinical supplies advisor and complete an incident report (Rationale 48).

Stabilise the vein by gently stretching the skin over the vein and maintaining throughout the insertion of the cannula (Rationale 49).

With the bevel up at the sharpest part of the needle, insert the cannula through the skin at an angle of between 10–45 degrees depending on the depth of the vein to be entered (Weinstein 2007).

The cannula can be inserted in various ways and the choice depends on the cannula length, vein location and skill of the HCP. Four possible methods are described in Appendix 3 (PDF). Whatever method is used, the cannula should enter the skin at such an angle that the needle punctures the vein wall and enters the lumen without piercing the opposite wall (Millam 1992)(Rationale 50).

On entering the vein, a first flashback of blood into the chamber of the stylet will be observed. This is known as primary flashback. This may be accompanied by a giving way sensation felt by the HCP as a result of resistance from the vein wall as the cannula enters the lumen of the vein.

Go slowly. It is imperative that this stage of the procedure is not rushed (Rationale 51).

Decrease the angle of the cannula so that it is now resting on the skin and withdraw the stylet slightly: a second flashback of blood known as secondary flashback will be observed along the shaft of the cannula. 

Maintain skin traction while the device is advanced. Slowly advance the cannula without advancing the stylet until it is fully inserted. There are various documented techniques for this (floating, two-handed, one-step and pushing off the stylet). These are described in full in Appendix 4 (PDF). Individual HCPs will discover their preferred technique through experience (Millam 1992; Dougherty 2008).

Release the tourniquet (Rationale 52).

Taking care to hold the cannula in position to avoid extravasation, position a piece of clean cotton wool or gauze beneath the end of the cannula hub to absorb any blood that may escape. 

Remove the stylet while applying digital pressure over the cannula with one finger (Rationale 53). 

Place the stylet safely in the tray, ensuring it is not allowed to contaminate clean unused materials (Rationale 54).

Continuing to protect the cannula, connect a T-extension using ANTT and flush with 1–2ml of 0.9% normal saline, using a 10ml syringe (Gyr 1995; Goode 1991; Dunn 1987)(Rationale 55, 56).

Clamp the T extension whilst still flushing using a pulsating push pause technique to create turbulent flow and positive pressure (Kleiber 1993; Phillips 2005)(Rationale 57).

Remove the syringe and apply a needless port (eg Microclave®) to the end of the T-extension.

The HCP is responsible for the safe disposal of the stylet in a sharps box and all other items in keeping with the Trust's waste policy.

The IV tray should be cleaned with detergent and hot water, dried with paper towel and stored away from the sink in a dry location. Prior to use, the tray should be disinfected with a 70% isopropyl alcohol wipe (eg Sani-Cloth 70®).

Cannulation – dressing the cannula

The cannula can be secured using a sterile clear polyurethane dressing, such as Opsite® IV3000®, 1 hand ported® or Tegaderm IV® (Needham & Strehle 2008). This helps reduce the risk of dislodgment and mechanical phlebitis (Rationale 2).

Do not use opaque tapes or elastic adhesive plaster such as Elastoplast® (Oldham 1991)(Rationale 58).

For extra security, particularly if the child is likely to sweat excessively or in the case of babies, wound closure strips such as Steri-Strips® can be applied prior to the clear dressing (McCann 2003).

Apply an appropriate size clean splint if necessary and bandage the entire area (Rationale 59).

The child’s fingers and toes should remain visible (Rationale 60).

Dispose of all sharps and other waste appropriately and perform a social hand wash.

Cannulation – summary points 

Take time to plan the procedure (Rationales 61, 62).

The HCP should record and evaluate the procedure in the child’s health record including date and time, a note of the techniques used, their relative success and failure, number of attempts, and the level of tolerance to the stress exhibited by the child and family. In addition, date, time, size of cannula and site should be recorded on the 'Peripheral IV cannula record chart'. If the cannula is expected to be removed on the same day, eg for day case patients, the 'Peripheral IV cannula record chart' does not have to be completed and documentation requirements as above in the patient's notes are sufficient. 

The majority of children will want/need to go off the ward. In order to facilitate this the HCP should ensure that the cannula is securely bandaged and protected at all times. The child and family must be briefed on the required intervention in the event of a possible complication eg the cannula becoming dislodged or accidentally being pulled out (Rationale 63).

In the event that the first attempt at cannulation was unsuccessful, it is considered good practice for the same HCP to have no more than one further attempt.

If this attempt is unsuccessful an experienced colleague should be asked to perform the procedure (Rationale 64, 65).

In the event that repeated attempts by various HCPs are unsuccessful, the team should consider and discuss with the child and family:

  • The relative importance and urgency of the procedure.
  • The reasons why a cannula is required.
  • Other staff who may be able to help, eg senior colleagues, anaesthetists. Please refer to Appendix 6 - Decision algorithm for cannulation of children with difficult venous access (PDF).
  • Equipment and products that may make the procedure easier eg different types of cannula, use of a light source.
  • Alternative methods of venous access, eg long and PICC lines.
  • The need to preserve veins for future use.
  • The ability of the child to tolerate further attempts and interventions.
  • Alternative therapies not requiring venous access.
  • The possibility of rebooking the procedure for a future date.

If after consideration and discussion it is concluded that further attempts will be made, the child and family should have a break if possible (Rationale 66).

Dispose of sharps in sharps bin immediately (Rationale 54).

Always ensure that all HCPs perform a social hand wash before and after the procedure.

Cannulation – postive re-enforcement and reward

Time should be taken to give positive feedback to the child for tolerating the invasive procedure (Action for Sick Children 2003) (Rationale 67).

The parents should also be given positive feedback for their valuable contribution (Rationale 68).

If a story or game has been used for distraction purposes, allow the child to complete the activity.

Any reward, such as certificates and stickers (see Appendix 7 (PDF) for suppliers), will help the child to feel a sense of achievement and control.

Care of the cannula – flushing

The HCP’s aim should be to maintain the patency of the cannula for as long as possible. There is no limit to the length of time that a cannula may remain in situ but, with appropriate care, several days may be possible (Bregenzer 1998; Lia 1998; DH 2007)(Rationale 69).

If the cannula is being accessed regularly for the administration of medication or blood sampling, (at least every eight hours) no further flushing will be required. However, in the event of infrequent access, the following regime should be followed on an eight-hourly basis: (Kleiber 1993)(Rationale 70).

  • Collect the required equipment on a clean tray that has been disinfected with a 70% isopropyl alcohol wipe (eg Sani-Cloth 70®) (see Appendix 8 (PDF)).
  • Explain to the child and family the reason for the procedure and what it will entail (Rationale 71).
  • Perform a social hand wash (Rationale 2).
  • Always wear personal protective clothing when flushing a cannula and employ ANTT (aseptic non-touch technique) throughout the procedure (Rationale 33, 72).
  • Remove the bandage from over the cannula.
  • Take the opportunity to thoroughly inspect the site of entry of the cannula for any sign of phlebitis or infection.
  • Assess the entry site using the visual infusion phlebitis (VIP) score, described in the VIP section below.
  • Firmly wipe port or hub with a 2% chlorhexidine/70% isopropyl alcohol wipe (eg Clinell®) using friction for 30 seconds (Rationale 31).
  • Allow the port to dry naturally; do not fan or blow dry (Rationale 73).
  • Unclamp the T extension and slowly flush the cannula with 1-2mls of 0.9% normal saline (Rationale 74).
  • Clamp the T extension, whilst still flushing, to create positive pressure (Kleiber 1993) (Rationale 57).
  • Ask the child to report any pain or discomfort experienced and, whilst flushing, observe the cannula entry site and surrounding area for any sign of swelling, phlebitis or extravasation.
  • In the event that resistance is felt whilst flushing, attempt turbulent flushing technique, delivered in a pause-push action (Goodwin 1993)(Rationale 75).
  • If resistance is so strong that it is not possible to flush the cannula, replace the T extension, having first primed it with 0.9% saline and repeat the process above (Rationale 76).
  • If it is impossible to flush the cannula using the techniques described, remove it according to the guidelines below. Ascertain the continued need for the cannula, reviewing treatment, management and investigations with the multi-disciplinary team (Rationale 77).
  • Ensure the splint is still in the correct position and re-bandage the area over the cannula (Rationale 78).
  • Give the child and family positive re-enforcement for tolerating this procedure.
  • Record the VIP score, as described below, in the child’s health record and document any important information, eg relative ease of flushing, any pain experienced and the reason for continuing clinical indication on the 'Peripheral IV cannula record chart' (Rationale 79).

Care of the cannula – visual infusion phlebitis

It is recognised that intravenous therapy involves significant risks of damaging side effects. However, infection of IV sites and phlebitis in children are an infrequent occurrence (Hecker 1998; Nelson 1987; Jackson 1998)(Rationale 80).

Infusion phlebitis is defined as the acute inflammation of the vein directly linked to the presence of an intravenous access device.

Phlebitis affects the inner endothelial layer (intima) of the vein and results from chemical, physical or mechanical irritation (Richardson 1993; Lamb 1995Ingram & Lavery 2005).

It is characterised at the cannulation insertion site by pain and tenderness along the course of the vein, erythema and inflammatory swelling with a feeling of warmth at the site or in the bloodstream causing fatigue, malaise, rigor and fever (Perucca 1993; Perdue 1995)(Rationales 81, 82, 83).

The incidence of phlebitis is between 20–80%, 60% occurring within 8 to 16 hours of insertion (Perucca 1993). The standard recommendation is 5%.

The three most common causes of irritation are:

Chemical

  • Properties of fluids or drugs. Children may be at increased risk of chemical phlebitis (Rationale 84).

Physical

  • Irritant cannula material, length or gauge. 

  • An inexperienced HCP lacking the skill of cannula insertion. 

  • Poor site placement of the cannula.

  • The use of too large a cannula, occluding the vein and limiting blood flow around the cannula. 

  • Prolonged duration of the cannula without review.

Mechanical

  • Associated with poor fixation of the cannula allowing movement such as rubbing against the vessel wall. 

  • Activity of the child or manipulation by the child may contribute to the development of phlebitis, eg a cannula in the foot of a walking child.

  • Experimental studies have ruled out infection as being the major cause of phlebitis (Maki 1976)(Rationale 85).

  • Contamination by microscopic particles may be transferred to the child by infusion fluids and drugs. 

Prevention

Aim to reduce the incidence of peripheral intravenous cannula infections.

Prevention should have no single focus. Be aware of possible causes, use appropriate monitoring tools and audit practice.The GOSH 'Peripheral Cannula Insertion Care Bundle' and the 'Peripheral Cannula Ongoing Care Bundle' are based on the Saving Lives Initiative (DOH 2007). The audits are done monthly using an electronic audit tool and act as a way of improving and measuring elements of the care process in relation to (a) insertion and (b) ongoing care.

Refrain from using veins in areas over joints and splint if unavoidable (Rationale 86).

  • Select veins with ample blood volume when infusing irritant substances (Rationale 87).
  • Securely anchor the cannula and replace loose or contaminated dressings (Rationale 88).
  • Frequently inspect and monitor the IV site, at least daily (Rationale 89).
  • Remove cannula at the first sign of discomfort and inflammation (score of two or above on VIP scale) (Rationale 90).
  • Whenever the bandage and/or splint are removed, the opportunity should be taken to assist the child to wash and dry the previously covered hand area. The nurse should also inspect the skin integrity (Rationale 91).

All children with an IV access device in situ should have the site inspected at least every 8 hours for signs of infusion phlebitis. Where children are receiving continuous intravenous fluids/medication, the VIP score should be documented hourly on the fluid chart for the duration of the infusion. The subsequent score and action taken, if any, should be documented on the 'Peripheral IV cannula record chart' (NMC 2010). 

Additionally the cannula site should be observed when:

  • bolus injections are administered
  • IV flow rates (hourly) are checked and/or altered
  • solution containers are changed

Visual infusion phlebitis (VIP) score (Dinley grading scale)

The VIP score is based around a traffic light design: 

  • 0 = IV site appears healthy: 
    • Action: observe cannula site
  • 1 = One of the following is evident: slight pain near IV site or slight redness near IV site 
    • Action: caution
  • 2 = Two of the following are evident: pain at IV site, with erythema, swelling or both 
    • Action: re-site cannula
  • 3 = All of the following signs are evident: pain along path of the cannula, erythema, induration or a palpable venous cord less than 5cm above the IV site
    • Action: re-site cannula
  • 4 = All of the following signs are evident and extensive: pain along the path of the cannula, erythema, induration or a palpable venous cord more than 5cm above the IV site 
    • Action: re-site cannula, consider treatment
  • 5 = All of the following signs are evident and extensive: pain along the path of the cannula, erythema, induration, a palpable venous cord and pyrexia 
    • Action:re-site cannula, consider treatment

The VIP score improves the process of checking the cannula site (Rationale 92).

The HCP should know what to look for and be aware of the risks of IV cannulation and available treatments (Rationale 93).

It is recommended that routine replacement of the cannula should be undertaken every 72–96 hours, or earlier if indicated clinically. If venous access is limited, the cannula may remain in situ if there are no signs of infection and the VIP score is below 2 (Rationale 94)(DH 2007).

A number of studies support the Department of Health in the above recommendation and show that prolonged cannulation does not increase the complications of phlebitis, infection and obstruction (Lai 1998; Phelps 1987; Jackson 1998). It is common practice in paediatrics to leave the cannula in situ if the VIP score is less than 2, or until treatment is discontinued or infiltration occurs (Phelps 1987).

Care of the cannula – blood sampling

It may be appropriate to insert a cannula specifically for the purposes of blood sampling if this is likely to be more convenient (Rationale 95).

The technique is particularly useful when it is necessary to take blood regularly over a period of time, for example, when performing diagnostic tests (Rationale 96).

It should be noted however, that some tests cannot be performed on blood sampled from a peripheral cannula.

Examples are:

  • Blood glucose cannot be monitored when the cannula has been used for the administration of any glucose solution (Rationale 97).
  • Lines used for giving antibiotics cannot be used for measurement of levels of that drug (Rationale 98).
  • Blood cannot be taken for clotting when the line has been flushed with heparinised saline (Rationale 99).
  • Blood cultures should only be taken from a newly inserted cannula if there is no alternative to obtain a blood sample for culture through a separate venepuncture. Strict asepsis must be maintained. The specimen must be clearly labelled indicating that the blood sample was taken from a cannula, as the risk of contamination is high.  

It remains worthwhile flushing a peripheral cannula with heparinised saline, if it is to be used for blood sampling (Franklin 1998; Todd 1998)(Rationale 100).

Keep the cannula splinted if it is positioned adjacent to a joint (Rationale 101).

Always wear personal protective clothing when blood sampling from a peripheral cannula and employ ANTT (aseptic non-touch technique) throughout the procedure (Rationale 33).

Always insert as large a cannula as possible when it is to be used for blood sampling. Generally, cannulae smaller than 22G (blue) are unsuitable (Rationale 102).

If any samples are collected for the purposes of research studies, the child and family must have consented to this using the appropriate process and documentation (Jackson 1998; NMC 2008b).

Collect all necessary equipment on a clean tray: see Cannulation - procedure (See Appendix 9 (PDF)(Rationale 103).

After referral to the appropriate laboratories or PiMS requesting, obtain the appropriate in-date bottle(s).

Additionally, the appropriate blood bottles and special handling/delivery instructions can be found on the request forms generated from the PiMS request process (Rationale 104).

Remove the bandage from over the cannula (Rationale 105).

Perform a hygienic hand wash including the application of alcohol gel and put on personal protective clothing (Rationale 33).

Apply an appropriate size tourniquet 7–8cm above the cannula but not so tight to occlude arterial supply (Rationale 106).

Clean the needleless system with a two per cent chlorhexidine in 70% isopropyl alcohol impregnated wipe (eg Clinell ) using friction for 30 seconds (Rationale 31).

Allow the port to dry naturally, do not fan or blow dry (Rationale 73).

Using a 2ml syringe, withdraw 1ml of blood and discard (Rationale 107).

Either: Attach an appropriate Monovette® connector and collect the required samples directly into the appropriate bottles, either using the vacuum method or using the bottles as syringes (Rationale 108).

Or: Using 2ml syringes, slowly withdraw the required quantity of blood. Transfer the required quantities of blood from the syringe to the appropriate Monovette® blood bottle(s). Please note the correct order of draw for Monovette® blood bottles in Appendix 10 (PDF).

Release the tourniquet (Rationale 109).

Flush the cannula with 1–2mls of heparinised saline immediately and clamp the T extension whilst still flushing to create positive pressure (Kleiber 2003)(Rationale 57).

Ensure the splint is still in the correct position and re-bandage the area over the cannula (Rationale 76).

Check the blood request forms to ensure that the correct quantities have been collected into the correct bottles. Label the bottles, ensuring the name and hospital number correspond on both form and bottle(s) and place both the form and the bottle(s) into a specimen bag (Rationale 110).

Please note:

  • Samples for blood transfusion must be handwritten on the blood bottle, signed by the person who identified and bled the patient.
  • If the child has a private patient number in addition to the usual GOSH number, the practitioner must ensure that the number that appears on the request form matches that used to identify the sample, and that the number used is the relevant one for this particular episode of care.

Check the name and hospital number on the sample and request form against the name and hospital number on the child’s ID bracelet. Alternatively, verify the child’s identity and date of birth with one of his parents (Rationale 111).

Send the samples with the completed request forms to the correct lab via the pneumatic tube if available, or place on a specimen collection rack during the hours of portering collections. 

Out of hours only, urgent or pre-arranged tests should be performed and the on-call lab technician should be contacted prior to the collection or sending of any specimens (Rationale 112).

Explain to the child and family the implications of any results, when they are likely to be available and who will communicate the results to them (Rationale 113).

Record the blood collected and tests performed in the child’s health record (Rationale 114).

Give the child positive re-enforcement for tolerating this procedure.

Care of the cannula – dressing change

Sometimes it will be necessary to change the clear dressing on a peripheral cannula if it becomes potentially, or actually ineffective, in securing the cannula and keeping the site of entry clean (Rationale 115).

It is worth the effort of employing this technique in these circumstances, as it may well delay or possibly even prevent the trauma to the child and family of insertion of a new peripheral cannula. However, there is no requirement for routine dressing changes and one dressing may last the life of the cannula.

Explain the procedure to the child and family and prepare any available distraction that may be helpful in gaining the child’s co-operation and trust. Involve the play specialist if appropriate.

Ask a colleague to assist in the changing of the dressing (Rationale 116).

Collect the required equipment on a previously cleaned tray that has been wiped with a Sani-ClothTM(Appendix 11 (PDF)).

Ensure that the chosen position will be comfortable for the child, parents and HCPs for the duration of the procedure (Rationale 38).

Perform a social hand wash (Rationale 2). 

Put on personal protective clothing and ensure that HCPs assisting are similarly attired (Rationale 33).

If possible, use a clinical room for this procedure.

Carefully remove the old dressing, holding the cannula in place at all times (Rationale 117).

Take the opportunity to thoroughly inspect the site of entry of the cannula for any sign of infection. 

If necessary, clean the area using sterile gauze soaked in 0.9% normal saline and then dry with sterile gauze (Rationale 118).

Taking care at all times to protect the cannula, apply a sterile clear polyurethane dressing, such as Opsite IV3000 1 hand ported®, or Tegaderm IV® (Strehle 2008) or a similar proprietary product (Rationale 115).

Wound closure strips, such as Steri-strips®, may be used for extra security, but do not use opaque tapes or elastic adhesive plaster such as Elastoplast® (Oldham 1991; McCann 2003)(Rationale 119).

Re-apply the splint and bandage, ensuring that all is secure.

Record procedure on the 'Peripheral IV cannula record sheet' and document any other important information (GMC 2003; NMC 2008b)(Rationale 120).

Give the child positive re-enforcement for tolerating this procedure.

Removal of the cannula

There are five possible reasons for removal of the cannula:

  1. extravasation and infiltration 
  2. intravenous access no longer required
  3. it may no longer be functioning effectively
  4. it may be causing the child excessive discomfort
  5. a VIP score of two or above

In the case of number two above, the practitioner must be absolutely certain that the cannula will not be required again. If in doubt, the HCP should seek guidance from senior colleagues or other members of the multi-disciplinary team (Rationale 121).

Collect the required equipment on a previously cleaned tray that has been wiped with a Sani-ClothTM (Appendix 12 (PDF)).

Always employ ANTT (aseptic, non-touch technique) throughout the procedure (Rationale 2).

If possible, use a procedure room for this intervention.

Explain the procedure to the child and family (Rationale 122).

Remove the bandage and splint.

Perform a social hand wash (Rationale 2). 

Put on personal protective clothing and ensure that HCPs assisting are similarly attired (Rationale 33).

Inspect the exit site and assess for phlebitis or infection, utilising the VIP scoring system.

If there is cause for concern, alert senior colleagues and medical staff (Rationale 123).

Carefully remove the old dressing, holding the cannula in place at all times.

Hold a piece of sterile gauze over the exit site but do not apply pressure (Rationale 124).

Slowly withdraw the cannula, maintaining a neutral angle with the child’s skin.

Immediately apply gentle digital pressure to the exit site for three to four minutes (Rationale 125).

Examine the cannula and place it carefully into a tray (Rationale 126).

Lift the soiled gauze and inspect the exit site to check that bleeding has ceased.

Do not wipe the exit site with the gauze (Rationale 127).

If necessary, clean the area using sterile gauze soaked in 0.9% normal saline, but avoid the exit site (Rationale 128).

Assist the child to wash the previously splinted and bandaged area thoroughly, using soap and water.

Apply a sterile plaster directly over the exit site and cotton wool ball, secured with medical adhesive paper tape, such as Micropore®, over the plaster. This pressure dressing may be removed after an hour (Rationale 129).

If the child prefers, they may choose only sterile gauze and tape without a plaster. Advise the child and family that the plaster/gauze and tape should remain in situ for short while. 

Dispose of the cannula in a sharps container or a yellow clinical waste bag (Rationale 130).

Perform a social hand wash (Rationale 2). 

Document the procedure, date of removal, duration of cannula, VIP score and action taken on the 'Peripheral IV cannula record chart' (Rationale 131).

Give the child positive re-enforcement for tolerating this procedure.

Rationale

Rationale 1: An intravenous cannula consists of a plastic catheter, which is inserted, with the aid of a stylet or needle placed in the lumen of the catheter with the sharp point protruding from the end.

Rationale 2: To prevent cross infection.

Rationale 3: Cannulation is a complex skill that cannot be learnt from a book or a guideline.

Rationale 4: To develop a sound theoretical base and to assist them with problem solving in practice.

Rationale 5: The trainee should feel confident before cannulating to maximise the potential for success.

Rationale 6: To minimise short and long term trauma and distress to the volunteer.

Rationale 7: This will develop skills whilst knowledge is fresh and allow them to gain confidence in their abilities (Frey 1998). Cannulation and the sequence of events is a complex procedure requiring numerous skills. The potential for distress to the child, family and practitioners involved should not be underestimated.

Rationale 8: To ensure that their knowledge remains valid and up to date and their practice safe and effective (GMC 2003; HPC 2004; NMC 2008a).

Rationale 9: To ensure that the child and family understand the reason for the procedure and are psychologically prepared. Well-informed parents are more likely to stay calm and will be in a position to support their child (Frederick 1991).

Rationale 10: Children do not usually develop coping strategies by themselves. Parents can often predict whether their child will co-operate.

Rationale 11: The better informed the child, the better able they will be to develop coping strategies (Sclare 1995).

Rationale 12: Active listening appears to be demonstrated mainly through non-verbal communication (Magnusson 1996).

Rationale 13: To ensure that they agree in principle to the proposed cannulation. Nurses are best placed to obtain this consent (Power 1997).

Rationale 14: To enable explanation in a non-threatening manner and give the child the opportunity to express fears in a familiar environment (Broome 1990; Lansdown 1993; Action for Sick Children 2003).

Rationale 15: To prevent the child’s whole attention being centred on the invasive procedure. These techniques can help to distract and relax the child (Heinley 1991; Langley 1999).

Rationale 16: Inspection of the vein will reveal the position of the veins, the direction which they run, their size and other physical features.

Rationale 17: Many families will have had previous experiences of cannulation or how their child copes with a stressful situation.

Rationale 18: Thumb sucking will be an important coping strategy during the stressful experience of hospitalisation (Dougherty 1996).

Rationale 19: This would represent a betrayal of the child’s trust (Frederick 1991).

Rationale 20: Increased risk of extravasation and phlebitis (Davies 1998).

Rationale 21: Sixty minutes will achieve analgesia to pin prick but not loss of sensation or touch and pressure (anaesthesia). The optimal application time for EMLA®, to achieve 95 per cent anaesthesia to the area is 90 minutes. This is due to the nerve fibre size and is particularly relevant in the age group 1-5 years (Biccard 2001; Arrowsmith 2000).

Rationale 22: Allergic reactions to Ametop® are associated with prolonged use of the cream (Hewitt 1998), incorrect use of the product or selection of inappropriate dressing materials (Smith and Nephew 2010).

Rationale 23: Application of local anaesthetic will reduce the pain of the procedure (Lawson 1995; Clarke 1986; Smith and Nephew 2007).

Rationale 24: Using cling film avoids the discomfort of removing the dressing later.

Rationale 25: To prevent local allergic reaction.

Rationale 26: To minimise the risk of exposure to allergens in the future and to ensure that the child’s health record is comprehensive.

Rationale 27: All equipment is close at hand and better task lighting is available in a clinical area. Risk of unsafe disposal of sharps will be reduced.

Rationale 28: To ensure the child’s own bed remains a safe haven (Frederick 1991).

Rationale 29: Greater privacy for the child and family.

Rationale 30: To ensure equipment is close at hand and the child and nurse are comfortably positioned.

Rationale 31: To reduce risk of introducing infection.

Rationale 32: To ensure that the most appropriate size and type of cannula is used (Murdoch 1990; Jensen 2001).

Rationale 33: To prevent cross infection and possible contamination of clothing (Lavery 2006).

Rationale 34: To allow easier palpation of the vein.

Rationale 35: The assistance of a colleague will help to maximise the chance of a successful insertion procedure (Turner 1993; Robinson 1997; Fulton 1996).

Rationale 36: The parents will be able to assist with holding, distraction and will provide emotional support for the child.
Rationale 37: A degree of restraint will be necessary and appropriate for most children, for the purpose of maintaining the safety of the child and all others present and to prevent the need for repeated attempts at cannulation (Robinson 1997; RCN 2010).
Rationale 38: To maximise the chance of a successful insertion procedure and aid compliance by the child.
Rationale 39: So that good eye contact can be maintained and to aid compliance with the procedure.
Rationale 40: This breaks the glue, causing less irritation and pain (Smith & Nephew 2010).

Rationale 41: To re-assure the child that the pain of the procedure will be reduced.

Rationale 42: To facilitate filling of the vein, enhance visualisation and to allow the assisting nurse to have hands free for other tasks (Millam 1992).

Rationale 43: The procedure enables the HCP to differentiate veins from arteries (arteries pulsate) and to locate valves.

Rationale 44: To clean the skin, to remove flora and prevent introduction of infection.

Rationale 45: Dry for one minute to ensure disinfection of the site and to prevent stinging as the needle pierces the skin.

Rationale 46: To prevent re-contaminating the skin (Franklin 1998).

Rationale 47: In general, the smallest gauge of cannula should be selected for the prescribed therapy to prevent damage to the vessel intima, and ensure adequate blood flow around the cannula to reduce the risk of phlebitis.

Rationale 48: To reduce the risk of foreign particles or material entering the blood stream and potentially causing a particle embolism.

Rationale 49: To ensure easy penetration of the skin with the cannula and to immobilise and anchor the vein.

Rationale 50: Catheters have the ability to soften once in the vein, allowing it to be firm when inserted but soft and therefore less traumatic once inserted (Jensen 2001).

Rationale 51: To ensure adequate filling of the hub and to prevent a failed procedure.

Rationale 52: To decrease the pressure in the veins.

Rationale 53: To prevent blood return and contamination of the surrounding area, creating an environment in which bacteria could thrive.

Rationale 54: To reduce the risk of an accidental needle stick injury.

Rationale 55: To ensure the cannula is correctly inserted, ensure patency and prevent clotting.

Rationale 56: A 10ml syringe prevents excessive pressure being exerted on the vein (Todd 1998).

Rationale 57: To prevent occlusion and blood backflow into the T extension.

Rationale 58: To facilitate easy observation and prevent contamination of the cannula insertion site (Millam 1992; Oldham 1991; Livesley 1996). This will help to prevent mechanical phlebitis, extravasation and the distress of re-cannulation.

Rationale 59: To immobilise the limb, preventing movement that may cause occlusion, extravasation and phlebitis (Lai 1998).

Rationale 60: To facilitate checks of the child’s circulation.

Rationale 61: To maximise the chance of a successful insertion procedure and aid compliance by the child.

Rationale 62: To ensure that the child’s health record is comprehensive and to provide information to other practitioners who may need to cannulate the child either later in this admission or at a later time (GMC 2003; NMC 2010).

Rationale 63: To give the child and family confidence, to assist them in following as normal a routine as possible and to improve the child’s experience of hospitalisation.

Rationale 64: Repeated attempts by the same HCP will damage both their self-confidence and the confidence of the child and family in their ability and skill.

Rationale 65: Repeated attempts at cannulation are stressful for all involved, family, child and staff and the team must attempt to maintain a realistic perspective.

Rationale 66: This will allow the child to regain his composure and HCPs to reflect and re-evaluate the procedure.

Rationale 67: To acknowledge the value of their involvement and teach parents mastery of the event, equipping them with coping strategies for future occasions.

Rationale 68: To conclude the procedure with a positive outcome.

Rationale 69: Re-cannulation should be avoided where possible, as this will cause the child and family further distress. Minimising cannulation procedures preserves veins for future access.

Rationale 70: Studies recommend 8-12 hourly flushing with 0.9 per cent normal saline (Gyr 1995; Goode 1991; Dunn 1987).

Rationale 71: To gain their confidence and trust and empower the child (UN General Assembly 1989; Charles-Edwards 2003).

Rationale 72: So that the site of entry of the cannula may be observed throughout the procedure.

Rationale 73: To prevent re-contamination of the port (Franklin 1998).

Rationale 74: Studies suggest that 1-2mls is sufficient (Gry 1995; Goode 1991; Dunn 1987).

Rationale 75: This is used as a method of preventing catheter occlusion.

Rationale 76: Blockages may occur in the T extension due to backflow or inadequate flushing. Cannulae smaller than 22 gauge do not include a valve, making backflow and blockage more likely (Danek 1992).

Rationale 77: The cannula should be removed if it is no longer required (Phelps 1987).

Rationale 78: To ensure patency for collection of next sample or administration of the next drug.

Rationale 79: To ensure that the child’s health record is comprehensive and to provide information to other practitioners that may flush the cannula at a later time.

Rationale 80: Complications increase hospital stays, duration of therapy and can put patients at risk of further medical problems. This has an impact upon resources if a patient acquires septicaemia. Additionally, the patient experiences pain and could become very needle phobic (Kolk 1999).

Rationale 81: Pain has been reported up to six months post cannula removal and everyday activities, eg wearing a wristwatch or leaning on forearms, may be affected for some time afterwards.

Rationale 82: Future access points may be reduced.

Rationale 83: Fibrotic veins and scarring results in an altered body image for the child, with possible limb immobility (extravasation).

Rationale 84: Children’s veins are smaller and subject to reduced blood flow around the device (Danek 1992; Weinstein 1993).

Rationale 85: After insertion of a plastic cannula into a vein, a loosely formed fibrin sheath collects around the device within 24-48 hours forming a nidus (Weinstein 1993). This helps the bacteria to adhere to the cannula and microbial agents in the blood, which means it is difficult to treat cannula related infections without removing the device.

Rationale 86: Movement of the cannula in the vein is a significant cause of infusion phlebitis.

Rationale 87: The larger the blood volume and flow, the lower the risk of infusion phlebitis.

Rationale 88: To prevent movement.

Rationale 89: To achieve early detection of infusion phlebitis.

Rationale 90: To prevent further deterioration, extravasation and infection of the IV site.

Rationale 91: To maintain personal hygiene and reduce the risk of infection and damage to the skin.

Rationale 92: It provides a mechanism for recording objectively, rather than the term satisfactory used previously.

Rationale 93: This will help to reduce IV related complications.

Rationale 94: To reduce the risk of bacterial sepsis (British Paediatric Association 1992).

Rationale 95: Taking blood samples from an existing peripheral cannula reduces the trauma of blood tests for the child and family.

Rationale 96: Only HCPs who have been formally assessed as competent IV givers should attempt this technique, following demonstration and training by an experienced practitioner.

Rationale 97: Dextrose adheres to the lining of the cannula resulting in inaccurate results.

Rationale 98: The antibiotic adheres to the lining of the cannula resulting in inaccurate results.

Rationale 99: The heparin present will lead to the result suggesting prolonged clotting times.

Rationale 100: Assists in maintaining patency of the line and allows sampling from the cannula for longer than would be possible if saline alone was used.

Rationale 101: To prevent the cannula from bending causing occlusion, phlebitis or extravasation.

Rationale 102: Small cannulae (24G) do not allow easy sampling of blood and can become occluded during the procedure (Danek 1992).

Rationale 103: To ensure that no samples are taken without the full approval of the child and family.

Rationale 104: Some tests must be undertaken by the lab within a specified time or delivered to them under certain conditions. Details of any special instructions are available on PiMS Requesting or in the appropriate laboratory manual.

Rationale 105: So that the site of entry of the cannula may be observed throughout the procedure.

Rationale 106: To assist filling of the vein, improving blood flow from the cannula.

Rationale 107: To withdraw saline or heparinised saline used previously.

Rationale 108: This method, being a closed system, should be favoured as it reduces the risk of contamination and splash injuries.

Rationale 109: To restore usual venous blood flow.

Rationale 110: To prevent errors and to ensure that the appropriate care and treatment are given to the child.

Rationale 111: To ensure that the sample has been collected from the correct child and to prevent critical incidents.

Rationale 112: To ensure that the sample is dealt with promptly and appropriately.

Rationale 113: To keep them fully informed of their care, management and the possibility of any change in treatment.

Rationale 114: To ensure that the child’s health record is comprehensive and to provide information to other practitioners that may collect samples from the cannula at a later time.

Rationale 115: These types of dressings have greater moisture responsive properties and allow the cannula site to be easily observed for thrombosis and phlebitis or extravasation (Smith & Nephew Ltd 2010).

Rationale 116: The assistance of a colleague with the technique will reduce the risk of the cannula becoming dislodged during the procedure.

Rationale 117: To prevent accidental dislodgement or removal of the cannula.

Rationale 118: To ensure effective adhesion of the replacement dressing.

Rationale 119: A clear dressing allows the site to be easily observed for signs of phlebitis or extravasation.

Rationale 120: To ensure that the child’s health record is comprehensive and to provide information to other practitioners that may be required to change the dressing at a later time.

Rationale 121: To avoid unnecessary re-cannulation.

Rationale 122: To gain their confidence and trust.

Rationale 123: A course of antibiotics may be required.

Rationale 124: Pressure should not be applied until the needle has been fully removed or it will cause the needle to be dragged out of the vein causing pain and venous damage.

Rationale 125: To absorb any blood that escapes and to prevent the formation of a haematoma.

Rationale 126: To ensure that no particles or cannula parts remain in the vein and to prevent possible inoculation injury.

Rationale 127: This could re-activate bleeding by dislodging the thrombus.

Rationale 128: The exit puncture site is a potential entry point for infection.

Rationale 129: To create a pressure dressing.

Rationale 130: The used cannula is not technically a sharp but does require disposal by incineration due to the inoculation risk that exists.

Rationale 131: To ensure that the child’s health record is comprehensive.

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Document control information

Lead Author(s)

Zoe Wilks, Head of Nursing and Operational Manager, Outpatients

Additional Author(s)

Barbara Brekle, Deputy Lead Nurse, Infection Prevention & Control

Document owner(s)

Zoe Wilks, Head of Nursing and Operational Manager, Outpatients

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
30 November 2005
Date approved: 
23 July 2017
Review schedule: 
Three years
Next review: 
23 July 2020
Document version: 
4.0
Previous version: 
3.0