What are the steps for intravenous (IV) cannulation and how can the process be improved?

From the Guidelines

Iv cannulation steps should prioritize patient safety and comfort, and to improve, one should use ultrasound guidance, especially in difficult cases, as recommended by the most recent guidelines 1. To ensure successful IV cannulation, the following steps should be taken:

• Gather all necessary equipment, including the appropriate cannula size, tourniquet, alcohol swabs, dressing, and securing tape.
• Wash hands thoroughly and apply gloves.
• Explain the procedure to the patient and obtain consent.
• Apply the tourniquet 4-6 inches above the intended insertion site and select a suitable vein, preferably in the non-dominant arm.
• Clean the site with an alcohol swab using a circular motion from center outward and allow it to dry completely.
• Hold the skin taut to stabilize the vein, insert the cannula at a 10-30 degree angle with the bevel facing upward until blood flashback appears, then lower the angle and advance slightly. Some key considerations for improving IV cannulation skills include:
• Practicing vein visualization techniques, such as using warm compresses or having patients clench and unclench their fist to increase venous distention.
• Using appropriate lighting and considering vein illumination devices for difficult access.
• Developing tactile skills by palpating veins before attempting insertion.
• Staying calm and maintaining a confident approach, as patient anxiety can cause vasoconstriction.
• Mastering proper positioning and anchoring techniques to prevent vein rolling during insertion.
• Regular practice with supervision and feedback will significantly improve success rates over time, as supported by guidelines from reputable organizations 1. It's also important to note that complications related to cannulation, such as infiltration injury, can negatively affect patients' ability to have a functioning dialysis access in the future, highlighting the need for careful technique and attention to patient safety 1.

From the Research

IV Cannulation Steps

• Familiarization with the operation of the specific ultrasound machine prior to initiation of a vascular access procedure 2
• Use of a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures 2
• Evaluation of anatomical variations and absence of vascular thrombosis during preprocedural site selection using two-dimensional ultrasound 2
• Assessment of the target blood vessel size and depth during preprocedural ultrasound evaluation 2

Improving IV Cannulation Success

• Use of real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for central venous catheter (CVC) insertion 2, 3
• Utilization of echogenic needles, plastic needle guides, and/or ultrasound beam steering when available to increase the success rate of ultrasound-guided vascular access procedures 2
• Implementation of a standardized procedure checklist that includes the use of real-time ultrasound guidance to reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion 2
• Use of real-time ultrasound guidance for internal jugular vein catheterization, subclavian vein CVCs, and femoral venous access to reduce the risk of mechanical and infectious complications 2, 3

Peripheral Venous Access Techniques

• Use of real-time ultrasound guidance for the insertion of peripherally inserted central catheters (PICCs) and peripheral intravenous lines (PIV) in patients with difficult peripheral venous access 2, 4
• Utilization of ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access 2, 4

Arterial Access Techniques

• Use of real-time ultrasound guidance for arterial access, which has been shown to increase first-pass success rates, reduce the time to cannulation, and reduce the risk of hematoma development compared with landmark-based techniques 2, 3
• Implementation of ultrasound guidance for femoral arterial access and radial arterial access to increase first-pass success rates and reduce the risk of vascular complications 2, 3

Training and Competency

• Completion of a systematic training program that includes a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting ultrasound-guided CVC insertion independently on patients 2
• Demonstration of minimal competence before placing ultrasound-guided CVCs independently, with a minimum number of CVC insertions and a proctored assessment of competence 2
• Periodic proficiency assessment of all operators to ensure maintenance of competency 2