Cannulation and complications

Cannulation and complications JOEL ARUDCHELVAM

1. Cannulation and complications JOEL ARUDCHELVAM MBBS (COL), MD (SUR), MRCS (ENG) CONSULTANT VASCULAR AND TRANSPLANT SURGEON

2. Cannula Latin - "little reed "* A hollow tube with a retractable inner core that can be inserted into a vein, an artery, or another body cavity

3. I ntravenous catheters Includes; Peripheral cannula – Arterial / Venous Central catheters

4. PARTS OF CANNULA

5. Indication for cannulation Intravenous fluid administration Intravenous medications Intravenous chemotherapy Intravenous nutrition Blood or blood products administration Administration of radiological contrast

6. Sizes of cannula COLOR CODE GAUGE OD m.m. FLOW RATE ml/min. Orange 14G 2.10 290 Grey 16G 1.70 176 White 17G 1.50 130 Green 18G 1.30 76 Pink 20G 1.00 54 Blue 22G 0.85 31 Yellow 24G 0.70 14

7. Upper limb veins Upper Limb superficial veins Cephalic vein Basilic vein

8. Upper limb veins Cephalic vein - Close to ; Radial artery at wrist Brachial artery at elbow Basilic vein - Close to ; Brachial artery at elbow and arm

9. Upper limb veins Cephalic vein - Close to ; Radial artery at wrist Brachial artery at elbow Basilic vein - Close to ; Brachial artery at elbow and arm

10. Upper limb veins Variations

11. Cannula Insertion Procedure Explain the procedure Select the appropriate size cannula Get all the equipment ready

12. The sites to avoid Wrist, feet, ankle Veins below a previous IV infiltration Phlebitic area or thrombosed veins Inflamed skin An arm with oedema , DVT, infection Arm with AVF

13. Cannula Insertion Surgical spirit Gloves Tourniquet An IV cannula Plaster A syringe Saline ,IV set and prime Kidney tray

14. Cannula Insertion Position the patient keep arm in a comfortable position Look for any abnormalities at the cannulation site , variations Apply tourniquet identify the vein Wear the glove and clean the site

15. Cannula Insertion Take the cannula open the wings of the cannula and hold the cannula between the thumb index and middle fingers Stretch the skin distal to the site of insertion and insert the cannula at 30°

16. Cannula Insertion Inspect for the flashback of blood in the hub Then insert the cannula a little more and then withdraw the needle and advances cannula into vein Keep the pressure at the tip of the cannula and put the cap to the hub Check for function

17. Cannula Insertion Apply plaster, mark date

18. Complications of cannulation Accidental intra arterial cannulation Infection Extravasation and compartment syndrome Fracture and retention of part of the cannula /embolisation

19. Infection

20. Sources of infection Site Ports Infusion fluid and devices S. aureus - 60 to 90% of infections

21. INFECTION PREVENTION Hand disinfection Sterile gloves Disinfect the skin insertion site. Cover with sterile dressing Remove catheter if signs of infection occur Change dressing only when necessary Close ports that are not needed with sterile caps

22. INFECTION PREVENTION Preparation and administration of intravenous mixtures

23. Accidental Intra Arterial Cannulation / Injection

24. Risk factors Unconscious or sedated patients Trauma patients , hypotensive patients Vascular anomalies Children Receiving multiple infusion Obese

25. Intra-arterial cannulation / injection of drugs Results in thrombosis by; Spasm Trauma to the vessel wall and thrombosis Occlusion of the vessels by particles in the drug Crystallization of the drug after injection Endothelial injury - chemical arteritis resulting in platelet adhesions High osmolarity causing vessel injury 

26. Prevention of intra-arterial cannulation / injection Knowledge about the anatomical variations · Avoiding cannulation close the known neurovascular bundle e.g. cubital fossa

27. Prevention of intra-arterial cannulation / injection Recognition of intra-arterial cannulation in case of accidental insertion of a cannula. When the cannula is within the artery - flashback of bright red blood

28. If the cannula is within the artery ………………….. There will be a pulsatile back bleeding of bright red blood There may be a hematoma formation If the cannula is connected with the infusion set or a syringe there will be back flow of blood into these under high pressure P ain along the arm to fingers with injection

29. Accidental intra arterial injection

30. If the cannula is within the artery ………………….. If accidental intra-arterial cannulation is recognised C annula should be immediately removed A pply local pressure The distal circulation should be monitored. Arudchelvam J, Marasinghe A (2019) Accidental Intra-Arterial Injection of a Drug in a Patient with Radial Artery Variation; A Rarity Leading to a Disaster. J Clinical Case Rep Case Stud 2019: 66-68 .

31. In case of accidental intra-arterial injection D o not remove the cannula the same cannula which was used for injection can be used……….. to flush the artery with heparin saline for injection of thrombolytic agents for injection of vasodilators can also be used to perform an angiography

32. In case of accidental intra-arterial injection Treatment options Analgesics systemic heparinization Catheter directed intra-arterial thrombolysis (with streptokinase, urokinase ) systemic use of dextran and steroids Surgical interventions - thrombectomy or bypass

33. Extravasation

34. Extravasation

35. CANNULA TIP (CATHETER) FRACTURE The migration and embolization - both towards and against the flow of blood. Results in Thrombosis Infection Embolisation Arrhythmia

36. Cannula tip (catheter) fracture

37. Cannula tip (catheter) fracture

38. Cannula tip (catheter) fracture A ssociated with Insertion at mobile sites longer duration of use P oor technique of insertion M ultiple attempts at cannulation R epeated reinsertion of needle

39. Prevention Avoid Insertion at mobile sites Avoid longer duration of use Poor technique of insertion Repeated reinsertion of needle Detect and inform

40. Thank you