hi everyone this is la here from abc's anesthesia i'm really excited to do this video on iv
cannulation 10 years after my very first video so back in 2012 i did an iv cannulation video
and you know that's the first video i ever made it took me for ages to actually post stuff on
youtube i think 2020 was when i posted the first video now i thought i'd redo that video and try
to make a lot of improvements because a lot of things and knowledge have advanced since then
especially with aseptic non-touch technique as well as just limiting
the use of all the consumables to be a bit more environmentally conscious so let's get started
so we're going to go through quite a number of things in this video i'm going to try and
replicate a lot of the steps in the old video because in that video a lot of the good stuff
still holds like a lot of it's still really useful and the technique is essentially the same today
we're going to go through the indication five your cannulation everything you need for a good setup
choosing a vein as well as making that being nice and large as well as the insertion techniques
everything from how to hold the hand or hold the skin and tether the skin correctly to holding the
cannula the insertion techniques and then all the things you need to make sure that it's dressed
well and also going to go through a bit of aseptic non-touch technique because again that's really
important now so one of the first things you want to do is clarify the indication iv cannulation is
probably one of the first things junior doctors and nurses and other health professionals learn
but it is still an invasive procedure so i don't take that lightly if i'm asked to do a cannula i'd
always say you know find out what the indication is maybe it's for fluids or antibiotics or
medications that could actually be given orally so always clarify the route that can be given
and if you can be given orally or by another means absolutely think about that as an option
you know cannulation has its risks there's always the risks of you know bleeding and a hematoma as
well as getting the wrong structures like tendons muscle nerves even and then you always got those
infection risks in the long term it isn't without harm so if you can find another way of giving that
medication or fluid um always think about that as well in some of my other videos i go through a lot
of detail on how to choose a vein but essentially most of the time you're going to be asked to
choose a vein on the arm so we'll go through a bit of that before i touch a patient i always
think about the five moments of hand hygiene by the who so before i touch the patient or interact
with the patient i always perform hand hygiene now most of the time i put on my gloves at this point
and generally speaking i use non-latex gloves just to make sure that my patients don't have any
reactions because latex allergy is pretty common so now the first thing i do is put on a tourniquet
and i do this even before setting up my equipment as tourniquet i generally put on the arm and not
the forearm that way i've got exposure completely all the way up and down from the arm forearm as
well as the hand now the tightness of this 200k like it really is just a gentle pull you know
it's too tight because simply the patient will be complaining those too tight or the fact that
you may not feel an arterial pulse just remember this is a venous tourniquet you just need above
venous pressure and not above arterial pressure it means that if you really want to make sure
that you're getting absolutely the perfect amount of pressure you can use a blood pressure cuff if
you use a blood pressure cuff that means that you can inflate it to just below arterial pressure or
arterial diastolic pressure and that way you make sure you get the maximum arterial inflow
and limit venous backflow one of the other things you might see is someone putting a tourniquet in
the forearm and that's completely fine like you know you can be absolutely successful doing this
just know that if you do that a patient with good veins it'll be no problem but there is a potential
that because there's two bones in the forearm the radial and the ulna there's some veins that will
traverse in between those bones and these veins might be uncompressible so it's kind of important
to know that i still may have some venous backflow which is not what i want therefore for most cases
i put the tourniquet up around the arm now i'll go through some of the things to make veins stand out
now the first thing is just to know your environment now hospitals are almost universally
really cold environments air conditioning blowing in this theater for example is is really quite
cold and so what you want to do is keep your patient warm if your patient is cold they will
naturally veno constrict so that they'll have all their veins constricting it'll be very difficult
to see the veins whereas if the patient is warm the veins will vasodilate because that's just one
of the mechanisms that the body uses to get rid of heat so almost always i'll have the patient
with a blanket on hopefully i can you know have a room that's warm especially if it's on the wards
and sometimes warm towers are really useful as well now one thing i don't do is use a
warm wet towel so hot water on a towel isn't that useful i find because the you know the water gets
cold very quickly and then as it's evaporating it creates even cooler environment now one of
the other steps in making your veins stand out is making sure that the veins that the vein in
question is below the level of the heart so really you're using the hydrostatic pressure gradient and
gravity to make sure that the veins are popping up you can see that these veins are quite prominent
but as soon as i raise it up you'll see that they just aren't the same even with the taunakion
whereas down below suddenly it increases a lot now my mate here has particularly good veins the other
thing you can do is tap the veins like so and that just increases the number of vasodilatory
mediators in that vessel and that allows the vein to pop up even more so i just gently tap again
some patients feel a lot of discomfort from this in which case i just rub but a few gentle taps
are usually really fine and well tolerated by the patient now really interesting fact
that my man has just told me in the statue of david the statue has one arm down and one hum
one arm up it's really interesting to note that the arm that's down has veins that are prominent
and visible but the arm that is up at the face doesn't have veins that are prominent invisible so
even even at that point in time he was so observant about the hydrostatic pressure
gradient and how that can affect you know your veins and the way they stand out so thanks for
a really interesting fact there so i think there's a lot of fantastic resources out there that show
really good aseptic non-touch techniques i'm not going to go through a lot of that in detail but
just know that aseptic non-touch technique is a really great format for understanding how to keep
your area and your patient contact and your procedures really clean and free from microbial
contamination which is really what you want to do you're doing these invasive procedures there's
a lot of bugs in the surrounding structures on yourself as well as the surfaces and instruments
that you're using potentially and you want to make sure that those microorganisms aren't interacting
or in contact with the patient so that's what aseptic von touch technique is all about now
there's two types of aseptic non-touch technique broadly speaking surgical and standard and so
in iv cannulation all that's required is standard aseptic non-touch technique which means that it's
usually a short procedure that's technically not too difficult and there's only a few key parts
and key sites that you really need to be aware of now key parts really refers to the fact that
there's not too many parts to iv cannulation the instruments i need are quite few so there's the
cannula the iv bung and the tegan potentially that's all that really stays on the patient and
the only invasive part is the iv cannula so it has very few key parts and i can avoid touching
any part of that while i'm interacting with the patient and doing this insertion
likewise with the patient there's only really one key site which is the iv in question and
the point of cannulation so the fact that there's very few key parts and key sites and it's a short
procedure and technically not too difficult means that you're able to do this with standard aseptic
non-touch technique and because of this i also use just non-sterile gloves if i needed to touch parts
of the cannula which are meant to be sterile i would then use sterile gloves so that's why
we're using standard technique so let's talk about the equipment and the setup now the great thing is
there's not too much that you need to set up for iv cannulation now i obviously need the iv cannula
and i'm just using a 22 gauge because i'm just demonstrating what the candidate technique is like
um there's a video for 14 gauge cannula as well as a few other interesting cannulations and difficult
cannulas as well so i'll put those in a link in a card just up above i've got the iv bang and
this is used just to cap off the cannula to make sure that you don't get any fluid back and it also
provides a port with which i can inject fluids and medications as well so that's the iv bung i've got
this tegadim film so that's a trademark name by 3m but essentially what i need is a dressing that's
waterproof but also breathable that's adhesive and sticks nicely and covers everything and holds
it in place and ideally i like something that's transparent and that's what the tegadem is i mean
there's a lot of different dressing options out there look i've just used this one for many years
so essentially a breathable waterproof adhesive dressing that is also transparent and clear i
make sure i have some kind of prep solution to disinfect the skin so this is an alcoholic and
chlorhexidine prep now just know that you've got to be really careful with chlorhexidine because
chlorhexidine is a relatively common and allergic substance so i always check with my patient if
they have allergies before i put chlorhexidine anywhere near them now finally once you place the
cannula you really want to make sure it's in so i usually use a saline flush and a 10 ml syringe and
that way i can just flush the cannula to make sure that it's working well so now when i do my setup
i first of all make sure i've done hand hygiene and i've done some non-sterile gloves and then
i make sure that when i open each of these parts i don't necessarily have to take it out of the cover
so i can open the tegadem just like so i can open the cannula like that and even though it has a cap
you can often just keep it in its plastic wrapper just like so same with the iv bung you don't need
to take it out of the wrapper you can just hold it at the last minute and keep it kind of clean
and have this micro sterile feel there it's what they call it i can use this when i need to use it
i often take this out open
and draw up the 10 ml of saline and have it capped so again that sterile it's not in contact with the
outside world i'll just put that there like so see how the most important thing to have in my
setup is a sharp spin and so that way i'm making sure that as soon as i've done the cannulation i
place that sharp straight in the bin and that way it minimizes the risk of sharp injuries to myself
or anyone else in the vicinity let's get started with this cannulation attempt so what i'm going to
do is i'm going to put the tourniquet on and again just put it at the right level now interestingly
when you first start out you know there's a lot of things that you're going to be keeping in mind
i think i outlined maybe 20 individual steps in cannulation so it isn't the simplest procedure
when you first start out so now after i put the tourniquet the next thing i do is i make sure that
i put something underneath the arm just in case i get a bit of blood spilled that way it doesn't
drop onto the patient or onto the bed and so the easiest thing to do is just put a towel down
and i put a towel instead of a bluey now the blueis we've realized that they're actually
really hazardous to the environment they also stay in landfill for over 100 years so really really
bad for the environment so that's why just using a towel is really easy to do for these purposes
so the next thing i do i just start by prepping the skin and so we've got a nice vein here
just across there and after i've wiped it with the alcohol cluckstein
i try not to touch that again in the area that i'm going to cannulate just to try and prevent
any problems next thing i do i hold the cannula like so again making sure that
my thumb and middle finger on either side my pointer finger here is free that way i can
see the chamber this point of finger is there to feed off the cannula as well i then loosen
the cannula like i've shown in many of my other videos and then i click it back into the place
i then tense the skin so what that means is that i make sure that my finger isn't in the way
of lowering the angle of my needle it's always to the side if i was cannulated somewhere
more distal i'd have it over the knuckles like that so i can always get a low angle
i'm just going in over the side that i sterilized in and i'm looking at the chamber for flashback
i see flashback i level out as you can see and then i advance even further a few millimeters
and then i thread off you can see that my hand position hasn't changed at all
next thing i do i put my thumb proximally and feed the needle off this needle goes straight to the
sharp spin that's disposed off and then this hand goes over here to the torn okay and that eases the
pressure there next thing i do is i take the iv bung i'm used to taking this cap off with one hand
so i've got the iv bung there now note that i don't have a spare hand free to stabilize the
cannula and that's okay i just jiggle it on like that and that way it's absolutely fine
and then i transfer my hand so all i did was have my thumb there jiggle it on once
it's pretty much on then i can stabilize the cannula and make sure that this is nice and tight
i then take this cap off ready to go my very next step
is to flush i do this before i put the tegadem on just in case i need to withdraw the cannula a
little bit or reposition it so i just push it onto the end and just make sure that it flushes easily
which it is which it absolutely is i can also do a pulse test to make sure that that pulse is felt
proximally and it is and there's no swelling that you can see which is also a good sign very
occasionally you might be able to aspirate but that's not always a positive sign
once i flush the saline that can be disposed of as well and finally i put that transparent
waterproof breathable dressing so that take it in i place that on and that keeps the whole area
sterile now and these are really great because they come with these little dated stickers
so i'll put that on here just to be able to label that later and then label this
and i just put my initials as well so that's that's cannulation done again it's really
important i dispose of all my waste materials and then i perform hand hygiene as i'm stepping
away from the patient as well now it's really important to document and date when the cannula is
put in and also it needs to be checked every day sepsis due to line infections is a real problem
in hospitals so we make sure that we date and review the cannula on a daily basis the cannula
should only be for a maximum of 72 hours so you really don't want to have it longer than that
and every day you need to be checking the cannula for example if there's any kind of redness
pus or swelling there if it's not flushing properly then you really need to reassess and
call someone for assistance and potentially even need to take this cannula away remove it and then
you know have someone have a look at the wound if there is a problem so infection risk is a real
problem maximum 72 hours make sure you document and review this cannula regularly now in my first
video 10 years ago i go through a couple of extra tips including how to hold the cannula properly
as well as how to put tension on the skin properly and how to avoid cutting the wrong surface of the
vein so let's go through a few of those tips now so whenever i hold the cannula i make sure that
the cannula is the lowest structure of my hand so it's not in this position that way i can't get as
lower angle as possible i make sure that when i pick it up my hand and my fingers are all above it
i hold it with the thumb and the little finger as you can see and that way i don't need to
change my grip to feed off the cannula sometimes i see people holding it with a grip like this
which means that they have to change the tension in the skin to then feed off the cannula which
means that you lose that structure you lose the structure and the tension on the skin and that
means that it's not going to be as accurate for the most difficult veins so this is my technique
for holding any cannula the most difficult veins you want to make sure all your structures are
aligned there's very minimal movement that's why i use this grip now when i put tension on the skin
i make sure that the thumb never gets in the way of my low angle at low angle is absolutely
vital to make sure that you're not cutting the wrong surface of the vein say i had a vein here
i wouldn't put my thumb there i'd put it over the knuckle edge that way once i've got flash back
i lower down and i advance if my thumb was there if i got flashback i just can't lower down enough
and i'm at risk of puncturing the deep surface of the vein now sometimes my vein will be on the
forearm so again there isn't a knuckle edge to go below so what i do is instead of going there
for a vein over here i might put tension on the skin there that way i get the needle through the
skin make a really low angle then advance this is similar with a cubital fossa vein i don't put my
thumb in the way i make sure that's just to the side as you can see even at the cubital fossa my
thumb is out of the way and that way as i get the flashback i can lower down really well something
else you might have noticed is that when i'm about to cannulate i rest my little finger and even the
ring finger and that gives me stability if my hand was floating in the air that means i'd have
everyone has a little bit of a tremor but this way i don't have a tremor i have much less trauma you
know you can do that in any circumstance even if you're cannulating a hand vein you may just
put rest your little finger on the hand and that way again you've got increased stability
i use any surface for that stability if i've got a vein around the back of the arm i'd again anchor
my fifth finger my ring finger and that just allows me to have more control and less tremor
when i was a sixth year medical student this is the one thing one of my interns taught me that
it's changed the way i cannulate and i've gone through this in a few other videos which i can
link to above but just remember that this needle is an amazing design so it's really really great
at cutting into the vein but also really great at cutting through the other side of the vein
but fortunately the bevel surface is really flat
so as soon as i get flashback i flatten out and i aim for the top surface
and that way there's just very little chance of cutting the top surface just because of the way
this needle is designed so that's my latest iv cannulation video i've gone from start to finish
all the aspects of iv cannulation that i think you need to do a successful cannulation
i hope that was interesting for you really just want to thank my helpers here um and yeah if you
like this video please share with anyone who might be interested and if you have any questions at
all please leave in the comments below thanks very much for watching and see you next time
you