Paediatric Intravenous Cannulation – OSCE Guide

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This paediatric intravenous (IV) cannulation guide provides a step-by-step approach to performing intravenous cannulation in children and young people. Our guide also covers how to collectΒ blood samples during paediatric cannulation.Β 


Preparation

Children should be offered a topical anaesthetic where time allows (e.g. Ametopβ„’, EMLAβ„’ or LMX-4β„’).

Check the minimum age the product is licensed for and the minimum and maximum durations the anaesthetic should be left on the skin, as this differs between products.

Apply a blob of cream over the vein and cover it with a clear film dressing. It can be helpful to wrap it with a bandage to prevent the child from removing the dressing and cream.

Older children can be offered a vapocoolant spray (β€˜cold spray’), used at the time of cannulation.1 It is reasonable to show them what it feels like first, as the spray can startle some children.

Babies can be given oral sucrose just before cannulation to minimise pain. The majority of evidence of effectiveness is in infants <3 months, but there may be an analgesic effect in infants up to 12 months.2 It can also help if they are held by a parent.

Once the topical anaesthetic has been applied for the recommended time, and you are ready to perform cannulation, take the child to a treatment room away from their bedspace if possible. This aims to keep the child’s bed space as a safe space which they do not associate with traumatic procedures.


Gather equipment

Collect the equipment required for the procedure and place it within reach on a tray or trolley, ensuring that all the items are clearly visible.

The equipment you need will differ depending on the age of the child.

  • Clean procedure tray
  • Non-sterile gloves and apron
  • Tourniquet (if appropriate)
  • Vapocoolant spray (β€˜cold spray’), if required
  • Alcohol swab (2% chlorhexidine gluconate in 70% isopropyl)
  • Appropriate size cannula, either winged or non-winged, depending on preference and availability
  • Sterile dressing pack (to provide a sterile field)
  • Cannula dressing
  • Extension set
  • Gauze swabs
  • Normal saline 0.9% (10 ml)
  • Syringe (10ml)
  • Sharps container
  • Support board/splint, if appropriate
  • Paediatric IV cannulation - gather equipment
    Gather equipment

Ask a play specialist to accompany you to distract and reassure the child.

In older children, a tourniquet can be used. In younger children, a colleague should act as the tourniquet by holding around the arm and squeezing. This will also help minimise movement from the child.

In babies, you should be able to hold the limb tightly enough to act as a tourniquet, but an assistant can help if required.Β 

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Introduction

Wash your hands using alcohol gel. If your hands are visibly soiled, wash them with soap and water.

Don PPE if appropriate.

Introduce yourself to the child and parent/caregiver, including your name and role.

Confirm the patient’s name and date of birthΒ with either the patient or parent (depending on age).

Briefly explain what the procedure will involve using age-appropriateΒ language.

For example, with younger children: “I need to take some of your blood to help find out why you are poorly. I’m going to put a bendy straw into your hand so we can get the blood and give you medicines to make you feel better”.

Older children, or children who have previously been cannulated, may have a better understanding of what is going to happen and so the explanation should be tailored to this. For example: “I’m going to put in a cannula, which is a small plastic tube, so we can take some blood samples and give you medication and fluids. I will use a small needle to insert it, then once the tube is in I will remove the needle, and that part goes in the bin, leaving the plastic tube”.

Managing fear

Some children become particularly frightened when you approach them with a tray of unfamiliar objects. It can help to ask, “would you like me to talk about what we are going to do first and show you all the equipment so you know what it does?”.

They may decide they don’t want to see anything, so you should ensure the parent knows what will happen. However, most are much less frightened once they know what the equipment does.

Gain consent (from the parent(s), and the child, if appropriate) to proceed with intravenous cannulation.

Check if the patient has any allergies (e.g. latex).


Expose the site

Remove any local anaesthetic cream with a paper towel or gauze, if used.Β 

Identify and expose the site.Β  Make sure you take your time looking for a vein you feel most likely to be successful in cannulating.

When choosing a vein:

  • Do not cannulate an arm with IV fluids running through it if you wish to obtain blood samples, as the results can be altered by the fluids.
  • Avoid areas of skin damage or bruises.
  • Aim for veins that appear straight and do not join together, as these are likely to have valves.

In children, veins are less likely to be palpable and β€˜spongy’.

In babies and younger children, particularly those who are not yet mobile, hands and feet are a good option. For older children, hands, arms and the ACF are possible sites. However, cannulae over joints are more uncomfortable, may dislodge sooner, and can be a nuisance for children.


Position the patient

Position the patient. For younger children, sit them on a parent’s knee, ensure they are securely held, and you have clear access to the site you are cannulating. Be mindful of where the other limbs are, as young children may kick.

When cannulating babies, the parent can hold them to reduce distress. If a firm surface is required, they can lay on the bed.

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Preparation

1. Don gloves (if not already wearing some).

2. Open the dressing pack and place the cannula, cannula dressing and other items onto the field.

3. Prepare the normal saline flush by drawing the saline into your syringe (if you have a pre-filled flush you can ignore this step).

4. If you are planning on using an extension set, you should attach this to the flush and prime the line.

5. Clean the site with an alcohol swab for 30 seconds and then allow to dry completely for 30 seconds:

  • You should start cleaning from the centre of the cannulation site and work outwards to cover an area of 5cm or more.
  • DO NOT touch the cleaned site afterwards at any point, otherwise, the cleaning procedure will need to be repeated prior to cannulation.

Inserting the cannula

1. Check everyone is ready to start, including the parent, play specialist, and the person holding the child’s arm. Apply the tourniquet.

2. Remove the cannula sheath.

3. Anchor the vein with your non-dominant hand from below by gently pulling on the skin distal to the insertion site. If someone is acting as your tourniquet, they can provide slight upward traction on the skin.

4. If you are using vapocoolant spray, ask your assistant to spray from a distance of 15-20cm from the skin, in either 2-3 short bursts or for a couple of seconds. The skin should turn slightly white (avoid β€˜frosting’ the skin as this can be painful).

5. Insert the cannula with the bevel facing upwards within 15 seconds of applying the vapocoolant spray. In children, the angle of entry is less than adult cannulation and can be almost parallel to the skin.

6. Observe for a flashback of blood into the cannula chamber, which confirms that the needle has punctured the vein.

7. Partially withdraw the introducer needle, ensuring the needle end is within the plastic tubing of the cannula (you should observe blood entering the plastic tubing of the cannula as you do this).

8. Carefully advance the cannula into the vein as you simultaneously withdraw the introducer needle until the cannula is fully inserted and the needle is almost removed.

10. Place some sterile gauze directly underneath the cannula hub.

11. Apply pressure to the proximal vein close to the tip of the cannula to reduce bleeding.

12. Gently pull the introducer needle backwards whilst holding the cannula in position until the introducer is completely removed.

13. Dispose of the introducer needle immediately into a sharps container.

13. Collect blood samples from the cannula if required (see below).

14. Release the tourniquet.

15. Connect a primed extension set to the cannula hub.

16. Flush and secure the cannula. There are various methods to do this, depending on whether the cannula has wings.Β 

Number of attempts

Children can quickly become distressed with repeated attempts to perform cannulation. As a general rule of thumb, a single practitioner should have no more than two attempts before seeking senior support.


Collecting blood samples during cannulation

One common technique for collecting blood samples from a child is to collect blood after inserting a cannula.

There are three main collecting methods – dripping, blunt needle collection, and syringe collection.

For each of these methods, the blood collection is usually performed before the cannula is secured, but it can be sensible to apply a Steri-Stripβ„’ over the cannula before collecting the blood to ensure it doesn’t slip.

Dripping

This is often the easiest way to collect blood and can be used in any sized cannula or child.

After removing the needle, blood can drip/flow freely into the paediatric sample bottles. This technique is usually used to collect routine biochemistry and haematology samples.

Once you have collected the blood, gently occlude above the tip of the cannula to minimise blood spillage whilst you are attaching the extension set. Flush the extension, and secure the cannula.

You should maintain hold of the child’s arm or leg during this with one hand. Often the assistant is needed to pass the bottles to you and secure the lids.

Blunt needle collection

This technique is used to collect blood cultures in infants and children in whom a vacutainer cannot be used. Before cannulation, prepare the needle and syringe:

1. Open a blunt fill needle without touching the end. Check it is not a filter needle (you cannot aspirate blood with a filter needle).

2. Open a 5ml or 10ml syringe, again without touching the end, and connect the two. Do not remove the needle sheath until ready to collect the blood.

Insert the cannula, remove the needle and wait for the blood to fill the cannula hub. Insert the end of the needle just into the hub of the cannula and pull on the syringe to extract the blood. Wait for the hub to refill, then repeat the process until you have enough blood.

If you are using this method to collect blood for cultures, this should always be done before collecting any other samples to maintain sterility. You can then collect the remaining samples with the drip method described above.

Syringe collection

A syringe can be used to collect blood out of cannulae that are 22G or larger. Once you have removed the needle, attach a 5 or 10ml syringe to the end of the cannula and gently aspirate the blood.

Larger syringes and vigorous aspiration are likely to collapse the vein and should be avoided. Once you have enough blood, attach the extension set and flush, then secure the cannula.

Decant the blood into the appropriate sample bottles.


Flush and secure the cannula

1. Inject the normal saline into the cannula using the flush you prepared earlier:

  • The flush should be easy to administer with minimal resistance.
  • Observe for signs of swelling or blanching around the site and pain during administration, stop if this occurs.

2. Secure the cannula (see below)

3. Bandage the cannula to prevent the child from removing the dressing. Apply a splint over cannulae in infants. In older children and young people, ask if they would like a bandage.

4. Once secure, let go of the child’s limb and congratulate them for being brave! Many children will respond well to rewards, such as stickers, after a painful procedure.

Securing the cannula

There are several methods for securing a cannula in a child, with many clinicians having a personal preference. We will discuss methods for securing both winged and non-winged cannulae.

This is not an exhaustive list, and various other methods will be encountered in clinical practice. It is important to follow local guidelines.Β 

Method one: β€˜under and over’

Usually best for cannulae without wings, although it can be used to secure winged cannulae.

1. Once the extension set is attached and flushed, ask the assistant to pass a Steri-Stripβ„’ (or similar) under the hub of the cannula, then wrap the two ends over the top of the cannula in an β€˜awareness ribbon’ shape.

2. Put a small piece of cotton wool under the hub of the cannula to prevent pressure damage.

3. Apply a second Steri-Stripβ„’ across the hub of the cannula.

4. Place the windowed dressing over the top, with the window covering the insertion point.

5. Apply the bandage.

  • Pass a Steri-Stripβ„’ (or similar) under the hub of the cannula, then wrap the two ends over the top of the cannula in an β€˜awareness ribbon’ shape

Method 2: β€˜over the wings’

As the name suggests, applicable only to cannulae with wings. This is fairly similar to securing a cannula in an adult.

1. Once the extension set is attached and flushed, place a small piece of cotton wool under the hub of the cannula to prevent pressure damage.

2. Ask the assistant to place a Steri-Stripβ„’, or the tape which comes with a window dressing, over each wing.

3. A thirdΒ  Steri-Stripβ„’ can be attached horizontally across the cannula to form an β€˜H’ shape.

4. Place the windowed dressing over the top, with the window covering the insertion point.

5. Apply the bandage.

  • Place a Steri-Stripβ„’, or tape which comes with a window dressing, over each wing of the cannula

Importantly, with both methods, do not let go of the cannula until you are sure it is secure!


To complete the procedure…

Explain to the patient and parent that the procedure is now complete.

Dispose of your PPE and other clinical waste into an appropriate clinical waste bin.

Wash your hands.

Document the details of the procedure on a cannulation chart or in the patient’s notes including:

  • The patient’s details: full name, date of birth and unique identification number.
  • The date and time that cannulation was performed.
  • The indication for cannulation.
  • The type of cannula used (e.g. 20 gauge).
  • The site of cannulation (e.g. dorsum of the left hand).
  • The date on which the cannula should be removed or replaced.
  • Your name, grade and contact details.

Reviewer

Dr Matt Fox


Editor

Dr Chris Jefferies


References

  1. Griffith RJ et al. Vapocoolants (cold spray) for pain treatment during intravenous cannulation. Published 2016. Available from: [LINK]
  2. Thyr M et al. Oral glucose as an analgesic to reduce infant distress following immunization at the age of 3, 5 and 12 months. Published January 2007. Available from: [LINK]
  3. Royal Children’s Hospital Melbourne. Intravenous access – peripheral. Updated in September 2019. Available from: [LINK]
  4. Don’t Forget the Bubbles. Twelve tips to pacing a well secured peripheral IV cannula. Published January 2016. Updated June 2012. Available from: [LINK]

 

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