Peripheral Venous Cannulae in Neonates on the Neonatal Unit - Standard Operating Procedure for the Insertion and Maintenance of
|Next review: 01/03/2024|
|Standard Operating Procedure|
|Approved By: Trust Clinical Guidelines Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2021|
This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
Please check the patients allergy status, as they may be allergic to Chlorhexidine, and alternative ( Providine iodine) solution will be required.
Be aware: Chlorhexidine is considered an environmental allergen.
Refer to the asepsis guidance.
Standard Operating Procedure for the Insertion and Maintenance of Peripheral Venous Cannulae in Neonates on the Neonatal Unit
Peripheral cannulation is a common invasive procedure carried out within the Neonatal Unit. It is the preferred method of vascular access in most non-emergent situations. Peripheral venous access is indicated for the administration of fluids and medication.
Vascular catheter related infection is an important cause of mortality and morbidity in hospitalised patients. The most common responsible organisms are Staphylococcus aureus and Staphylococcus epidermis. Most catheter related infections occur shortly after insertion. The strict application of appropriate aseptic techniques and subsequent care of the catheter are the most important factors in the reduction in the incidence of sepsis.
- To maintain fluid/electrolyte balance in infants unable to take enteral fluids
- To achieve predictable drug levels e.g. antibiotics for infection
- Emergency situations
- Prior to a surgical procedure
- For infants whose gastrointestinal tract has to be rested e.g. patients with non-functioning or inadequately functioning gastrointestinal tracts, or following gastrointestinal surgery
- When the medicine is not broken down in, or not absorbed from the gastrointestinal tract
- When an injection is required but injection into the skin or muscle would cause pain or trauma
- When the medicine is not available in alternative formulation
- Patient identification: Practitioners must identify that they have the correct patient in accordance with LTHT Policy for Positive Patient Identification and they should try to obtain verbal consent prior to undertaking the procedure from the infant’s carers.
- Infection Prevention and Control
- Insertion should take place in an appropriate clinical area.
- Strict hand hygiene must be followed (LTHT Hand Hygiene in Practice Policy).
- An aseptic technique must be used (LTHT Asepsis Policy).
- All cannulation equipment must be sterile prior to use and sterile examination gloves and an IV cannulation pack must be used to undertake the procedure.
Cannulation should only be performed by a practitioner who has the relevant knowledge and skills to do so .
An insertion attempt is defined as one needle puncture of the skin. Peripheral venous cannula attempts must be limited to two attempts (two needle punctures) by each health care professional. If a baby is deemed to have difficult venous access, the first attempt should be made by an experienced operator. For each separate attempt, the skin must be cleaned again with fresh ChloraPrep® and a new cannulation pack and new cannula used.
Metal trolleys should be used, and must be decontaminated with Sani-cloth before use (see Trust IPC asepsis video http://lthweb.leedsth.nhs.uk/content/aseptic/v6/ch3.php ). The operator and/or assistant should prepare all necessary equipment on the clean trolley. Once the operator is sterile, if further equipment is required, the observer must fetch and open packs.
The preferred sites for neonatal cannulation are
- The dorsum of the hand
- The dorsum of the foot
- The cephalic vein on the radial border of the wrist
Cannulation should be avoided on bruised, painful or infected sites.
Peripheral venous cannulation should not be attempted in the areas preferred for peripherally inserted central venous catheters (Long lines) i.e. antecubital fossa and medial aspect of the ankle and lower leg.
Intravenous cannulation is a painful procedure for the Neonate. The procedure should be carried out in a developmentally supportive manner.
- Swaddling (providing containment and support)
- Provide neutral thermal environment and prevent cold stress
- Administer sucrose in accordance with the Neonatal Pain Management guideline Procedural Pain in the Newborn
The site should be cleaned with 2% chlorhexidine/70% alcohol (ChloraPrep® and allowed to air dry for 30 seconds. In babies under 30 weeks gestation, use a dabbing rather than rubbing motion to maintain skin integrity. In babies < 28 weeks gestation and < 1 week old, clean skin again with sterile 0.9% sodium chloride, to minimise risk of skin burns due to pooling.
Refer to the neonatal procedures handbook for insertion technique. Handling of the cannula should be kept to the minimum.
Blood samples may be taken immediately from the line according to the SOP for neonatal blood cultures Blood Culture Sampling in Neonates
The entry site is an open wound. In order to prevent migration and infection of the cannula it should be dressed appropriately with a transparent semi-permeable dressing this will prevent bacterial access while still allowing visual inspection. The device should be secured with steri strips and dressed in a manner that should not impair the visual assessment of the insertion site or obstruct delivery of the prescribed therapy.
An insertion date label should be applied to the dressing.
A cannula dressing which becomes loose, or where moisture is seen beneath the dressing must be replaced. Following removal of the dressing the cannula site should be cleaned with 2% Chlorhexidine in 70% alcohol and allowed to dry for 30 seconds. The dressing should be changed using an aseptic non touch technique.
Bandages are not recommended for the additional securing of the peripheral cannula as they make observation of the insertion site difficult. Single use splints may be used.
Cannulae should be flushed with 1-2mL of 0.9% Sodium Chloride for injection in a 2ml syringe. All flushing solutions should be prescribed and recorded once administered.
Cannulae should be flushed using a pulsatile ‘push-pause’ technique. This creates turbulence, removing debris from the internal wall ensuring clearance of drugs.
If resistance is met when attempting to flush a cannula excessive pressure should not be exerted. This may damage the vein or expel thrombus from the cannula.
Cannula should be flushed (using appropriate flush as per IV drug monographs guidelines):-
- Following device placement
- To check patency
- Before drug/solution administration
- Before connection of infusions
- Between multiple drug administration
- Following drug/solution administration
- Following sampling (blood samples can only be taken from peripheral cannulae immediately following insertion and before they have been flushed).
All attempts at cannulation (successful and unsuccessful) should be documented using the Infection prevention booklet (IPC). The following information must be recorded as a minimum standard
- Date and time
- Site of cannula (successful and unsuccessful)
- Reason for insertion
- Operators name and signature
The cannulation record should be placed in nursing kardex. IPC booklet in orange folder.
All infants with a cannula must have the site checked at least twice daily for signs of phlebitis. The Visual Infusion Phlebitis VIP score (appendix 1) must be documented on the LTHT insertion and ongoing care record (see appendix 3).
If there is any redness, tenderness or swelling around the insertion site action should be taken. Refer to VIP score.
Cannula sites should also be observed:
- Hourly when IV fluids are infusing
- When bolus injections are administered
- When IV flow rates are checked or altered
- When solution containers are changed
- When vesicant or irritant medication is administered
For recommendations on management of VIP score see appendix 2.
The continuing need for IV access must be considered daily and documented in the patient’s notes. A cannula that is no longer required should be removed immediately.
If a patient’s cannula site has a phlebitis score of 2 or more, the cannula should be removed immediately and replaced if venous access is still required at another distant site.
- Maintain asepsis and universal precautions throughout procedure
- Stop the infusion and disconnect tubing ensuring device is clamped
- Release the transparent dressing from the skin.
- Withdraw the catheter outside the vein and apply pressure using gauze for at least 5 minutes. Observe site for bleeding. Do not apply dressing.
- Inspect the catheter for fragmentation.
- Document removal on the Paediatric and Neonatal Cannulation documentation record including the following information
- Date and time of removal
- Reason for removal
Management of complications
Remove device immediately
Apply pressure until bleeding stops
Document in patient’s notes
Seek urgent medical help if bleeding persists; large hematoma develops or signs of limb ischemia.
Vascular surgery if bleeding persists
The leakage of intravenous drugs from the vein into the surrounding tissue
Risk reduced by:
If extravasation does occur follow the Management of Extravasation: Treatment summary
Apply pressure until bleeding stops
Local site Infection
Infection at or near cannula insertion site.
See VIP score
Peripheral Venous Cannula Associated Bacteraemia
An infection of the blood stream (bacteraemia) caused by a cannula. May develop following a local site infection.
Remove cannula if still insitu
To promote and standardise best practice in the insertion, ongoing care and removal of peripheral venous cannulae on the neonatal unit.
Neonates requiring cannulation
|Target patient group:||Newborn infants|
|Target professional group(s):||Secondary Care Doctors
Secondary Care Nurses
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Trust Clinical Guidelines Group
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