11/13/24, 7\:26 PM Guide | Paediatric cannulation

Paediatric cannulation

Table of contents

Preparation

Children should be o™ ™ ™
, EMLA or LMX-4 ).
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 di
Apply a blob of cream over the vein and cover it with a clear
prevent the child from removing the dressing and cream.
Older children can be o1
them what it feels like
It is reasonable to show
Babies can be given oral sucrose just before cannulation to minimise pain. The majority of evidence of e
infants \<3 months, but there may be an analgesic e2
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 di
Clean procedure tray
Non-sterile gloves and apron
Tourniquet (if appropriate)
Vapocoolant spray (‘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
Cannula dressing
Extension set
Gauze swabs
Normal saline 0.9% (10 ml)
Syringe (10ml)
Sharps container
Support board/splint, if appropriate
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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.

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.
Con
Brie
For example, with younger children\:
" I n e e d t o t a k e s o m e o f y o u r b l o o d t o h e l p
b e n d y s t r a w i n t o y o u r h a n d s o w e c a n g e t t h e b l o o d a n d gi v e y o u m e d i c i n e s t o m a k e y o u f e e l b e t t e r"
.
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 g o i n g t o p u t i n a c a n n u l a , w h i c h i s a s m a l l p l a s t i c
t u b e , s o w e c a n t a k e s o m e b l o o d s a m p l e s a n d g i v e y o u m e d i c a t i o n a n d
t h e t u b e i s i n I w i l l r e m o v e t h e n e e d l e , a n d t h a t p a r t g o e s i n t h e b i n , l e a v i n g t h e p l a s t i c t u b e"
.
Managing fear
Some children become particularly frightened when you approach them with a tray of unfamiliar objects. It can help to
ask,
"
w o u l d y o u l i k e m e t o t a l k a b o u t w h a t w e a r e go i n g t o d o
d o e s ?"
.
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.
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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.
Identify and expose the site. 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
by the
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 ‘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

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
3. Prepare the normal saline
4. If you are planning on using an extension set, you should attach this to the
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 ‘frosting’ the skin as this can be painful).
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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
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.
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-Strip™ 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/
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
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.
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Insert the cannula, remove the needle and wait for the blood to
hub of the cannula and pull on the syringe to extract the blood. Wait for the hub to re
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
Decant the blood into the appropriate sample bottles.

Flush and secure the cannula

1. Inject the normal saline into the cannula using the
The
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.
Method one\: ‘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
cannula, then wrap the two ends over the top of the cannula in an ‘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-Strip™ 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.
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Pass a Steri-Strip™ (or similar) under the hub of the cannula, then wrap the two ends over the top of the cannula in an ‘awareness ribbon’ shape
Method 2\: ‘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
pressure damage.
2. Ask the assistant to place a Steri-Strip™
, or the tape which comes with a window dressing, over each wing.
3. A third Steri-Strip™ can be attached horizontally across the cannula to form an ‘H’ shape.
4. Place the windowed dressing over the top, with the window covering the insertion point.
5. Apply the bandage.
Place a Steri-Strip™
, or tape which comes with a window dressing, over each wing of the cannula
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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 identi
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

Source\: geekymedics.com
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