hi everyone there's Lahiru from abc's of anesthesia now in one of the videos there's
an interesting request which was that i'd make a compilation video of lots of cannulations back to
back and i thought that's quite interesting it's nice to not just go through all the
theory but actually see multiple cannulations from different angles with different cannulas
in rapid succession so fortunately this morning it's quite a rapid turnover list
it's a cataract operationalist so i'll be doing the anaesthetic for ten of these
and i'll hopefully get a few patients for consent to having the videos of
the iv candidates taken so yep let's get started and i hope you enjoyed this video
so i just wanted to give a quick plug for some online courses that i'm creating
so these courses will cover everything from iv cannulation to medical students guide to
anesthesia as well as some introductory topics as well as exam preparation and hopefully a lot of
other things as well so i'll put some links to those courses in the story numbers below and i
hope you enjoy them thanks a lot so for this video as we're watching these cannulations i thought
i'd do a bit of commentary so this is my first cannula of the day and again i'm using one of
these fancy cannulas it's really great cannula you don't need an iv bung to cap on the end so
just means there's less parts to be used but as you can see i'm just so used to using a normal
cannula i've even put my thumb approximately to stop any backflow but that's not really possible
now i noticed as i advanced this cannula there's a bit of tethering in the skin so it's probably up
against a valve so you'll notice i pulled it out just a millimeter just so it wasn't up against a
valve that meant i could flush it easily now this cannula is an old video it's a 14 gauge on on my
superstar friend julian and as you can see i'm going at a really low angle going slowly i observe
the flashback and then i really level out and you can see the the i guess the upward trajectory of
my cannula and that i go at least a centimeter advancement before threading the cannula you
can see the secondary flashback there i put lots of fingers over the proximal part of the cannula
that's just to make sure there's no blood flow back and then i screw on the
iv bung and as always you want to flush all these cannulas in a lot of these videos i'm
not showing the flushing just because i end up doing that with some medications very soon after
now this is one of those difficult cannula videos that i've already got up on youtube i can put a
link to that as well and you know often you'll be told that the wrist is not a place to go and it's
it's almost always true i mean the wrist is not that comfortable for a patient the veins are very
small very fragile but sometimes that's the only vein that i've got to go for and it's such a short
procedure for cataracts that it's completely reasonable to use this for a temporary period
of time you know this in some patients you can find really large veins that are very stable not
fragile and so you know you can actually keep it for as long as the vein holds up again with
these with these cannulas whichever whichever site you put a cannula into you want to review
that cannula every day make sure that's working and make sure that each injection is also working
and this was another it wasn't exactly a difficult cannula it's a very visible vein it can put
probably put a 20 and even 18 gauge through that but again just for the purpose of demonstrating
you can see that my knuckle for tensing the skin is over the ridge of the knuckle so it doesn't
impair my low angulation of the cannula and because it's so superficial you can see my angle
it isn't even 5 degrees it's almost parallel to that vein because i know that this this vein is
really superficial you'll see that in some other cannulation demonstrations in the cubital fossa
the vein is just marginally deeper so i've got a steeper angle even five to ten degrees
now just to highlight the fact that my grip is very specific you know it's thumb and middle
finger allows me to visualize the flashback and then i can push off the cannula with my
pointer finger there's very little change to my structures so here's a cute little fossil vein
so i can barely see that vein but i can feel it so that's one that i had to palpate i couldn't
really see again i'm being really careful in that cubital fossa region because there are tendons
nerves and the brachial arteries in that position so my depth of insertion is always very narrow
this cannulation yeah obviously a big visible vein and again i've gone at a low angle because
it's very superficial my thumb is out of the way again i accidentally put my thumb to prevent
any backflow but really these cannulas already have a bung inbuilt so they don't have backflow
now there's cannula and i'm sterilizing the area with a claw hex alcohol swab making
sure the patient has no allergies and i go for again palpable but not visible vein and again
that region has lots of structures there this particular cannula is not my favorite cannula
it doesn't have a bung but it also doesn't have a safety needle and it twists around a lot when you
thread it through so i just want to demonstrate now just there you saw me taking pressure off
the thumb just to see that i do have backflow and that's one of the techniques i use to make
sure that i'm in the vein so lack of back flow of blood doesn't mean you're not in the vein
but the presence of that backflow is really reassuring that you are inside the vein now
apologies for this really poor camera angle but essentially i'm going through a caphalic
vein on the inner side of the arm on the radial side now the great example here is that my ring
and little finger are anchoring the hand making sure they don't have a tremor just makes my whole
structure really stable again really useful for the most difficult veins where even the
slightest tremor could cause a problem and could cause a you know puncture on the other side
you want everything to be really really stable when you're doing these difficult cannulations
again i put pressure approximately just jiggle the bung on
and then i transfer my finger only then and i can screw it on tightly
so here's a cubital fossil vein um it's not a visible vein but it is palpable so i swapped
the area but then i realized i'm not really sure exactly where it is so i retouch repalpate
but then i have to swab that region again just to make sure i'm using the aseptic non-touch
technique philosophy now this is again one of those cannulas that i'm really not a big fan of
and this cannula kind of rotates around as i throw it off it's just not as stable
and it's not a safety cannula so the needle as it comes out isn't protected by any kind
of mechanism now you'll notice that i threaded the cannula with my left hand which i don't
normally do i usually thread with my right hand but in this case it was kind of hard with this
particular cannula because it just wasn't a stable cannula so as long as i'm in the
vein it's okay for me to take the tension off the skin and thread with my left hand
now this cannula so i'm palpating it just over the knuckle and that's not the ideal position if the
k if the cannula is kind of over the knuckle then it's kind of more prone to trauma and
getting you know caught on things but again for a short case it's completely reasonable
and this patient had very few options for cannulation it's often one of those things
where sometimes you just have to get the best vein possible even though it's not the perfect vein
so again this is a cubital fossil vein and i'm using one of my favorite cannulas which is
the bee braun intracan safety cannula again a fantastic cannula because it's very stable and
when i advance then the cannula it doesn't rotate so it's very easy to advance with my
pointer finger and again you can see the low angle that i was using to insert that cannula
and i really want to make sure i don't go through the opposite side of the wall
so this cubital foster cannulation again i'm using my favorite cannula the bee brown intra can safety
cannula i might get my thumb out of the way going at a really low angle make sure i can get that low
angle and yeah then i apply pressure proximally to make sure i don't get any blood flow back
and then i jiggle the bung on and once it's on then i'm able to tighten it
and then flush just to make sure that's in
so you'll notice that this is the video from my very first cannulation video
on my mate julian back in 2012 so here i'm just showing all the aspects of you know anchoring my
hand using my ring and little finger i've got the right grip on the cannula i'm going at a low angle
i'm tensing the skin with my left hand but my thumb is over the edge of the knuckle so i can
you know still get a really low angle with my right hand that thumb isn't impeding the
angulation i'm just going really slowly like when you start out it's i think it's completely
okay to go slowly you've got to make sure that your technique is really correct and
as you get more and more experienced you can go faster especially with these easy cannulations
notice that with difficult cannulas i will still go slowly because you need time for that flashback
to occur you know i'm threading with my pointer finger everything's pretty stable at this point
you can see that blood rushing back and i make sure that i have my thumb over at the right point
the blood flowing back means that it's in the vein and that's all working really well
you'll notice i'm really careful when i'm taking the needle out i just don't
want to remove the candle at the same time and that's definitely happened to people
in this video i do something here that i don't really do anymore because i'm in anaesthetics
and i'm constantly you know putting a cannula in and then flushing it with some medications that
are pre-medications but yeah generally speaking you should always flush your cannula with some
normal saline to make sure that it's in and make sure that's flashing easily in one of my videos
i go through a few techniques to make sure that you're in the right position and i'll put a link
up there as well now here's the second cannulation again on my very good friend
and he's a great example of fantastic vascularity and i'm demonstrating here that when you're
starting out it's really great to go for big veins like the one i'm showing here big visible veins
means that it's very or less likely that you will go and puncture the other side of the wall or near
the side walls i'm also saying that it's really great to go for bifurcations like the ones you can
see just here that means that if you go in as the bifurcation meets that bigger vein at this point
roughly here um it's less likely that the vein's going to roll so again more chance of success
now for the purpose of the demonstration i'm going to try and make these smaller veins visible by
tapping and then i'm going to line up my cannula along the trajectory of that vein just remember
the axis of your needle should line up with the axis of the vein
you don't want it going to one side because again more chance of puncturing
so i'm tensing the skin and then i'm inserting at a point that i've chosen
you know roughly you know maybe a couple of centimeters away from the knuckle
and i'm inserting along the axis of that smaller vein
again slowly inserting there you see a flashback occurring at which point i really lower my
angle i advance the needle maybe you know four millimeters at which point after that advancement
i then thread the plastic cannula with my pointer finger you can see the secondary flashback which
is again proof that you're in if you don't see that flashback it's very likely that you're not
in the right position release my tonic as you can see pressure proximally to stop blood flow back
carefully take my needle out and dispose in the sharp spin and then put on the iv bung
just to secure and then flush with normal sound to make sure it's in and you can see
that it's flowing really easily and that's all secure and then secure it with a transparent
adhesive dressing that's breathable just like a tegaderm which is the one i commonly use
so now we're going to go through a replay of all of those cannulations just doing some quick cuts
just again in rapid succession so you can see the technique and how it's done
and hopefully this helps
so
so thanks again for watching i really hope you enjoyed this video if you have any questions
please leave them in the comments below i'll try to get to them and then thanks
for watching please share with anyone who might be interested see you next time