Chapter 17: Vascular access devices: insertion and management
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Post‐procedural considerations
Immediate care
Once sited, the peripheral cannula should be flushed using a pulsatile flush ending with positive pressure (Dougherty [124], RCN [381], Weinstein and Hagle [465]). The cannula should be secured using an IV film dressing, clean tape or a securing device (Figure 17.19). Tape should not cover the insertion site, and taping with the sterile tape provided with the IV film dressing should enable the site to remain visible and the cannula stable (Figure 17.20). The approach shown in Procedure guideline 17.4: Peripheral cannula insertion, Action figure 30, is recommended (Dougherty [124], Hadaway [192]). Securement devices are now available and reduce the risk of dislodgement and other complications (Bausone‐Gazda et al. [25], Higgingson [210], Moureau and Iannucci [334], Ullman et al. [448]). Low‐linting gauze should only be used if IV film dressing is contraindicated (Gorski et al. [181], Loveday et al. [278], RCN [381]).
Figure 17.19 Peripheral cannula secured with StatLock.
Figure 17.20 (a) Cannula in situ. (b) Cannula secured with a semi‐permeable transparent IV film dressing.
Ongoing care
A peripheral cannula should be flushed before and after each use to check for patency prior to administration of a medication, and at least daily if not in use, using 0.9% sodium chloride. The dressing should be changed as required (if transparent) or each time the device is manipulated (gauze). In order to determine skin health at the PIVC site, the clinician should inspect the skin for colour, texture, uniformity of appearance and integrity (Broadhurst et al. [50]). The site should be monitored daily or when the device is used. The site should be inspected for signs of infiltration, extravasation and leakage, using a recognized scale such as the VIP scale for signs of phlebitis or infection (Bitmead and Oliver [39], DH [117], Gorski et al. [181], RCN [381], Ullman et al. [448]). To avoid contamination when accessing the cannula, good hand hygiene and aseptic non‐touch technique are required, and the needle‐free connector should be disinfected with a wipe saturated with 2% chlorhexidine in 70% alcohol for 15 seconds and left to air dry (Bitmead and Oliver [39]). All ongoing care must be documented (DH [117], Gorski et al. [181], RCN [381]).
Removal
Van Donk et al. ([451]) and Webster et al. ([464]) recommended the re‐siting of cannulas based on clinical indication instead of time in situ. Lee et al. ([266]) further state that this approach does not increase infection rates but they do recommend that insertion is done by highly skilled intravenous teams or rates could increase. Rickard et al. ([384]), who conducted a study of over 5000 peripheral cannulas, found no difference in phlebitis, infection or failure rates between replacing cannulas every 3 days compared with leaving them in situ and replacing them when clinically indicated. They concluded that peripheral devices need only be removed as clinically indicated and that this would save millions of unnecessary re‐sites, reduce associated discomfort, and reduce costs of both equipment and staff time. This is supported by recent changes in guidelines that suggest that PIVCs should be re‐sited only when clinically indicated and not routinely, unless device‐specific recommendations from the manufacturer indicate otherwise (Gorski et al. [181], Loveday et al. [278], RCN [381]).
Removal of the peripheral intravenous device or cannula should be an aseptic procedure. The device should be removed carefully using a slow, steady movement keeping the hub parallel with the skin, and pressure should be applied until haemostasis is achieved. This pressure should be firm and not involve any rubbing movement. A haematoma will occur if the device is carelessly removed, causing discomfort and a focus for infection (Perucca [369]). The site should be inspected to ensure bleeding has stopped and should then be covered with a sterile dressing (Bitmead and Oliver [39], Gorski et al. [181]). The cannula's integrity should be checked to ensure that a complete device has been removed (Dougherty [124], Gorski et al. [181], RCN [381]).
Documentation
On insertion, the practitioner should document the date and time, the site and size of the cannula, the number of attempts and the flushing solution used. They should also date and time the dressing and sign their name. This can be done as part of a specific cannula care plan or by use of a sticker in the patient's notes (Figure 17.21) (DH [117]). If a tool is used to monitor the site, for example VIP score, then this should be recorded on a regular basis (e.g. every shift change or at least once a day) (Gorski et al. [181], Loveday et al. [278], RCN [381]). The date, time and reason for removal of the cannula must also be documented in the patient's notes (DH [118], Dougherty [124], RCN [381]). This documentation ensures adequate records for the continued care of the patient and device and also enables audit and gathering of statistics on rates of phlebitis, infiltration and so on.
Figure 17.21 Documentation example from The Royal Marsden NHS Foundation Trust's vascular access device documentation booklet. Source: Reproduced with permission of The Royal Marsden NHS Foundation Trust.
Education of the patient and relevant others
See ‘Discharging patients home with a VAD in situ’ above.
