Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [356], C).
2. 2.Show
   Apply a tourniquet to the arm. Assess venous access and locate veins using ultrasound guidance (if using MST), then release the tourniquet. Repeat for the other arm if needed.
   To ensure the patient has adequate venous access and to select the vein for catheterization (Gorski et al. [181], C; RCN [381], C).
3. 3.Show
   If necessary (e.g. in very anxious or needle‐phobic patients, or children), apply local anaesthetic cream or gel to the chosen venepuncture site and leave for the allotted time.
   To minimize the pain of insertion (BNF [42], C).
4. 4.Show
   Apply apron, draw screens and assist the patient into a comfortable position.
   To ensure privacy. To aid insertion and correct placement. E
5. 5.Show
   Using the tape measure, measure from the selected venepuncture site up the arm to just below the axilla.
   To enable selection of the most suitable catheter length and to know how far to advance the catheter in order for its tip to be located in the correct position. E
6. 6.Show
   Take the equipment required to the patient's bedside. Open the outer pack.
   To gain access to the equipment. E

Procedure

1. 7.Show
   Wash hands with soap and water, or an alcohol‐based handrub, and dry.
   To minimize the risk of infection (Fraise and Bradley [156], E; NHS England and NHSI [348], C).
2. 8.Show
   Put on sterile gown and gloves; open sterile pack, arranging the contents as required. Draw up the syringe with 0.9% sodium chloride (provided by assistant if possible) or use sterile 0.9% sodium chloride pre‐filled syringes.
   To prevent contamination. E
3. 9.Show
   Remove the cap from the extension set and attach the syringe of 0.9% sodium chloride; gently flush with 2 mL and leave the syringe attached.
   To check that the catheter is patent and to enable easy removal of the guidewire. E
4. 10.Show
   Using the graduated markings along the catheter, select the marking required and pull back the stylet (if present) 1 cm from the desired new tip, and using sterile scissors trim the catheter. Never trim the stylet.
   To ensure the catheter will be the correct length for placement and to prevent damage to the vein if the stylet is damaged. E
5. 11.Show
   Place a sterile towel under the patient's arm.
   To provide a sterile field to work on. E
6. 12.Show
   Clean the skin at the selected site with an appropriate disinfectant, for example 2% chlorhexidine in 70% alcohol, using back‐and‐forth strokes with friction. In this way, prepare an area of 15–25 cm².
   To ensure skin flora is destroyed and to minimize the risk of infection (Fraise and Bradley [156], E; Gorski et al. [181], C; Loveday et al. [278], C; RCN [381], C).
7. 13.Show
   Allow the solution to dry thoroughly.
   To ensure coagulation of bacteria and completion of disinfection process (Loveday et al. [278], C).
8. 14.Show
   Drape the patient with a fenestrated towel.
   To provide a sterile field (Loveday et al. [278], C).
9. 15.Show
   Draw up and inject local anaesthetic intradermally, if required, using a 25 G safety needle and wait for a few minutes for it to take effect.
   To provide adequate anaesthesia (BNF [42], C).
10. 16.Show
    Reapply the tourniquet.
    To aid venous distension (Dougherty [124], E).
11. 17.Show
    Either:
     
    If not using MST (modified Seldinger technique), perform the venepuncture with the introducer by entering the skin 1 cm from the desired point of entry, at a 15–30° angle. Advance 0.5–1.0 cm once flashback is seen. Continue to step 24.
    To gain venous access (Dougherty [124], E).
    Or:
     
    If using MST, while visualizing the vein under ultrasound, perform the venepuncture with a needle or cannula. (If using a cannula, when flashback is seen, advance the cannula into the vein.) Continue to step 18.
    To gain venous access (Gabriel [161], E; Moureau [329], E). To prevent blood loss and through‐puncture and enable advancement of the catheter (Gabriel [161], E).
12. 18.Show
    Remove the stylet and advance the guidewire through the needle (or cannula) until there is 10–15 cm of wire in the vein (Action figure 18).
    To maintain venous access. E
13. 19.Show
    Release the tourniquet.
    To prevent blood loss and through‐puncture, and enable advancement of catheter (Dougherty [124], E).
14. 20.Show
    Advance the introducer over the wire up to the puncture site. (If using a cannula, first remove it, applying digital pressure.)
    To prepare for insertion. E
15. 21.Show
    Reinfiltrate over the puncture site with 1% lidocaine (intrademally) if necessary, until a small bleb is observed (Action figure 21).
    To achieve anaesthesia and minimize patient discomfort. E
16. 22.Show
    Check the patient has no sharp sensations at the puncture site and then make a small incision by sliding the tip of the scalpel blade along the top of the wire (Action figure 22).
    To ensure the area is anaesthetized before proceeding. E
17. 23.Show
    Activate the safety function on the scalpel and place it back onto the sterile field.
    To minimize the risk of sharp stick injury. E
18. 24.Show
    Grip the introducer firmly and advance through the puncture site (Action figure 24).
    To enable advancement of the dilator. E
19. 25.Show
    Remove the guidewire and the dilator from the introducer/peel‐away sheath. Grip the catheter a few centimetres from the tip and thread through the introducer/peel‐away sheath.
    To enable catheter insertion. E
20. 26.Show
    Continue slow advancement of the catheter and aspirate (if possible) and flush to check for blood return or resistance.
    To minimize damage to the tunica intima of the vein (Gabriel [161], E). To check there is no obstruction and that the catheter advances into the correct location. E
21. 27.Show
    Position fingers in a V, with index finger on wings and middle finger above sheath tip, and gently remove stylet. Apply pressure.
    To contain flashback, prevent contamination of the area with blood and minimize the amount of blood loss from the patient (Dougherty [124], E).
22. 28.Show
    Grip the catheter at least 1 cm from the tip and thread through the introducer sheath.
    To ensure the tip is not contaminated (Dougherty [124], E).
23. 29.Show
    Continue slow advancement of the catheter to the desired length.
    To minimize damage to the intima of the vein (Dougherty [124], E).
24. 30.Show
    Apply pressure above the introducer and carefully withdraw the introducer and peel apart.
    To ensure there is no movement of the catheter. To remove the peel‐away introducer (Dougherty [124], E).
25. 31.Show
    Aspirate for blood return and flush the catheter with 0.9% sodium chloride.
    To check the patency of the device and ensure continued patency (Dougherty [124], E).
26. 32.Show
    Apply gentle pressure on the catheter and slowly withdraw the stylet.
    To ensure there is no withdrawal of the catheter (Dougherty [124], E).
27. 33.Show
    Attach a needle‐free connector and flush as per local policy.
    To ensure the patency of the device (Dougherty [124], E).
28. 34.Show
    Secure the catheter with sterile tape or another securing device and a small pressure dressing over the insertion site. Apply a semi‐permeable transparent IV film dressing. Add the insertion date to the dressing. Apply gauze and a bandage or a tubular bandage.
    To ensure stability of the device and protection of the site (Dougherty [124], E). To know when the dressing needs to be changed (RCN [381], C).

Post‐procedure

1. 35.Show
   Remove gloves and gown, and dispose of equipment appropriately. Dispose of sharps and clinical waste.
   To ensure safe disposal in the correct containers and avoid laceration or injury of other staff. To prevent reuse of equipment (NHS Employers [346], [347], C).

   To reduce the risk of sharps injury (HSE [217], C).
2. 36.Show
   Document the procedure in the patient's notes:

   • type, length and gauge of catheter
   • where it was inserted
   • any problems
   • how it was secured.
   To ensure adequate records are maintained and enable continued care of the patient and device (NMC [356], C).