Peripheral Venous Cannulation

Handy Hints:

  • Finding the best veins:
    • Time spent optimising patient positioning, preparation and finding the best vein is rarely wasted.
    • If you cannot feel a vein in the first arm, stop and review the other sites.
    • Downstream of the convergency of 2 veins the vein is less mobile.
    • Avoid valves and just proximal to a convergence point.
  • Guide-wires can be used to insert wide bore cannulas if only a 20G could be sited (e.g. RICC)
  • Cannulae may fail to advance fully if they encounter a valve or a site of vein convergence.
  • NB. In a life-threatening situation the lymphoedema or renal graft arm may be used!
  • Accurate basic electrolytes and hematologic values can be drawn from peripheral IV lines when infusions are shut off at least 2 minutes, at least 5 mL of blood are wasted, and all tubes are filled to the top to avoid inaccurate bicarbonate readings. Avoid excessive suction on the cannula which can cause hemolysis

Techniques to increase chance of successful cannulation

  • Lower the arm below the heat
  • Heat packs or towels (10-20min)
  • 0.5 to 1 cm of 2% nitroglycerin is applied to a 2.5 cm square area, left on for 2 minutes, and then rubbed off
  • Open and close fist
  • Light tapping (heavy tapping may cause vasospasm)

The use of local anaesthetic for peripheral venous cannulation

Subcutaneous infiltration with local anaesthetic  (0.3mL 1% lignocaine) can significantly reduce the pain of cannulation and reduce persistent discomfort at the site of cannulation

  1. Harrison N, Langham BT, Bogod DG. Appropriate use of local anaesthetic for venous cannulation.Anaesthesia 1992;47: 210-12 [PubMed]
  2. Lightowler JV, Elliott MW. Local anaesthetic infiltration prior to arterial puncture for blood gas analysis: a survey of current practice and a double blind placebo controlled trial. J R Coll Physicians Lond 1997;31: 645-6 [PubMed]
  3. Van Der Berg AA, Abeysekera RM. Rationalising venous cannulation: Patient factors and lignocaine efficacy. Anaesthesia 1993;48: 84. [PubMed]
  4. Local anaesthesia for venous cannulation and arterial blood gas sampling: are doctors using it? [PubMed]
  5. Yentis SM. Use of intravenous cannulae by junior hospital doctors. Postgrad Med J 1993;69: 389-91 [PubMed]
  6. Langham BT, Harrison DA. Local anaesthetic: Does it really reduce the pain of insertion of all sizes of venous cannula. Anaesthesia 1992;47: 890-1 [PubMed]
  7. Ong EL, Lim NL, Koay CK. Towards a pain free venepuncture. Anaesthesia 2000;55: 260-2 [PubMed]
  8. K. D. Röhm Do we necessarily need local anaesthetics for venous cannulation? A comparison of different cannula sizes. European Journal of Anaesthesiology (2004), 21:3:214-216 [Cambridge Journals]
Procedure for ‘blocked’ cannulae
  • Pain at the infusion site or the alarm sounding on an infusion pump device requires inspection of the infusion site for extravasation
  • Cease IV fluids/fluid pump.
    • Check pump is working (disconnected, flat bettery)
    • Check bag not empty, check line not filled with air
      • Attempt aspiration from cannula → OK →.
      • Failed aspiration → Gently flush with 2-3 mL normal saline → OK → Recommence fluids
      • If ­ resistance, extravasation, pain, erythema, signs of infection → Resite cannula.
Complication of peripheral cannulation
  • Local
    • Local tissue infiltration (tissuing) following cannula dislodgement, or through-and-through vein perforation
    • Haematoma
    • Line occlusion secondary to backflow of blood or kinking of tubing
    • Vein irritation and thrombophlebitis
    • Local infection. IV cannulae should be replaced every 48-72 hours to minimise the risk of infection
    • Nerve, tendon or ligament damage.
  • Systemic
    • Vasovagal reaction on insertion
    • Systemic infection
    • Air embolism, particularly with large-bore cannula.
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