12 Nursing Times 21.08.12 / Vol 108 No 34/35 / www.nursingtimes.net

Keywords: Peripheral venous cannula/ Intravenous therapy/HCAIs This article has been double-blind

peer reviewed

Nursing PracticePractice educatorVenous cannulas

Author Louise McCallum is lecturer – adult nursing, University of the West of Scotland, Ayr; Dan Higgins is charge nurse critical care, University Hospitals Birmingham Foundation Trust and a freelance clinical educator.Abstract McCallum L, Higgins D (2012) Care of peripheral venous cannula sites. Nursing Times; 108: 34/35, 12-15.Peripheral venous catheters are commonly used in hospitals to deliver intravenous therapy. They are associated with a range of complications that can be damaging to patients’ health and increase healthcare costs. In order to minimise the risk of these complications, thorough patient assessment and careful catheter management are essential.

It has been estimated that as many as one in three hospital patients have a peripheral venous catheter (PVC) in-situ at any given time (Reilly et al,

2007). These small hollow catheters are advanced over a needle into a peripheral vein via the skin, and are used predomi-nantly for the delivery of intravenous (IV) therapy. However, PVCs are not without complications. Infection and phlebitis are of primary concern (Royal College of Nursing, 2010), so registered nurses must ensure their knowledge and skills related to the management of PVCs are up to date and evidence based (Nursing and Midwifery Council, 2008) in order to reduce the com-plications associated with these devices.

This article discusses some of the com-plications associated with PVCs, focusing specifically on phlebitis and infection, and how they might be prevented through careful observation and meticulous care of the site.

5 key points 1Peripheral

venous catheters are commonly used in hospitals to deliver intravenous therapy

2PVCs are associated

with several complications, some of which can have serious consequences

3Careful observation

and monitoring are crucial to identifying complications at an early stage

4Scrupulous hygiene and

site management will minimise the risks of healthcare-associated infections

5PVCs should be removed as

soon as they become clinically unnecessary

Indications and sites Peripheral venous cannulation is indicated for short-term use in many clinical situa-tions. These mainly include administra-tion of: » IV fluids; » Drugs; » Blood and blood products; » Dyes and contrast media.

Common sites of insertion are the cephalic or basilic veins of the lower arm; or the dorsal venous arch located on the back of the hand (Lavery, 2007) (Fig 1). The superficial veins of the lower limbs may also be cannulated, but these tend to be avoided as they are associated with a higher risk of infection and embolism (RCN, 2010).

Several factors must be considered when selecting a site for peripheral venous cannulation. The risk of infection or phle-bitis can be minimised by considering the following: » The general condition of the veins;» Avoidance of points of flexion; » The type of drug to be administered

(determined by the osmolality or pH); » Speed of drug delivery; » Duration of intended therapy; » The size of the cannula versus the size

of the vein.

Complications Several complications are associated with having a PVC in situ and the administra-tion of IV therapy (Box 1). The most serious are discussed below.

PhlebitisPhlebitis is the inflammation of a vein, or more specifically its inner lining, the tunica intima (RCN, 2010). Clinical signs of

In this article... Why peripheral venous catheters are used Complications associated with peripheral venous catheters Minimising the risk of complications

Use of peripheral venous catheters is common but infection can occur, and prove fatal, if care is not taken to monitor the site and reduce the risk of complications

Care of peripheral venous cannula sites

It is estimated one in three inpatients have a peripheral venous catheter in situ

14 Nursing Times 21.08.12 / Vol 108 No 34/35 / www.nursingtimes.net

phlebitis are localised redness, heat and swelling, which can track further along the length of the vein, eventually leading to induration and a “palpable venous cord” (Jackson, 1998). The patient may complain of pain, either continuously or during infusion of drugs through the cannula. Phlebitis is precipitated by mechanical, chemical or infective causes (Higginson and Parry, 2011).

Mechanical phlebitisThis is caused by the cannula rubbing and irritating the tunica intima; the risk of this complication may be reduced by using the smallest gauge cannula capable of deliv-ering the prescribed drug (Joanna Briggs Institute, 2008).

Chemical phlebitisThis occurs as a consequence of irritation to the tunica intima caused by properties of the drug being infused. Strongly alka-line, acidic or hypertonic drugs can cause significant irritation if injected into a small vein with an insufficient blood flow (JBI, 2008). Drugs for IV admin-istration should always be reconstituted and delivered according to the manufac-turer’s recommendations, and informed by local policy.

Infective phlebitisThis occurs as a consequence of micro- organisms entering the vein through the puncture site. These can originate from the patient’s own resident skin flora or from cross-contamination of microorgan-isms onto the PVC site and injection ports. Infective phlebitis can be a consequence of poor hygiene practices of healthcare pro-viders (Health Protection Scotland, 2012).

Catheter-related bloodstream infectionsCatheter-related bloodstream infections are caused by similar means as infective phlebitis but microorganisms – including Staphylococcus epidermidis, Staphylococcus aureus, candida species and enterococci – can also be introduced within contaminated infusion fluid (Pratt et al, 2007). Once introduced into the PVC tubing they combine to form a biofilm; this is a collection of microorganisms that grows on both living and inert sub-stances in the presence of moisture. If fragments of biofilm become dislodged and enter the systemic circulation, they can precipitate a bloodstream infection; this can cause bacteraemia or sepsis, which can have potentially fatal conse-quences (HPS, 2012). Al

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BOX 1. COMPLICATIONS OF PVC AND IV THERAPY!

Catheter-related bloodstream infection Microorganisms introduced into the bloodstream via the cannula cause bacteraemiaExtravasation Vesicant solution is administered into surrounding tissueHaemorrhage Bleeding occurs at puncture siteInfiltration Non-vesicant solution is administered into surrounding tissuePhlebitis The tunica intima is inflamedSource: RCN (2010); Pratt et al (2007)

FIG 1. VEINS COMMONLY USED FOR CANNULATION

The complications associated with PVCs and IV therapy can have a devastating effect on patients’ health and quality of life, and increase the costs of healthcare through prolonged hospital stays and treatment (Dychter et al, 2012).

Patient careObservation and monitoring of the PVC site and localised tissue are essential to ensure any significant changes are identi-fied and responded to appropriately, to reduce the risk of complications. If two or more signs indicative of phlebitis are present (Jackson, 1998), or if the PVC is not functioning, it should be removed imme-diately; it should only be resited if the clin-ical need for a PVC remains (HPS, 2012). Phlebitis scales, such as the Visual Infu-sion Phlebitis Scale (Jackson, 1998; Fig 2), can assist nurses in assessing and man-aging PVC sites (RCN, 2010).

The clinical necessity for a PVC should be under constant review. Clinical require-ment should be considered at least daily

and the PVC should be removed as soon as it is deemed unnecessary. It has been sug-gested that clinical indication alone should drive the removal of PVCs (Webster et al, 2010). However, national guidelines state that removal should be considered if the PVC has been in situ for longer than 72 hours (HPS, 2012) or 72-96 hours (Depart-ment of Health, 2011), as the risk of compli-cations increases with time (Dougherty and Lister, 2008). PVCs inserted in emer-gency situations should be removed within 24 hours (RCN, 2010).

The RCN (2010) and HPS (2012) recom-mend that PVC sites are checked at least on a daily basis. It is also recommended that the site is assessed during injection of drugs, when IV fluid bags are changed or when drip flow rates are checked (RCN, 2010). To facilitate this, the PVC should be dressed with a transparent dressing to allow the site to be seen. The dressing should be sterile and semi-permeable; non-sterile tape should never be used. Correct application of an adhesive dressing will keep the PVC secure and minimise the risk of mechanical phlebitis; if the dressing becomes damp or loose it must be changed.

PVC-site care must always be per-formed using an aseptic non-touch tech-nique (Rowley, 2001) to prevent cross-infection (Pratt et al, 2007). Dressings must not be secured with a bandage as this causes them to retain moisture and makes it impossible to see the insertion site (Dougherty and Lister, 2008).

Handwashing has been indicated to be the single most important step in breaking the chain of infection. The World Health Organization (2009) indicates that hands should be decontaminated before clean and aseptic procedures, and handwashing

Dorsal venous arch

Cephalic vein

Basilic vein

Nursing PracticePractice educator

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is a key recommendation in national care bundles that aim to reduce the risk of healthcare-acquired infections associated with PVCs (HPS, 2012; DH, 2011).

The high-impact PVC care bundle used in England and Wales (DH, 2011) advocates that PVC access ports, particularly needle-less connections, are cleansed with 2% chlorhexidine gluconate in 70% isopropyl alcohol before drugs are administered. These recommendations stem from national epic2 guidelines for preventing HCAIs in central venous catheters (Pratt et al, 2007).

More recently it has been argued, based on further microbiological research studies and similar recommendations within American national guidelines (O’Grady et al, 2011), that the type of cleansing solution might be less impor-tant than the physical action of cleaning the port (HPS, 2012). The Scottish PVC care-quality improvement tool, therefore recommends scrubbing the port with an antiseptic solution containing 70% iso-propyl alcohol for 15 seconds or more before use (HPS, 2012). However, HPS (2012) acknowledges that there are limita-tions in the quality of research used to inform the choice of antiseptic solution for PVCs, so further studies are necessary to improve the evidence base underpin-ning these recommendations.

Nurses should ensure their clinical practice adheres to local hospital policies in relation to this issue. Regardless of the cleansing solution selected, the DH (2011) and HPS (2012) agree that the PVC port must be allowed to dry before the device is used.

DocumentationThe date, time and reason for removal of the PVC should be documented within the patient’s notes with the corresponding grade on the phlebitis scale (RCN, 2010). The widespread acknowledgement that PVCs are associated with HCAIs has prompted many hospitals to adopt quality assessment and monitoring tools in an attempt to reduce these infections. Docu-mentation plays an important role in the audit process, facilitates the generation of measurable real-time data (HPS, 2012; DH, 2011), and has been found to improve staff compliance with care bundles. This should help to improve the quality of care for patients with a PVC in situ (Boyd et al, 2011; Easterlow et al, 2010).

Conclusion The complications associated with PVCs can have potentially damaging or even fatal consequences for patients. Infection and phlebitis are avoidable if simple hygiene and safety principles are adhered to for each patient at every point of contact. Nurses can significantly influence the quality of care provided by adopting the principles associ-ated with the safe management and care of patients who have these devices in situ (HPS, 2012; DH, 2011). NT

ReferencesBoyd S et al (2011) Peripheral intravenous catheters: the road to quality improvement and safer patient care. Journal of Hospital Infection; 77: 37-41.Department of Health (2011) High Impact Intervention No 2: Peripheral Intravenous Cannula Care Bundle. tinyurl.com/DH-HIA2-cannulaDougherty L, Lister S (2008) The Royal Marsden Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell.

Dychter S et al (2012) Intravenous therapy: a review of complications and economic considerations of peripheral access. Journal of Infusion Nursing; 35: 2, 84-91.Easterlow D et al (2010) Implementing and standardising the use of peripheral vascular access devices. Journal of Clinical Nursing; 19: 721-727.Health Protection Scotland (2012) Targeted Literature Review: What are the Key Infection Prevention and Control Recommendations to Inform a Peripheral Vascular Catheter (PVC) Maintenance Care Quality Improvement Tool? tinyurl.com/HPS-PVC-rev Higginson R, Parry A (2011) Phlebitis: treatment, care and prevention. Nursing Times; 107: 36, 18-21.Jackson A (1998) Infection control: a battle in vein infusion phlebitis. Nursing Times; 94: 4, 68-71.Joanna Briggs Institute (2008) Management of peripheral intravascular devices. Best Practice; 12: 5, 1-4.Lavery I (2007) Peripheral intravenous cannulation: safe insertion and removal. Nursing Standard; 22: 1, 44-48.Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC. tinyurl.com/NMC-Code-standardsO’Grady N et al (2011) Guidelines for the prevention of intravascular catheter-related infections. Clinical Infectious Diseases; 52: e162-e193.Pratt R et al (2007) epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection; 65S: S1-S64.Reilly J et al (2007) NHS Scotland National HAI Prevalence Survey. Volume 1 of 2: Final Report. Glasgow: Health Protection Scotland. tinyurl.com/HPS-Prevalence-2007Rowley S (2001) Theory to practice: aseptic non-touch technique. Nursing Times; 97: 7, 7-8.Royal College of Nursing (2010) Standards for Infusion Therapy. London: RCN. tinyurl.com/RCN-InfusionWebster J et al (2010) Clinically indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Systematic Review. 3: CD007798.World Health Organization (2009) WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge. Clean Care is Safer Care. Geneva: WHO. tinyurl.com/WHO-hand-hygiene

FIG 2. VISUAL INFUSION PHLEBITIS SCORE

IV site appears healthy No sign of phlebitis Observe cannula

One of the following is evident: Slight pain near IV site

Slight redness near IV site

Possible sign of phlebitis Observe cannula

Two of the following are evident: Pale near IV site Erythema Swelling

Early stage of phlebitis Resite cannula

All of the following are evident: Pain along path of cannula Erythema

Induration

Medium stage of phlebitis Resite cannula Consider treatment

All of the following are evident and extensive: Pain along path of cannula Erythema

Induration Palpable venous cord

Advanced stage of phlebitis or start of thrombophlebitis

Resite cannula Consider treatment

All of the following are evident and extensive: Pain along path of cannula Erythema

Induration Palpable venous cord Pyrexia

Advanced stage of thrombophlebitis Initiate treatment Resite cannula

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