Peripheral Venous Cannulation

[pinksparkle]

It's the time of year where the 3rd year medics at Cardiff get/have to do our student selected projects. And mine is to write a paper about how to make putting in a Venflon easier. So i'm spending time with the anesthetists, trying to find out their top tips and getting to practice putting i some myself. (And trying to find papers about it, which dont really seem to exist!)
But i'd really like to know tips from you guys, as I think tips you learn when you first start putting them in may disappear as you get more proficient. So any help and tips you've picked up would be much appricated.
Thanks in advance
xXx

[Touche]

There is the "lateral approach" technique rather than approaching right in from the top, go along side the vein and then into the side. Apparently this 'z'-ing leads to less bleeding when you remove them and makes them easier to get in.

There is the "get flashback and flush" technique. Get flashback, flush with a tornequet still on (10ml saline pumps up the vein nicely), then go right into a juicy fat dilated vein.

Got those off others and used them to varying degrees of success, but my own top tip is to keep anchoring the vein down inferiorly. Never let this go or the needle moves around and you loose it. Get flashback, go in an extra 2-3mm advance the cannula over the needle all the while keeping that inferior anchor.

[heed]

patients who you know are coming up on a list with crap veins - try getting them to wear a nitrile glove for half an hour before they come down. the heat helps dilate the veins in the back of the hand. have also heard of people using GTN patches as a last ditch effort to find a vein.

[rjm]

GTN patch - hmm, and drop their BP with subsequent consequence of ischaemia somewhere, give them a headache, make them fall over etc, definitely not sure about that one!

My tip would be to take your time and not rush it. Bowl of hot water for impossible to find veins. I dont like that lateral approach.

[yazoo]

If time allows: are you comfortable, is the patient comfortable. If they are notoriously hard, have a seat, take your time. Find a good vein. If they all look crap, and time allows, get the patient to warm up - dressing gown on, bowl of hot water as RJM says, get those veins dilating! Look for medial forearm veins which are often less commonly used.

Look for the soft, bouncey veins. If they are hardish, they may be thrombosed. If the patient is very elderly and skinny, or they have recently lost a lot of weight, these veins are especially prone to movement! Anchor them well.

One of the most commonly made novice mistakes is to give up too soon while looking for a flashback. If you do not have a haematoma growing in front of your eyes, keep persisting at the same vein if the patient does not seem in discomfort. Remember, the most painful part is (generally) going through the skin. If it's still painful after that, the vein may be thrombosed. If so, try elsewhere.

If you spot several good veins on one arm, start with the more proximal sites. That way, if you miss first time, you can move the tourniquet down the arm without getting a big haematoma! But try to avoid the antecubital veins if possible – awkward for the patient if the cannula is at a joint, and tissueing of drugs may be harder to spot. This is esp important if irritant chemicals are being given.

Tap the vein – this causes local release of vasodilators. As a med student, you cannot prescribe GTN, so this is out. As a Dr, I still wouldn’t use a GTN patch, but I have seen people use GTN spray (with caution, considering contra-indications). Personally, I don’t.

Flush the vein well after, slowly and with a reasonable size flush. Look carefully for tissueing. If you are not sure (and the patient can’t tell you it’s sore), flush again.

Don’t try more than 3-4 times (unless the situation demands it). Ask for consent each time. Ask for help sooner rather than later.

That’s almost a novella, so I’ll stop here!

[yazoo]

Oh, and if they are all that hard, put a bandage on the arm too, once the cannula is in! If you have been nice to the nurses they will generally do this for you...

[BabyDoc06]

if you are advancing the cannula and you hit a valve, just flush some saline in and advance at the same time. This should open the vein and allow you to put the cannula past the valve.

[heed]

think carefully about where exactly you are putting the venflon aswell - you might get it in easily, but will it be useless in that position? in theatre, it might be really easy to put a big orange beast into someones ACF, and then not be able to reach it the whole way through the procedure! As a wee aside, was told to avoid venflons in the ACF if giving thiopentone as there is a higher chance of arterial cannulation (thiopentone + artery = no arm left)

[pinksparkle]

Thanks so much for helping out, that is definitely gonna fill up a bit more of my page than the useful (and true) advice "practice and confidence"! I shall head off to theatres next week with a few new tips to try out!
If anyone else thinks of nething let me know!
Thanks
xXx

[M Clayton]

If the patient is not in urgent need of agressive fluid resus, don't be a lazy bugger and go for the antecubital fossa. It may feel good to wham that pink in there first time round... but when you get called to see the patient in 2 days time and they have a blood pressure of 40 systolic, you're going to really regret it.

Top tip - start distal and think about what you're going to be putting through the cannula - use the smallest you can get away with. Putting an orange in when all the patient needs is once daily gentamicin will not make you popular.

(And finally! Don't send a shocked patient to theatre with only a blue in the antecubital fossa - if you do, do not be surprised when the anaesthetic staff take the piss out of you forever)