How to insert an intravascular cannula into fragile veins when ultrasound (ultrasonography) is not available?

From the Guidelines

To insert an intravascular cannula into fragile veins without ultrasound, it is recommended to use a small-gauge cannula (22-24G) and apply a tourniquet loosely to avoid collapsing delicate veins. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of minimizing trauma to vessel walls in patients with fragile veins 1.

When inserting the cannula, several key steps can be taken to improve the likelihood of success:

• Begin by thoroughly palpating for suitable veins, focusing on the forearm rather than the hand where veins are often more fragile.
• Apply warm compresses for 5-10 minutes before the procedure to promote vasodilation.
• Position the limb below heart level to increase venous filling.
• Clean the site with antiseptic solution and allow it to dry completely.
• Use a shallow angle (10-15 degrees) and reduce the angle further once flashback occurs.
• Advance the cannula slowly and steadily, using minimal forward pressure.

Consider using a butterfly needle (winged infusion set) for very fragile veins as it causes less trauma. If the first attempt fails, remove the tourniquet temporarily to allow veins to recover before trying again. Avoid multiple attempts in the same area. For extremely difficult cases, consider using transillumination with a penlight pressed against the skin in a darkened room to visualize veins. The use of experienced cannulators and consideration of smaller-gauge needles, as recommended by the 2020 guideline update 1, can also help to minimize complications and improve outcomes. Additionally, the guideline suggests that self-cannulation in well-trained patients may be beneficial, and documentation of complications should be reviewed as part of each cannulator’s training and evaluation.

It is also important to note that the insertion of intravascular cannulae into fragile veins should be done with caution, taking into account the potential risks and complications, such as local infection, and the need for careful assessment and monitoring of the patient's condition, as highlighted in the 2016 guidelines 1.

From the Research

Insertion of Intravascular Cannula into Fragile Veins without Ultrasound

• When ultrasound is not available, the insertion of an intravascular cannula into fragile veins can be challenging.
• There are no specific research papers that provide guidance on how to insert an intravascular cannula into fragile veins without the use of ultrasound 2, 3, 4, 5, 6.
• However, studies suggest that the use of ultrasound guidance can significantly improve the success rate of vascular access procedures and reduce the risk of complications 2, 3, 4, 5, 6.
• In the absence of ultrasound, healthcare providers may need to rely on traditional landmark-based techniques or other alternative methods to insert the cannula.
• It is essential to note that the lack of ultrasound guidance may increase the risk of complications, such as vascular damage or infection, and healthcare providers should take extra precautions to ensure sterile technique and proper insertion methods.

Alternative Methods for Vascular Access

• Some studies suggest the use of other imaging modalities, such as biplane imaging using portable ultrasound devices, to improve vascular access 6.
• However, these alternative methods may not be widely available or feasible in all clinical settings.
• Healthcare providers should be aware of the potential limitations and challenges associated with inserting intravascular cannulas into fragile veins without ultrasound guidance and take steps to minimize the risk of complications.

Importance of Training and Experience

• Studies emphasize the importance of training and experience in performing vascular access procedures, including the use of ultrasound guidance 2, 3, 4, 5, 6.
• Healthcare providers should receive adequate training and supervision to develop the necessary skills and competence to perform these procedures safely and effectively.
• Regular practice and updates on the latest techniques and guidelines can help healthcare providers improve their skills and reduce the risk of complications.