first of all i apply a tourniquet like so
you know the tourniquet is too tight if the patient complains that it's too painful or if
you can't feel a radial pulse other things are to lower the hand below the patient
this increases the hydrostatic pressure gradient and makes the veins stand up more than they would
if the patient's hand was above their head simple things are to get the patient to open and close
their hand to make a fist and this increases the amount of blood flow to that particular region
other simple measures include tapping the hand gently or rubbing the vein what this does is
increases vasodilatory mediators which make the vein dilate again now hospitals
are almost universally very cold places and cold place cold patients will vasoconstrict
whereas warm patients will base dilate so another very important tip is to make sure
your patient is comfortable and warm and this will help the vein stand out
some patients are very very difficult intravenous access and it's important in these patients to
ask them where is your best vein and so they will tell you exactly where the best vent access is so
first of all wash your hands or cleanse them with an alcoholic solution like so i first apply the
tourniquet and then set up my equipment as this gives time for the veins to enlarge and to dilate
i prepare by putting the fluid underneath the arm and this
avoids a lot of cleaning up later if you do have a bit of an accident i bring the sharps container
so it's right nearby and very easily accessible
i then open the dressing pack and assemble all my equipment so i then open my dressing pack
and assemble the rest of my equipment it's in the dressing bag i mean this is pretty
comprehensive but all you really need is a container to put flaxseed in and some gauze
i fill with chloroxylamine and alcohol solution and this being shown to be better than alcohol
itself to reduce infection rates with peripheral artery cannulation and put
the gauze inside as well yeah nice thing is the rest of our kitten involves a tegaderm
an iv bun which seals off the cannula at the end which i'll show you in a second
i want 10 ml of normal saline
which i drop in a 10 ml syringe
and i usually put this and place it on the end of the cannula just so i have it ready and loaded
and i flush the cannula the iv fung with that i then get a appropriate size cannula and i have
this ready as well so essentially i've got my tub with polystyrene and alcohol solution i've got my
cannula ready i've got my bun to place on the end and i take it in the rest of the other equipment
here is really unnecessary for this particular step the next step is to done a pair of gloves
it's absolutely important that you put gloves on before any invasive procedure
as over the lifetime of your practice as a medical practitioner it may actually save your life i then
identify the area that i'm going to cannulate i tap and rub the vein as we demonstrated previously
and i apply the correct steam with alcohol solution to ensure that the area is nicely cleaned
i then stabilize the skin like so and i'll outline exactly how to do the extra tips that will go
through i then pick up the cannula my thumb and middle finger and now i'm ready to cannulate
i need to then identify the best vein and when you're starting out the bigger the vein is
and the straighter it is the easier it will be the cannulated i also like to identify any bifurcating
veins in this patient there isn't one but if it bifurcates it means that if you go at the
point of bifurcation the vein is less likely to roll away from your cannula i then talk the
skin tense the skin i line up my cannula along the axis of the vein and note the axis there
i do not go either side as again that will increase the risk of rupturing one of the walls
i approach at a very low angle it's about five to ten degrees at the very most if i was to go to a
much steeper angle the risk of me puncturing the other side of the vein is much greater
so i approach at a low angle i ins i tense the skin and i insert my cannula
like so i don't rush this point once i'm through the skin i advance the cannula very very slowly
again along the axis of the vein until i see a flashback up in the chamber of the cannula
when i see that and level the knee light even further and advance up to one centimeter
at which point i now can stop i know that my needle and my cannula is in the vein i use then my
pointer finger to advance the cannula the plastic part of my cannula across i can now pause at this
point because i know everything is there and in i then take my tourniquet off and put pressure
on the distal part of my cannula to avoid any blood rushing back i then very slowly and control
i take the needle out and put it directly in my shaft's container
i take the iv bar and i screw it on to this cannula stabilizing it again with my other
hand to check that the cannula is in the vein i simply flush with my normal saline solution
i twist off my syringe of normal saline
and apply a tega down to ensure that the cannula stays in its proper place
i'll now demonstrate some important principles when anchoring the skin so firstly i use the
thumb of my non-dominant hand to stretch the skin the important principle here is to stop
the skin moving as my needle enters the skin and makes this step much smoother and less painful
it's very important to make sure my thumb is out of the way
of the needle if my thumb was here on top of the knuckle ridge i wouldn't be able to gain
the right low angle because my thumb would be in the way for that reason i have my thumb
below the knuckle edge which allows me to lower the angle of this needle as much as is required
i'll now demonstrate the correct way to hold the cannula so first of all place the cannula with
the bevel facing up on your dressing pack pick the cannula between your thumb and middle finger
and always have the cannula below your hand if the cannula is above your hand it means
that you won't be able to get the right angle necessary to advance the right low angle that's
necessary so having the cannula look below is always quite vital for this procedure
your pointer finger should always be out of the way so it's not covering the hub this way you
can observe a flashback of blood in the chamber as soon as that occurs and having this pointer finger
free also allows you to advance the cannula without using your other hand to do so this
makes the whole the whole system much smoother and efficient as you put the cannula inside
finally i used my fifth finger as a very important part of stabilizing my hand and avoiding tremor
so say i have my patient whose little finger to stabilize it against any firm structure
allowing me to advance smoothly without a tremor
i'm now going to demonstrate some important cannula features first of all the cannula
has a very very sharp tip which means it's easy to get access into the vein like so
but unfortunately also means it's very easy to go through the other side and blow your vein
like so the other aspect of this is that the cannula has a relatively non-cutting upper
bevel edge so it's quite smooth it means that when you go into the vein if you were to flatten out
this very little chance of you even if you tried very hard to cut the upper surface of the vein
and that's why i highly recommend flattening out the cannula as much as possible
before advancing because there'll be much less likelihood of you going through the other side
even if you're at an angle say 10 degrees or 5 degrees
in a very small vein there's a good chance that you may go through the other side of the vein
before you cannulate it's important to identify the best vein and when you're starting out
the big straight veins are probably the easiest ones like this one here it means
it's less likely that you'll go through one of the side walls or the deep wall
it's also a good idea when you're starting out to look at bifurcations and this is a
good example the vein runs this way and then bifurcates into two pathways there if you go
in the middle of that it's less likely that the vein will roll to one side or the other
so for these purposes i'm going to approach at
the vein just in the middle of his the dorsum of his hand here
so first of all i tend to i stretch the skin five and a maximum of 10 degrees and this means
that i won't have a sharp angle that is more likely to puncture the other side of the vein
i identify a point of needle insertion and i line up my cannula along the line of the vein
and not to one side or the other which means i might go through the side wall
i stretch the skin firmly as i first enter with my cannula
i go slowly as is required always looking at the blood chamber blood filling chamber to see if i
get a flashback and see you can see the flashback in the blood flowing up at this point i take all
the time i need and level out even further as i advance the cannula up to a centimeter
this point i then use my pointer finger to advance the cannula into the vein
i then take the tourniquet off and using my non-dominant hand my thumb over the distal end of
the cannula to stop this bleeding i then take my sharp and put it directly in the sharps container
note that i've got all the time in the world i don't need to rush there's not going to be any
blood flowing back and my cannula is in the vein it's safe and now i need to secure it
i take my syringe with the iv bung and place it directly on the end of it i then
flush the cannula with normal saline to ensure that it is in the vein
i then secure a tegaderm or an upside or some sort of dressing
over the cannula to ensure that it stays in the right position and there you have
it you