12.1 PROTOCOL SUBJECT: PAEDIATRIC PERIPHERAL INTRAVENOUS CANNULA CARE DOCUMENT NUMBER: 12.1 DATE DEVELOPED: 11/06 LAST REVISED DATE: NEW PLANNED REVIEW DATE: 11/09 DISTRIBUTION: All Clinical Areas Kaleidoscope GNS, excluding NICU John Hunter Hospital Operating Theatres, Intensive Care and Emergency Department. PERSON RESPONSIBLE FOR MONITORING AND REVIEW: Clinical Nurse Consultant Surgery COMMITTEE RESPONSIBLE FOR RATIFICATION AND REVIEW: JHH Emergency Executive Committee Kaleidoscope GNS Quality Committee Disclaimer It should be noted that this document reflects what is currently regarded as a safe and appropriate approach to care. However, as in any clinical situation there may be factors that cannot be covered by a single set of guidelines, this document should be used as a guide, rather than as a complete authorative statement of procedures to be followed in respect of each individual presentation. It does not replace the need for the application of clinical judgment to each individual presentation. SAFE WORK PRACTICE Paediatric Cannula Care. 2008 Page 1 of 9
This document does not apply in the Neonatal Intensive Care Unit OUTCOME: Parent/caregivers and child where appropriate will be educated about the cannula and made aware of care requirements. The child s anxiety and pain will be addressed appropriately and minimized. Paediatric peripheral cannulae will be secured and dressed in a manner that minimizes the risk of accidental dislodgement, infiltration or extravasation. Cannula related infections and complications will be prevented or minimized by scrupulous hand hygiene, aseptic technique and appropriate taping/dressing. Any complications of cannulation will be recognised and managed early. The cannula will be removed as soon as it is no longer needed, after consultation with the team. DEFINITIONS: (as per HNEAHS Policy Paediatric Intravenous Cannula Care 2007.) Children: Those aged 16 years and less, excluding neonates. For people aged over 16 years, please refer to the Hunter Area Health Service Policy- Intravenous Peripheral Short Cannula and IV Therapy Management Policy for Adults 96/01. 2004. Induration: hardening of a tissue as a result of swelling and inflammation. Vesicant: an irritant, drug or solution capable of causing blistering or tissue necrosis when administered into tissue. E.g. bicarbonate, calcium, caffeine, cytotoxic drugs, 10% dextrose. A vesicant drug or solution should only be administered via a central line, however if this is not possible, the peripheral cannula should only be placed in the dorsum of a hand to reduce the likelihood of extravasation. Infiltration: Definition: the inadvertent administration of a non-vesicant medication or solution into the surrounding tissue instead of into the intended vascular pathway, resulting in induration and discomfort. Action: Confirm the infiltration with an experienced member of staff. Paediatric Cannula Care. 2008 Page 2 of 9
Remove the tissued cannula using aseptic technique. Elevate the limb 30º. Record pain score using pain scale and administer analgesia as indicated. Heat packs are not to be utilised due to the risk of a thermal injury. Explain the infiltration to the patient / parent / caregiver. Document the cannula removal and site condition in the medical record. Document the removal and details on the IV cannula form NMH251 if being used. Adjust the fluid balance chart. Complete an IIMs notification if clinically significant. Under "Incident type" select "Medication/IV fluid". Notify the RMO and set up for replacement if required. 3.3 Extravasation: Definition: the inadvertent administration of a vesicant medication or solution into the surrounding tissue instead of the intended vascular pathway, resulting in damage to the tissue. Action: Immediately cease the infusion. Confirm the extravasation with an experienced member of staff. Explain the extravasation to the patient / parent / caregiver. Seek expert medical advice prior to the removal of the cannula. Attempt to withdraw as much fluid from the cannula as possible prior to removal. Following advice, remove the tissued cannula using aseptic technique. Mark the area of inflammation with a marking pen. Elevate the limb 30º. Record pain score using pain scale and administer analgesia as indicated. Document the removal and site condition in the medical record. Document the removal on the IV cannula form NMH251 if utilised. Adjust the fluid balance chart. Complete an IIMs notification - Under "Incident type" select "Medication/IV fluid". Notify the RMO and set up for cannula replacement if required. Make referral/contact the Paediatric Surgical CNC JHCH for monitoring and followup if required. Paediatric Cannula Care. 2008 Page 3 of 9
PROTOCOL FOR INSERTION OF PERIPHERAL CANNULA: Topical anaesthetic (see 13.14 or 13.18) and distraction techniques should be used to minimize pain and anxiety (TLC Distraction Box Program, 2003). After two unsuccessful insertion attempts, assistance should be obtained from a practitioner who is more experienced in cannulation. In the emergency situation, intraosseous cannulation should be used early or after two failed peripheral attempts. PROCEDURE: Preparation: Identify the patient and check the order for a cannula. Inform the parent/caregiver and child about the procedure and their role, and obtain a verbal consent from the parent/caregiver. Ensure that adequate and successful analgesia has occurred and that distraction techniques are available unless an emergency. Ensure adequate assistance to support the child and maintain safety. Refer and adhere to 2.4 Paediatric Restraint Protocol if the child is not able to fully co-operate. Site Selection: Avoid areas of phlebitis, infection, infiltration, extravasation and previous cannula sites. Avoid Flexor surfaces, areas with diminished sensation, legs and inner aspects of the arms. Remove the patient ID band, bracelets and medic alerts if they are situated on the cannulated limb. Replace them on a non-cannulated limb. Clinician Hand Hygiene: Remove any watch or wedding ring. Wash or gel hands initially and set up a clean work field. Don personal protective equipment plastic apron, eyewear, mask if required. Remove topical anaesthetic i.e. EMLA or AnGEL cream (Amethocaine Gel) from the proposed sites. Wash hands for 1 minute with antimicrobial handwash. Dry hands thoroughly. Don gloves. Paediatric Cannula Care. 2008 Page 4 of 9
Insertion: Intravenous cannula insertion is an advanced skill for registered nurses. Education and competency must be achieved and maintained in order to practice this skill. The skin is to be cleaned with PERSIST PLUS or 70% isopropyl alcohol or chlorhexidine and alcohol. Care must be taken not to contaminate the cleaned site. Insertion is to be accomplished using an aseptic, no touch technique by a trained clinician. Dressing and Stabilization of the Cannula site: After confirmation of the correct placement, the cannula hub is to be taped with sterile tape e.g. steristrips, and reinforced with leucoplast strips as required (see Appendix 1). Alternatively, a clear occlusive sterile dressing may be applied in older children but the cannula must be secured. Ensure that the extension piece and IV line is firmly anchored to the limb to decrease the risk of dislodgement. The extension piece should be anchored with 2.5cm leucoplast to prevent accidental dislodgement. The cannulae insertion site is to be readily visible and accessible at all times, so as to ensure the early detection of inflammation, disconnection, infiltration or extravasation. Limbs with a peripheral intravenous cannula insitu should be secured, to immobilize the limb, above and below the joint closest to the cannula site with 2.5cm Elastoplast and an approved, moisture impervious splint, as per Appendix 1. Elastoplast should be dabbed with cotton wool over the areas in contact with the skin to allow for gentle removal. Leave the ends sticky to attach to the arm board. Wooden tongue depressors are not to be fashioned into splints for infants or children due to a confirmed infection risk. (Dept. of Health Patient Matters and Information Bulletin 97/9). Limbs with peripheral cannulae insitu are not to be covered or restrained using full arm (wrap around) splints or bandages. A sock-type covering such as Tubifast in an appropriate size may be used provided the site remains readily available for surveillance and constriction is avoided. Paediatric Cannula Care. 2008 Page 5 of 9
Extremities must be visible at all times for circulation checks. Paediatric cannulae are to remain insitu until no longer required, or if signs of infiltration, extravasation or phlebitis appear. Document these occurrences in the medical record and IIMs if clinically significant. No child should remain cannulated when their admission comes to an end unless under the express order of the consultant. Insertion Site Care and Documentation: After insertion, the location and condition of the cannula site must be documented in the patient s medical record along with the size and type of cannula inserted. Form NMH251 may be used to assist with this documentation. Peripheral Intravenous cannulae with IV fluids infusing must be inspected hourly for signs of extravasation or infection (i.e. redness, pain, swelling or heat) and pressure areas from clamps and equipment contact. (i.e. pain, redness, indented skin) A cannula not infusing IV fluids must be inspected 4 th hourly with documentation in the medical record and/or on form NMH251. Hourly cannula checks must be signed for on the patient s fluid balance chart at the time of recording the hourly input. Comment will be made in the patient s medical record each shift regarding the condition of the cannula site. Maintenance of IV Patency: Prior to the administration of any intravenous medications the cannula site is to be inspected for redness, pain, discharge or swelling. The patency of the cannula must be confirmed prior to the administration of any vesicant solution. IV cannulae that do not have a continuous infusion are to be flushed with Normal Saline 4-6 th hourly (as charted) to maintain patency. All intravenous fluids and medications should be administered according to the manufacturers instruction. Paediatric infusion burettes are to be used with giving sets when IV infusions are required. All paediatric patients must have fluids infused via an infusion pump. Paediatric Cannula Care. 2008 Page 6 of 9
IV lines should not be disconnected from the cannula to facilitate mobility or dressing as this poses infection and patency risks. If using IV pumps in bath or shower areas, they must be running on battery only, kept well away from the water source and the pump unit must be covered by a plastic bag which has been firmly secured at the top and the bottom to prevent moisture entering the pump. Prior to reconnection to the power source, the pump must be inspected for the presence of moisture and only be connected if it is dry. (JHH OH&S Guideline- Electrical Safety Issues Related To Using Electrical Equipment In Hospital Bathrooms, 2008). Changing of IV Giving Sets and IV Fluids: IV giving sets, IV fluids, burettes (and filters if required) are to be changed with every new cannula insertion. A cannula should only be changed if infiltration, extravasation or infection have occurred (i.e. redness, pain, discharge, swelling or heat at the affected site). See below for management. Intravenous solutions must be changed every 24 hours. Intravenous lines must be changed every 72 hours. IV giving sets must be changed if contamination occurs and / or after blood products or some medications (as indicated) have been infused. Injection Ports: A needleless IV access port e.g. the Interlink System, will be used on all paediatric cannulae. The injection port must be aseptically swabbed prior to use with isoprophyl alcohol to prevent the entry of microorganisms into the vascular system. REFERENCES: JHH OH&S Guideline (2008) - Electrical Safety Issues Related To Using Electrical Equipment In Hospital Bathrooms. Patient Matters Department of Health Publication. Year n/a Paediatric Cannula Care, 2006. HNE Southern Sector. Oishi, L.A. (2001) The Necessity of Routinely Replacing Peripheral Intravenous Catheters in Hospitalized Children: A Review of the Literature. Journal of IV Nursing 24(3)p. 3-4 Paediatric Cannula Care. 2008 Page 7 of 9
TLC Distraction Box Program. (2003). Why TLC Distraction Boxes help children during medical procedures and examinations. TLC for Kids. Melbourne. DEPARTMENT OF HEALTH CIRCULARS: Wooden Tongue Depressors Used As Splints. Information Bulletin 97/9 AREA POLICIES: Upper Hunter Sector Paediatric Peripheral Cannula Management Policy. Procedure number 1-70-225. Lower Hunter Sector Paediatric Peripheral Cannula Management Policy. Procedure number 70-20-048 HNEAHS Policy - Paediatric Intravenous Cannula Care. (2007) (Final Draft) HNEAHS Policy Compliance Procedure - Paediatric Intravenous Cannula Care. (2007) (Final Draft) NSW Health PD 2007_036 Infection Control CHW Accreditation of and Procedure for Intravenous Cannulation by Registered Nurses. 02-0015. (2004) AUTHOR: Elizabeth Kepreotes Clinical Improvement Facilitator Kaleidoscope GNS CONSULTATION: Janis Brown ACNC Paediatric Neurology Lawrence Roddick Paediatrician JHCH Mark Lee - Paediatrician JHCH, Emergency Physician JHH Juliet Holbert ACNC Emergency Dept. JHH Sandy Berenger CNC Infection Control Kerri Sullivan CNC Paediatric Surgery JHCH APPROVED BY: CPGAG- 7th July 2008 KGNS Quality 4 th August 2008 Paediatric Cannula Care. 2008 Page 8 of 9
APPENDIX 1: Used with permission of Rhonda Winskill- Paediatric Outreach CNC Southern Sector HNEAHS. Paediatric Cannula Care. 2008 Page 9 of 9