Procedure: Intravenous Cannulation

Casebank Combined
1

Who you are:
You are FY2 in Surgery Department

Who the patient is:
Jamie Smith, 28-year-old male has had an appendectomy few hours ago. His cannula is blocked

Other information:
Your consultant has asked you to change his IV cannula

Special Note:
The patient is on 5mg IV morphine 4 hourly. His last dose was 1hr ago

What you must do:
Take focused history, do the relevant procedure, and address the patient’s concerns

History Taking

  • Start the station well (I can see from my notes that you have been undergone an operation to remove your appendix a few hours ago)
  • IPS:
    – Pick up on non-verbal cues (the patient will be in pain) - Build
    – Rapport.
    – Ask how the operation went.
  • Why? & Why?
    – My consultant has asked me to change your blocked cannula to give medications and fluids
  • Focused History relevant only to your procedure
    – Explore the Pain (SOCRATES)
    – Ask about any bleeding, pain, or discharge from the operation site.
    – Ask about bowel motion since after the operation.
  • Red flags - bleeding, signs of infection
  • MMA
    – Medical Conditions (specify any bleeding disorder) - Medications (specify any blood thinner)

Patient preparation

Patient

  • Benefit : I would like to change your cannula in order to be able to give you fluids and medications through it.
  • Risk: It should not be painful, but if you feel uncomfortable at any time let me know.
  • Explain: explain exactly what you are going to do: (I will be inserting a thin needle into one of the blood vessels (veins/ arteries) of your (forearm/ wrist).
  • It will feel like a sharp scratch, but I will be as quick and gentle as possible

Doctor

  • Position : Can you please straighten your elbow/ wrist for me.
  • Exposure: Can you please roll up your sleeves for me.
  • Please be observant. (Notice whether the patient has short sleeves, or has rolled up the sleeves already, and comment on it accordingly).

Both

  • Privacy: I will ensure your privacy.
  • Chaperon: Blood procedures do not require a chaperone.
  • Consent: Do I have your consent to proceed.
  • Ask about any arm soreness and any arm preference.
  • Do not forget to inform the patient that if you fail, you may need to repeat the procedure.

Procedure:

  • Remove the blocked cannula, discard it into the waste bin and ask the patient to press the cotton down.
  • Collect your equipment:
    – Tourniquet
    – Alcohol swab
    – Cannula
    – Tegaderm - 2 cc syringe filled with saline The syringe will be already prefilled with saline
    – Gauze piece - Cotton piece.
  • Prepare your equipment in your clean area, then put them in your tray:
    – Partially open the alcohol swabs.
    – Make cannula ready to use, remove the stopper, loosen the cap on top and loosed the cap covering the needle and place in your tray.
    – Prepare the Tegaderm: Take the 3 stickers off and stick them on the
    side of the tray.
  • Gloves: Assume you are wearing gloves
  • Feel the vein
  • Torniquet (Tie the torniquet above the cubital fossa)
  • Clean Prick Collect
    – Clean the area with one single stroke
    – Insert the cannula with the bevel facing upwards. Flashback of blood is seen in the hub at the back of the cannula- advance the needle into the vein at 15 degrees (Lower) and progress the entire cannula a further 2mm to ensure it is in the vein.
    – Fix the needle by holding the end of the needle steady with your non-dominant hand and slide the rest of the cannula forwards slightly.
    – Withdraw (Retract) the needle slightly so that its sharp point is inside of the plastic tubing.
    – Advance cannula fully into vein – The needle still inside the tubing will stop the plastic from kinking.
    – Loosen the tourniquet
    – Place some gauze directly underneath the cannula. Then remove the needle fully and dispose it into the sharps bin.
    – Put the stopper back to the cannula.
    – Put two of the stickers on both sides of the cannula. Then flush the cannula and close the cannula port.
  • Label: Fix the Tegaderm on securely and verbalize labeling the date and time and discard your waste.

Management

Sit down and discuss with the patient the management details:

Examination:

  • Vitals- respiratory depression (because of Morphine)
  • GPE- shock/dehydration
  • Operation site
  • Abdominal examination- internal bleeding

Investigations

  • FBC, LFT, RFT
  • Coagulation profile
  • Monitor Urine output

Treatment

  • For the pain: according to the patient’s charts and the last dose of morphine
    – If he is on 5 mg IV morphine 4 hourly and his last dose was 1 hour ago, then no morphine but we give instead 1g IV PCM o Check
    Vitals- RR before giving morphine
    – If still in pain: o Encourage to wait for some time- reassess in 10-15 mins
  • For the Nausea: IV Metoclopramide 10mg

Safety net

  • about the procedure itself (any bleeding, swelling or soreness)
  • about the patient’s general condition (Tummy pain, discharge, bleeding from the operation site, constipation, if pain does not resolve…)