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Got called by a Dr for a cannula in a very odematous patient with low blood pressure. Triple tourniquet method and taking my time got me there first try. Thank you for the video
I am a retired CRNI and taught IV certification courses for many years. The mistakes I saw most frequently are 1. “rushing”, not allowing enough time for peripheral veins to fill and 2. clinicians using their eyes instead of “feel”, using sense of touch to isolate the veins. Failure to not know sufficient vein anatomy can really be problematic too. Allowing 2 minutes for the veins to fill also gives time for the alcohol prep to evaporate and hence minimize any alcohol sting upon venipuncture.
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É muito útil tb usar a gravidade a nosso favor, 1 a 2 min com o membro "caído" ao lado da mesa, antes do garroteamento. Top! Obrigado por seus ensinamentos Prof. Radzic!
I think one thing often overlooked is the fact that in a difficult IV situation, especially after multiple attempts by multiple people, is go smaller; a 24g iv usually works perfectly well for induction, then if needed, a larger iv can be inserted after the pt is asleep. Not only can you be more aggressive without hurting the pt, but the anesthesia will cause the veins to dilate, making successful cannulation easier.
My biggest worry getting surgery or a procedure is the darn IV; I've gone through pure torture so many times because of all the unsuccessful jabbing and shoving. The small one works best for me, but it seems they know better and never listen to me or my body. 😕
Great ideas. Beware of walking away with the tourniquet left on and forgetting it. Also these techniques of stagnating blood flow will lead to hemolysis of RBCs so drawing labs at same time may lead to a hemolyzed sample
Hi Carlos. Agree, where available - venostasis function on an automated blood pressure cuff is better. Best regards and thank you for sharing experience!
was looking for this reply, Inflate to 60mmHg. You can go a bit higher, or go lower for pts with fragile atherosclerotic veins that pop the moment you insert the needle.
We usually applied medical techniques that we´ve learned before without taking into consideration many obvious maneuvers. The main reason is falling under pressure to become procedures as fast as possible, and that´s the biggest mistake we do make when we probably have wrong decisions. Then we have to be aware that we are under pressure, and then we must slow down and take it calmly, then we will succeed the first time and we´ll get it in a short time. Then don´t worry, and take it easy!
@@pamowen3452 Well. It´s obvious. Our work as anesthesiologists is regarding goals and organization. If a medical organization is not working by professional criteria, then we´ve anesthetized faster and succeeded at the first attempt to recover the wrong way. Then the mistakes came up quickly. Then, we were under pressure as I told you in the previous comment. That's all.⏳⌛
@@joseramoncabanas now that makes more sense to me, might be a difference of language that made it difficult for me to understand. Thank you for clarifying!
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I once saw a group of doctors call an old midwife at a local hospital, to put an iv on a 600gr tiny human, it was "too risky" they said, tiny human can die if it is wrong. She got the iv, look at tiny human, said something to tiny human, made eye contact, talk like if it was her child, grab the arm, wiggle it around carefully, then put the iv like she had done the exact the same thing a couple million times, not a flinch, not a cry, nothing, one swift -elegant- movement, everyone was dead silent and look at her like a goddes.
Easy heat source - get a glove fill with hot water (test on your acf it isn't too hot) then place over veins with tourniquet on & arm lowered. Works a treat and "kit" available on every ward!
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for difficult veins we use elastic bandage, BP cuff with bending the iv cath ( bifurcation) but this technique is a good addition to allow enough time for vein engorgement
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I tend to use a larger blood pressure cuff, it seems to push blood distal to the cuff and fill the veins after placing a tourniquet then place the blood pressure cuff below the tourniquet,or go straight to external jugular or saphenous vein.
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Never used triple tourniquets. Interesting. Went to school 1 year extra for IV nurse. Good discussion. Always start distally, working proximal especially if on long term therapy. Cepalic vein is natural splint. I also used basilic vein, standing behind patient. It is a skill, have used direct and indirect puncture. It seems, a lot go for ACF, ruining, lower veins, and infiltration is a higher risk( my opinion). I used 1 hand technique, never letting go of initial traction, until I thread, lowering bevel of needle, the threading catheter. Well done
That is really great. Thank you for sharing. We all get better this way. Make sure you subscribe to this channel; a lot more is coming soon! Greetings!
Hey Josh! Greetings! And thanks for watching. Do subscribe to this channel as there's more coming up. And let's share the collective experience so that we all get better in what we do!
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Gosh I have difficult veins 1. Your rt they rush rt in and miss 2. I've suggested a warm towel and wait a few min. Most won't 3. Since it usually takes up to 9 tries 4. U can bet I will suggest 3 now. Thanks
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The only issue with using heat, on renal and chf patients their veins are already overly dilated distal from the forearm. Even if you can pierce these veins successfully, any irritation or pressure can cause the vein to blow.
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Sometimes I’ll dim the lights and shine my iPhone flashlight by the side of the patient’s arm and creep the light gradually over the arm using the slight shadows caused by the veins followed by light palpating to verify vein location.
Full respect. Just as a side note- once the skin has been thoroughly scrubbed with solution (pref alc and chlorhex) and has dried - the site shouldn’t be touched and the skin should be fully dry during insertion rather than re wet.
Hi Hilmi, thank you for showing your interest in this topic. For more information, Subscribe to Nysora's Compendium oF RA nysoralms.com/courses/nysora-compendium-of-regional-anesthesia/ and you can have a dedicated topic on "Triple tourniquet technique". This is the source used by NYSORA's students, fellows, and over 10,000 clinicians worldwide"
Yup agreed, and esp when advicing wait 1-2 min - agreed the wait is so often missed. But never oewve bedside w 1 (or more) torniquets on - if you get pulled away/distracted the results may be serious.
Learn vascular anatomy exemplary, you will now exactly the veins position and practice more, because not always can use the tourniquet !!! Don’t keep stasis too long, can affect the blood test results, can affect the circulation , can create a big haematoma and swollen and many another causes… when the veins are collapsed, a tourniquet does not help either! Anatomy , practice and experience it’s the keys !
in caso di vene molto difficili da trovare,prima di adottare delle procedure invasive o comunque fastidiose per i pazienti per la somministrazione di farmaci opto sempre per una venipuntura arteriosa radiale;premettendo che con un ago a farfalla numero 25 si riescono a trovare numerose vene sulle dita della mano,ricordando che le vene sui piedi e sulle gambe talvolta evitano procedure fastidiose e dolorose per i pazienti.in caso poi di emergenza da codice salvavita ci si opta ove non reperibili vene ed arterie la somministrazione intraossea.
Very interesting video! Sure the triple tourniquet technique is easy, cheap and very likely to be available in any setting. I have two questions pertaining this technique: 1) Compared to one tourniquet or the reverse Esmarck technique you previously described, is there a bigger risk of the vein breaking at puncture? 2) Though widely use in acute care settings, is bending the catheter prior to insertion 100% safe or could it cause a potentially dangerous damage to the outer cannula?
Hi Davide and Gedder. Answers to the questions: #1) I do not know this - I am not aware of any data that would support my position on this. However, in my clinical experience of 3 decades, I have not observed the "vein breaking at the puncture". However, I have observed that a too slow advancement of the needle into the vein, when the veins are very distended with blood results in higher chance of hematoma. This is because the venous puncture is not sealed by quick insertion of the needle-catheter system. As such, I have adapted a technique of quickly advancing the needle through the skin and into the vein with any IV insertion. #2 I can confidently say that bending the needle-catheter system does NOT cause damage or breaking of the outer cannula. This is something that you can easily tested without IV canulas without patients - it is simply impossible. Greetigns and we will cover this in one of our future videos.
@@DRBLUESNYC thank you so much for your input. Your info for the first question is something for me to try out, trying to advance the catheter faster once flashback to reduce chances of hematoma.
@@qedder Indeed, once the needle tip enters the distended vien, the needle shaft/catheter must follow swiftly to prevent leakage from the punctured wall of the vein. Greetings
@@MLarios97 it’s my favorite when people use God to demean and demoralize someone on a public forum. I’m sure your imaginary friend in the sky is smiling down in pride at your grace and tenderness.
Hi Docterdad! This is definitely a great technique. Thank you for the suggestion. Whatever the venous stasis function is available on automated blood pressure machines is most definitely the most convenient and advisable. Thank you and have a good day!
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Hey David! Greetings! And thanks for watching. Do subscribe to this channel as there's more coming up. And let's share the collective experience so that we all get better in what we do!
Do you have any tips for peripheral IV insertion on a patient with extreme pitting edema, without using US? I'm a new ER nurse and I've found this scenario the most difficult to tackle. I've tried this & BP cuffs on some pts and still had difficulty seeing & palpating veins when they are extremely edematous
when i have patients with pitting oedema: i put pressure on their hand/where you normally want to cannulate, leave ur hand on it for 1-2 minutes, once u let go, you can see the vein. quickly clean and put the IV in. you just have to make sure your cannula itself is long enough to still be in the vein once the oedema is no longer pitting.
@@sapphirarusli3891 patients with severe pitting edema in the upper extrememeties many times have had lymph node removal in which case that particular arm should not be used for IVs or venipuncture, or BPs. If edema is cardiac, renal, or sepsis sourced, than a central line should already have been inserted. If edema is not too severe you can also elevate the arm. Use of a lamp angled tangentially to the arm may allow you to see "ripple" shadows of veins, especially if you gently rotate the arm to see arm topography better. Experiment on yourself and friends to see if you can find and or trace a vein. It's fun and educational.
Thank you for this video. What do you mean by 'bending the catheter'. bending down? are you literally using finger to push catheter down before insertion? Please explain.
Hey Ms KSS! “Bending the needle-catheter” meaning - bending the needle slightly to allow shallow angle of insertion into the vein. Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
Thank you so much for your videos. Plan on getting your book. One question, can you use a 4x 4 ace bandage in reverse in place of the esmarch bandage? I can’t seem to find it anywhere where I am at. Thank you
Big thanks for your fantastic comments and support! If you or your nurses or colleagues are having trouble with IV access, the new NYSORA IV Access App is here to help. Enjoy a 7-day free trial and tell us what you think. Together, we'll nail IV access like pros! www.nysora.com/iv-access-app/
We appreciate all your fantastic comments and support! If you or your nurses or colleagues are having trouble with IV access, the new NYSORA IV Access App is the answer. Try it free for 7 days and let us know what you think. Let's conquer IV access together! www.nysora.com/iv-access-app/
I’m a nurse in a cticu, and have been purposely practicing placing IVs and am ultrasound trained. I have always done at least two turner kits, and have used three before. Never understood why people honestly thought this would “blow” a major vein.
Paramedic here and in some older adults who have visible but extremely fragile veins/excess tissue I’ve actually gotten much more success without any tourniquet. They don’t tend to blow and a flush doesn’t provide any back pressure.
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Big thanks for your fantastic comments and support! If you or your nurses or colleagues are having trouble with IV access, the new NYSORA IV Access App is here to help. Enjoy a 7-day free trial and tell us what you think. Together, we'll nail IV access like pros! www.nysora.com/iv-access-app/
Big thanks for your fantastic comments and support! If you or your nurses or colleagues are having trouble with IV access, the new NYSORA IV Access App is here to help. Enjoy a 7-day free trial and tell us what you think. Together, we'll nail IV access like pros! www.nysora.com/iv-access-app/
Try to let fill 1 or 2 minutes ONLY in DIFFICULT patients. If you let the tourniquet with "normal" patients, high vein pressures maybe go toward fails because extravasations or bleeding.
When I was just in the hospital and the nurses couldn't find a vein a nurse from a special team used ultrasound. He couldn't find any veins in one arm, but got one in the other but it wasn't to find even then.
A warm washcloth will have the same effect and requires no orders and can soothe a nervous patient. If that doesn't work sing them a lullibye...just better have a good voice.😅
Wow. Not correct. You should open those doctors their eyes - top notch medical care start with nursing care. Nurses are highly trained medical professionals and should be allowed to be a lot more independent. THey certainly are, and super well respected for their independence, in our practice. Best regards
@@DRBLUESNYC very true. I work in a low resource setting and nurses have to be highly independent as long as we are practicing within the scope. We have to make it work with just the basics as we do not match up with other institutions in terms of technology as well as equipment and supplies.
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@@NurseSeethal well a vein that spasms is an artery…so just don’t poke those at all. But there is a rule of thumb that when dealing with older people expecially when they have superficial veins, ones you can see very easily, and big bouncy veins you may want to avoid a tourniquet to avoid blowing the vein.
I like using a manual BP cuff for those veins. I lower the pressure as low as I can go to still access the veins. The lower pressure seems to help me a lot.
It's called a VCB = Venus Constricting Band, a tourniquet blocks all blood flow, including arterial. Semantics, I know, but I tell this to my students all the time. Personally, I have never had a need for this. The most I have done is the BP method mentioned below. But still useful info.
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The alcohol increases evaporation and vasodilatation of the vein, but it has lower antiseptic effects on the skin. It´s much better to apply chlorhexidine with an alcoholic solution.
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What I find very challenging is the male arm with a ton of arm hair...I still cannot visualize as well...I request repeatedly that the arms be shaven before my arrival to the home, but they do not comply...ugh..Thanks so much for the video
I’m in my ED placement right now, so having the tourniquet on for 1-2 minutes before canulating isn’t an options, as we also draw blood from the canula. Having the tourniquet on for that long messes up the potassium, so not really an option
Hi Prashant. No Tourniquet is perfect. THere is always leakage underneath, unless excessive tourniquet pressure is applied - which is not recommended. Therefore, adding a couple of more tourniques enhances the effect of the single tourniquet - more surface. Greetings.
I rarely see videos with hard viens to cannulate. Typcaly 80 - 90+ 10 comorbidities, no viens left, collapseing viens, all used up viens, veins the roll to easily and so on.
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At this point, use an ultrasound to start an IV or get a central line/midline. Even if you start an IV at these baby veins, they aren't viable and have inadequate flow. Stop ego IV insertions and get the right equipment.
And starting IVs around the “watchband” area increases risk for nerve damage which can be permanent. I absolutely loathe PIVs in flex points when there are other options along the hand and forearm OR if US is available by a proficient user. I am changing those sometimes before even 6 hours has passed.
Yeah unsure why so many of his vids seem unwilling to go US. If I need 3 tourniquets, I very much doubt the stability of those veins that popped up! But I guess this is good in an emergency or when US equipment isn’t available! If this actually works, it has a place in clinical practice w low resources !
Hi @@cherylpwestmoreland5439 sorry for the very late reply to this. I had always assumed that it would be the case, but do you have any evidence to support the nerve damage rate being higher? Thank you.
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I resort to guiding the so called trained people straight to the veins. They then hardly palpate and then proceed to jam the needle through the vein and it feels like into the bone. The initial bit of blood they get when piercing through the vein for some reason makes them push deeper?? I've just come back from an MRI without contrast because they couldn't get the cannula in as they went straight through the vein. Veins aren't deep! You need to be controlled, to palpate and feel the vein, to allow time for the veins to fill, to slowly guide the needle in until you get flashback then stop there/guide in the cannula. It's so simple yet so many 'professionals' can't do it. Every single patient had cannula issues in a ward on my recent hospital stay in the UK, alarms constantly going off from misplaced and faulty cannulas, the elderly recipients being butchered by uncaring/untrained nurses. It was horrific. Bless those who are watching videos like this to improve their technique. Also, the patient will feel if you're doing it wrong, listen to their winces. It should only ever be a light scratch at worst, otherwise its you that's the problem.
i fully agree with what you said but plenty of times patients over reacts to needles sometimes they start screaming even before i touch the skin with the needle and say to me it hurts be more gentle please. some of them still act as if they are in pain even after i remove the needle from the cannula
Dang right! Would rather have a natural childbirth than have multiple failed IV attempts! Going to tell these tips to other providers who try this and fail on me! The warming worked for me.
I wouldn’t be so sure that the theory behind triple tourniquets is science based - assuming the placement of the first one is at the correct pressure to stem venous flow then the other two are superfluous.
A few things you need to change. Reusable tourniquets should not be used as they spread bacteria from patient to patient. If you want to touch the vein after skin antisepsis then you must wear sterile gloves. There is no antisepsis if you retouch what you just cleaned with non sterile gloves. Also dragging your Angio cath across the wristband is total contamination, as is laying it on the skin prior to advancing.
I find the most useful technique is heat but those hot packs you “break” are damn near useless. I’ve used plastic bags filled with hot tap water wrapped in a pillow case and not only do I get 80-90% of my IVs like that, patient’s love them! Just DO NOT apply without some barrier/cloth between the bag and the patient’s skin.
Peripheral I.V. canulation is taken very casually due to over confidence.The assistant and the main procedurist must have patience and should not speak during the procedure.Also the height of the bed should be adjusted according to the procedurist's convenience.
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Triple tourniquet is a ridiculous notion. 3 is not better than one appropriately applied tourniquet. How could 3 tourniquets make any difference on blockage of venous return of blood, one tourniquet of light force, no warming, no exercise needed. I have over 30 years experience with IV access.. The person receiving the IV is the most important variable. When patients have a significant subcutaneous fat layer, in general, the IV access is more difficult, but not always. Some people will need Doppler visualization of the deeper tissues to identify peripheral veins, it’s not rocket science, it’s visualization first, palpation second, and luminal size third that creates the ideal IV access subject vein.
HI Wildbill! Thank you for sharing. Indeed, we all do things differently; in the end - it is what works 4 you. Thank you for watching and do subscribe to the channel - we have a lot more coming up soon; let's share the experience, learn from each other, and all get better at what we do. Cool that we have this medium now to collaborate without barriers. Greetings from NYSORA!
This video could have been 10 seconds long. Lol “3 tourniquets plus a little bit of warmth and a little bit of time will engorge the veinS a bit more. If you have trouble with the actual venipuncture, you won’t find any help in this video.”
Hello… I am a Vascular Access Nurse and I assess every patient with my eyes and touch first while having a conversation about past history with IV access, good or bad. Based upon that initial assessment and conversation, I will either place the IV in a vessel I have found to be healthy and viable OR retrieve the US to visually assess what I have felt and determine if indeed that vessel is healthy enough to use. If so, I will use the US to actually place the line to increase success, decrease number of sticks, and use the correct device (short peripheral vs long peripheral) of the appropriate gauge. I do this for each patient and for patients known to me as difficult intravenous access (DIVA) I will go straight to US guided IVs or suggest the most appropriate device (Midline or central line). I hope that helped. 😉
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Why do health care professionals insist on maintaining techniques that are antiquated. Why would anyone attempt difficult access using a blind stick? Ultrasound allows visualization of the vessels during the cannulation process. Instead, we allow anesthetist and other clinicians to obtain access using a tiny catheter only to pass the problem on to the next person when that 22 or 24 Guage catheter goes bad (surprise!). Oh, don't ever place an IV on the inside of the wrist, it's just bad practice. Let's encourage each other to advance our practice, not maintain practices that have been evidence based to be poor.
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I'm nurse in india all of these techniques are good but just not practical in low income setting healthcare Again all these fancy techniques fall shy in hands of experienced nurse who pricks 30-40 arms a day
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*data theft is the most common invasive procedure in medical settings. you crooks.* also, who would want to learn annulation from another dr, no offense...but come on. -JC
Really?? This s nice vein that i can cannulate with my eyes closed without a tourniquet. This is a joke. Can you show us how you do that on a really obese patient with dark skin?? Someone that you can not even visualize the vein??
Hi Sam. Indeed, those patients require more time and additional techniques, some of which we have described in other videos. However, the vein in this video were not visible/palpable before application of the 3-ple tourniquet. Greetings.
Its not applicable for everyone, but my hospital has an ultrasound machine. With the help of coworkers and youtube, I learned to access deep and difficult veins
@@RESophia 99% of IVs placed are veins that you can not palpate. In emergency room or operating room. So you just read a textbook or someone taught you that and you are repeating it?
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Thank you for all your fantastic comments and support! If you or your nurses or colleagues are struggling with IV access, be sure to check out the new NYSORA IV Access App. Try it free for 7 days and share your feedback! Let's master IV access together! www.nysora.com/iv-access-app/
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Got called by a Dr for a cannula in a very odematous patient with low blood pressure. Triple tourniquet method and taking my time got me there first try.
Thank you for the video
Glad it helped. Thank you!
I am a retired CRNI and taught IV certification courses for many years. The mistakes I saw most frequently are 1. “rushing”, not allowing enough time for peripheral veins to fill and 2. clinicians using their eyes instead of “feel”, using sense of touch to isolate the veins. Failure to not know sufficient vein anatomy can really be problematic too. Allowing 2 minutes for the veins to fill also gives time for the alcohol prep to evaporate and hence minimize any alcohol sting upon venipuncture.
That’s a long time to have the tight tourniquet on!!
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@@joannaluca8495 pop goes the K from the cell
É muito útil tb usar a gravidade a nosso favor, 1 a 2 min com o membro "caído" ao lado da mesa, antes do garroteamento. Top! Obrigado por seus ensinamentos Prof. Radzic!
Lol I wish we could do it for two minutes. That’s way too long. Elevated labs for sure.
Dr. Hadzic, hope you realize just how big an impact you are having on the lives of patients. Thank you. 🙂
Hi Sana! Thank you! We are grateful for your message. Greetings from NYSORA!
I think one thing often overlooked is the fact that in a difficult IV situation, especially after multiple attempts by multiple people, is go smaller; a 24g iv usually works perfectly well for induction, then if needed, a larger iv can be inserted after the pt is asleep. Not only can you be more aggressive without hurting the pt, but the anesthesia will cause the veins to dilate, making successful cannulation easier.
My biggest worry getting surgery or a procedure is the darn IV; I've gone through pure torture so many times because of all the unsuccessful jabbing and shoving. The small one works best for me, but it seems they know better and never listen to me or my body. 😕
@@MrsDauphineeyou can tell them no, not to stick you unless it’s with a 24g
@@Marieezy40And in return they can tell you no, no surgery today.
Hvala doktore na divnim snimcima!
Zadovoljstvo je naše!
Great ideas. Beware of walking away with the tourniquet left on and forgetting it. Also these techniques of stagnating blood flow will lead to hemolysis of RBCs so drawing labs at same time may lead to a hemolyzed sample
Using a blood preasure cuff accomplishes the same thing and allows better control of backpreasure in older adults with fragile veins.🤕
Thankyou for your comment!
Hi Carlos. Agree, where available - venostasis function on an automated blood pressure cuff is better. Best regards and thank you for sharing experience!
Excellent comment thank you!!!
was looking for this reply, Inflate to 60mmHg. You can go a bit higher, or go lower for pts with fragile atherosclerotic veins that pop the moment you insert the needle.
The blood pressure cuff thing was shown less than 2 mins into the video, are you mentally challenged?
We usually applied medical techniques that we´ve learned before without taking into consideration many obvious maneuvers. The main reason is falling under pressure to become procedures as fast as possible, and that´s the biggest mistake we do make when we probably have wrong decisions. Then we have to be aware that we are under pressure, and then we must slow down and take it calmly, then we will succeed the first time and we´ll get it in a short time. Then don´t worry, and take it easy!
Hi Jose. This is 100% correct. Greetings!
I can’t make sense of this comment, medical techniques, falling under pressure to become procedures as fast as possible?
@@pamowen3452 Well. It´s obvious. Our work as anesthesiologists is regarding goals and organization. If a medical organization is not working by professional criteria, then we´ve anesthetized faster and succeeded at the first attempt to recover the wrong way. Then the mistakes came up quickly. Then, we were under pressure as I told you in the previous comment. That's all.⏳⌛
@@joseramoncabanas now that makes more sense to me, might be a difference of language that made it difficult for me to understand. Thank you for clarifying!
Efectivamente. Respirar y parar un poco antes de pinchar aunque tengamos 200 cosas por hacer despues de poner la via.
Wow, IV magic show !
Thx for your expert insight
Hi HA Wong! Thank you for your comment! Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
Big thanks for your fantastic comments and support! If you or your nurses or colleagues are having trouble with IV access, the new NYSORA IV Access App is here to help. Enjoy a 7-day free trial and tell us what you think. Together, we'll nail IV access like pros! www.nysora.com/iv-access-app/
I once saw a group of doctors call an old midwife at a local hospital, to put an iv on a 600gr tiny human, it was "too risky" they said, tiny human can die if it is wrong. She got the iv, look at tiny human, said something to tiny human, made eye contact, talk like if it was her child, grab the arm, wiggle it around carefully, then put the iv like she had done the exact the same thing a couple million times, not a flinch, not a cry, nothing, one swift -elegant- movement, everyone was dead silent and look at her like a goddes.
Easy heat source - get a glove fill with hot water (test on your acf it isn't too hot) then place over veins with tourniquet on & arm lowered. Works a treat and "kit" available on every ward!
Obviously tie the top of the glove securely :p
Great idea!
A lot of places will not allow this, re policy. Great idea though
It looks so easy when you know and use the right technique 🤩
Indeed. There is a skill for everything! Regards and thanks for watching.
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for difficult veins we use elastic bandage, BP cuff with bending the iv cath ( bifurcation) but this technique is a good addition to allow enough time for vein engorgement
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AS an LPN in ER, I was called to start many IV’s. Love your advice.
Thanks for the positive feedback, Patricia. That's what it's all about :). Greetings from our team.
I tend to use a larger blood pressure cuff, it seems to push blood distal to the cuff and fill the veins after placing a tourniquet then place the blood pressure cuff below the tourniquet,or go straight to external jugular or saphenous vein.
Hey David Traylor! That is also great. We all get better this way. Make sure you subscribe to this channel; a lot more is coming soon! Greetings!
We appreciate all your fantastic comments and support! If you or your nurses or colleagues are having trouble with IV access, the new NYSORA IV Access App is the answer. Try it free for 7 days and let us know what you think. Let's conquer IV access together! www.nysora.com/iv-access-app/
Never used triple tourniquets. Interesting. Went to school 1 year extra for IV nurse. Good discussion. Always start distally, working proximal especially if on long term therapy. Cepalic vein is natural splint. I also used basilic vein, standing behind patient. It is a skill, have used direct and indirect puncture. It seems, a lot go for ACF, ruining, lower veins, and infiltration is a higher risk( my opinion). I used 1 hand technique, never letting go of initial traction, until I thread, lowering bevel of needle, the threading catheter. Well done
That is really great. Thank you for sharing. We all get better this way. Make sure you subscribe to this channel; a lot more is coming soon! Greetings!
Finally a helpful iv video
Glad you liked it!
Hey Josh! Greetings! And thanks for watching. Do subscribe to this channel as there's more coming up. And let's share the collective experience so that we all get better in what we do!
We appreciate all your fantastic comments and support! If you or your nurses or colleagues are having trouble with IV access, the new NYSORA IV Access App is the answer. Try it free for 7 days and let us know what you think. Let's conquer IV access together! www.nysora.com/iv-access-app/
Gosh I have difficult veins
1. Your rt they rush rt in and miss
2. I've suggested a warm towel and wait a few min. Most won't
3. Since it usually takes up to 9 tries
4. U can bet I will suggest 3 now. Thanks
Bookmark this video and get them to watch it at the blood draw place!
@@donnam5060it's not "drawing blood", which is very easy... this is about starting IVs.
better to use a hot pack than a warm towel.
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The only issue with using heat, on renal and chf patients their veins are already overly dilated distal from the forearm. Even if you can pierce these veins successfully, any irritation or pressure can cause the vein to blow.
would this be used for blood sampling if make quickly enough?
I gonna try...thanks for ur valuebale video
Most welcome!
Thank you Depu! Glad you like the video. Thank you for watching. Do subscribe to this channel and share with your colleagues; a lot more videos are coming up - let's share our clinical experience! Cheers!
Sometimes I’ll dim the lights and shine my iPhone flashlight by the side of the patient’s arm and creep the light gradually over the arm using the slight shadows caused by the veins followed by light palpating to verify vein location.
Full respect. Just as a side note- once the skin has been thoroughly scrubbed with solution (pref alc and chlorhex) and has dried - the site shouldn’t be touched and the skin should be fully dry during insertion rather than re wet.
Thats look cook and usefull!
But There is any thesis or evidence about triple tourniquet technique?
Hi Hilmi, thank you for showing your interest in this topic. For more information, Subscribe to Nysora's Compendium oF RA nysoralms.com/courses/nysora-compendium-of-regional-anesthesia/ and you can have a dedicated topic on "Triple tourniquet technique". This is the source used by NYSORA's students, fellows, and over 10,000 clinicians worldwide"
When you say bend the catheter, what exactly do you mean? I have never done that before
I’m interested in what that looks like.
Forgetting one tourniquet is bad, Forgetting 3 is a disaster.
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Yup agreed, and esp when advicing wait 1-2 min - agreed the wait is so often missed. But never oewve bedside w 1 (or more) torniquets on - if you get pulled away/distracted the results may be serious.
Learn vascular anatomy exemplary, you will now exactly the veins position and practice more, because not always can use the tourniquet !!! Don’t keep stasis too long, can affect the blood test results, can affect the circulation , can create a big haematoma and swollen and many another causes… when the veins are collapsed, a tourniquet does not help either! Anatomy , practice and experience it’s the keys !
in caso di vene molto difficili da trovare,prima di adottare delle procedure invasive o comunque fastidiose per i pazienti per la somministrazione di farmaci opto sempre per una venipuntura arteriosa radiale;premettendo che con un ago a farfalla numero 25 si riescono a trovare numerose vene sulle dita della mano,ricordando che le vene sui piedi e sulle gambe talvolta evitano procedure fastidiose e dolorose per i pazienti.in caso poi di emergenza da codice salvavita ci si opta ove non reperibili vene ed arterie la somministrazione intraossea.
Great. Thank you for sharing. And make sure you subscribe to this TH-cam channel - we have a lot more really interesting videos coming up soon.
Very interesting video! Sure the triple tourniquet technique is easy, cheap and very likely to be available in any setting. I have two questions pertaining this technique: 1) Compared to one tourniquet or the reverse Esmarck technique you previously described, is there a bigger risk of the vein breaking at puncture? 2) Though widely use in acute care settings, is bending the catheter prior to insertion 100% safe or could it cause a potentially dangerous damage to the outer cannula?
Can we get an input on number 2? Thanks
Hi Davide and Gedder. Answers to the questions: #1) I do not know this - I am not aware of any data that would support my position on this. However, in my clinical experience of 3 decades, I have not observed the "vein breaking at the puncture". However, I have observed that a too slow advancement of the needle into the vein, when the veins are very distended with blood results in higher chance of hematoma. This is because the venous puncture is not sealed by quick insertion of the needle-catheter system. As such, I have adapted a technique of quickly advancing the needle through the skin and into the vein with any IV insertion. #2 I can confidently say that bending the needle-catheter system does NOT cause damage or breaking of the outer cannula. This is something that you can easily tested without IV canulas without patients - it is simply impossible. Greetigns and we will cover this in one of our future videos.
@@DRBLUESNYC thank you so much for your input. Your info for the first question is something for me to try out, trying to advance the catheter faster once flashback to reduce chances of hematoma.
@@qedder Indeed, once the needle tip enters the distended vien, the needle shaft/catheter must follow swiftly to prevent leakage from the punctured wall of the vein. Greetings
@@DRBLUESNYC Thank you! Your videos are amazing, can’t wait to see the next ones. 👋
I’m so gonna try this the next time when I find it difficult to find a vain. Thx 🙏🏻
You should. And take your TIME. Do NOT rush. Greetings.
Vein
God's mercy on anyone that ends up under your hands, you can't even spell vein
😂
@@MLarios97 it’s my favorite when people use God to demean and demoralize someone on a public forum. I’m sure your imaginary friend in the sky is smiling down in pride at your grace and tenderness.
“If one is helpful, 3 is more helpful”
Apply the BP cuff and inflate to half way between diastolic and systolic pressure to ensure arterial flow but no venous return…
Hi Docterdad! This is definitely a great technique. Thank you for the suggestion. Whatever the venous stasis function is available on automated blood pressure machines is most definitely the most convenient and advisable. Thank you and have a good day!
Cool technique 😎
Thank you! Cheers!
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Nobody’s made this dudes videos mandatory to watch, lol.
Hey David! Greetings! And thanks for watching. Do subscribe to this channel as there's more coming up. And let's share the collective experience so that we all get better in what we do!
Do you have any tips for peripheral IV insertion on a patient with extreme pitting edema, without using US? I'm a new ER nurse and I've found this scenario the most difficult to tackle. I've tried this & BP cuffs on some pts and still had difficulty seeing & palpating veins when they are extremely edematous
This and when they have Aton of adipose tissue
Ultrasound
when i have patients with pitting oedema: i put pressure on their hand/where you normally want to cannulate, leave ur hand on it for 1-2 minutes, once u let go, you can see the vein. quickly clean and put the IV in. you just have to make sure your cannula itself is long enough to still be in the vein once the oedema is no longer pitting.
@@sapphirarusli3891 patients with severe pitting edema in the upper extrememeties many times have had lymph node removal in which case that particular arm should not be used for IVs or venipuncture, or BPs. If edema is cardiac, renal, or sepsis sourced, than a central line should already have been inserted. If edema is not too severe you can also elevate the arm. Use of a lamp angled tangentially to the arm may allow you to see "ripple" shadows of veins, especially if you gently rotate the arm to see arm topography better. Experiment on yourself and friends to see if you can find and or trace a vein. It's fun and educational.
Worst scenario you can use exteral jugular vein with grey or green iv cannula.
Thank you for this video. What do you mean by 'bending the catheter'. bending down? are you literally using finger to push catheter down before insertion? Please explain.
Hey Ms KSS! “Bending the needle-catheter” meaning - bending the needle slightly to allow shallow angle of insertion into the vein. Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
Thanks 😊
Welcome 😊
Thank you so much for your videos. Plan on getting your book. One question, can you use a 4x 4 ace bandage in reverse in place of the esmarch bandage? I can’t seem to find it anywhere where I am at. Thank you
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Great Video!!! Thanks
Glad you liked it!
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Fantástico,muy instructivo y práctico 👍🏻
I’m a nurse in a cticu, and have been purposely practicing placing IVs and am ultrasound trained. I have always done at least two turner kits, and have used three before. Never understood why people honestly thought this would “blow” a major vein.
What’s a turner kit
Tourniquet*
Paramedic here and in some older adults who have visible but extremely fragile veins/excess tissue I’ve actually gotten much more success without any tourniquet. They don’t tend to blow and a flush doesn’t provide any back pressure.
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@@ashtonduda9971 Totally agree!
s march is a great idea.
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Thank you for making this! Helps a lot :)
Glad it helped! Stay connected-a lot more is coming soon! Greetings!
Thank you for your demonstration.. iam nurse from Indonesia..
Thank you for watching!
Where can get that wide ternique?
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Try to let fill 1 or 2 minutes ONLY in DIFFICULT patients. If you let the tourniquet with "normal" patients, high vein pressures maybe go toward fails because extravasations or bleeding.
Dear Freddy, Thank you for sharing! Greetings!
When I was just in the hospital and the nurses couldn't find a vein a nurse from a special team used ultrasound. He couldn't find any veins in one arm, but got one in the other but it wasn't to find even then.
Unfortunately at my hospital for some reason we have to get a doctor's order for us nurses to place a cold pack or warm pack...
A warm washcloth will have the same effect and requires no orders and can soothe a nervous patient. If that doesn't work sing them a lullibye...just better have a good voice.😅
Wow. Not correct. You should open those doctors their eyes - top notch medical care start with nursing care. Nurses are highly trained medical professionals and should be allowed to be a lot more independent. THey certainly are, and super well respected for their independence, in our practice. Best regards
@@DRBLUESNYC very true. I work in a low resource setting and nurses have to be highly independent as long as we are practicing within the scope. We have to make it work with just the basics as we do not match up with other institutions in terms of technology as well as equipment and supplies.
Just close the door and ask for forgiveness later. That is a retarded policy.
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Should we do IV without a tourniquet in fragile veins?
One of my colleagues told me.
What is your understanding of fragile?
@@taylor3022
Veins that easily get spastic
@@NurseSeethal well a vein that spasms is an artery…so just don’t poke those at all. But there is a rule of thumb that when dealing with older people expecially when they have superficial veins, ones you can see very easily, and big bouncy veins you may want to avoid a tourniquet to avoid blowing the vein.
@@taylor3022 thanks for the info
I like using a manual BP cuff for those veins. I lower the pressure as low as I can go to still access the veins. The lower pressure seems to help me a lot.
Nice interesting collection of pesrls
i like ur glasses sir
It's called a VCB = Venus Constricting Band, a tourniquet blocks all blood flow, including arterial. Semantics, I know, but I tell this to my students all the time.
Personally, I have never had a need for this. The most I have done is the BP method mentioned below. But still useful info.
That is great also. Thank you for sharing! B-safe!
Also ... Gravity ;)
Let the limb/vein dangle freely well below heart level
Indeed. Must apply Tourniquet with the arm/hand below the heart level. Thank you
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Perfect
To tap directly on the sterilized area isnt the most preferable from a hygien perspective, right?
(1 semester nurse student)
Thanks for ur content!
🤗
Tourniquets should be applied proximally to distally.
in my experience using relatively more alcohol also helps. or is this a bias? would you have any explanation for this effect?
The alcohol increases evaporation and vasodilatation of the vein, but it has lower antiseptic effects on the skin. It´s much better to apply chlorhexidine with an alcoholic solution.
@@joseramoncabanas I like using alcohol first then the chloraprep too. Seems like the alcohol itself has the most vasodilating properties
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Stabilised the hand but didn’t stabilise the camera 😜 Just kidding. Thanks for the video. New thing learnt today!
Noted! We really appreciate your feedback! Thank you!
Big thanks for your fantastic comments and support! If you or your nurses or colleagues are having trouble with IV access, the new NYSORA IV Access App is here to help. Enjoy a 7-day free trial and tell us what you think. Together, we'll nail IV access like pros! www.nysora.com/iv-access-app/
What I find very challenging is the male arm with a ton of arm hair...I still cannot visualize as well...I request repeatedly that the arms be shaven before my arrival to the home, but they do not comply...ugh..Thanks so much for the video
Hi Wisdom Speaks! True, thank you for your comment and greetings from Nysora!
Just bring a bic shaver and ask a tattoo artist how they shave arm hair.
I’m in my ED placement right now, so having the tourniquet on for 1-2 minutes before canulating isn’t an options, as we also draw blood from the canula. Having the tourniquet on for that long messes up the potassium, so not really an option
Not really man
I haven't had that issue.
What is the added advantage of using 3 tourniquet over a single tourniquet?
Hi Prashant. No Tourniquet is perfect. THere is always leakage underneath, unless excessive tourniquet pressure is applied - which is not recommended. Therefore, adding a couple of more tourniques enhances the effect of the single tourniquet - more surface. Greetings.
Next video by NYSORA:
Difficult IVs with five tourniquet technique
Thanks for the suggestion. We will definitely put this on our list. Greetings from NYSORA!
One word, ultrasound. Thank me later, patients will sing u praises🙏👊
I rarely see videos with hard viens to cannulate. Typcaly 80 - 90+ 10 comorbidities, no viens left, collapseing viens, all used up viens, veins the roll to easily and so on.
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At this point, use an ultrasound to start an IV or get a central line/midline. Even if you start an IV at these baby veins, they aren't viable and have inadequate flow. Stop ego IV insertions and get the right equipment.
And starting IVs around the “watchband” area increases risk for nerve damage which can be permanent. I absolutely loathe PIVs in flex points when there are other options along the hand and forearm OR if US is available by a proficient user. I am changing those sometimes before even 6 hours has passed.
@@cherylpwestmoreland5439 yes hate IVs there!
Yeah unsure why so many of his vids seem unwilling to go US. If I need 3 tourniquets, I very much doubt the stability of those veins that popped up! But I guess this is good in an emergency or when US equipment isn’t available! If this actually works, it has a place in clinical practice w low resources !
Hi @@cherylpwestmoreland5439 sorry for the very late reply to this. I had always assumed that it would be the case, but do you have any evidence to support the nerve damage rate being higher? Thank you.
Could have edited it into 2 to 3mins.
Helpful in watching
Thank you for your feedback!
Let me do it. I love doing it with 💯 perfect.
Use iv line as tourniquet.☆
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I resort to guiding the so called trained people straight to the veins. They then hardly palpate and then proceed to jam the needle through the vein and it feels like into the bone. The initial bit of blood they get when piercing through the vein for some reason makes them push deeper?? I've just come back from an MRI without contrast because they couldn't get the cannula in as they went straight through the vein. Veins aren't deep! You need to be controlled, to palpate and feel the vein, to allow time for the veins to fill, to slowly guide the needle in until you get flashback then stop there/guide in the cannula. It's so simple yet so many 'professionals' can't do it. Every single patient had cannula issues in a ward on my recent hospital stay in the UK, alarms constantly going off from misplaced and faulty cannulas, the elderly recipients being butchered by uncaring/untrained nurses. It was horrific. Bless those who are watching videos like this to improve their technique. Also, the patient will feel if you're doing it wrong, listen to their winces. It should only ever be a light scratch at worst, otherwise its you that's the problem.
i fully agree with what you said but plenty of times patients over reacts to needles sometimes they start screaming even before i touch the skin with the needle and say to me it hurts be more gentle please. some of them still act as if they are in pain even after i remove the needle from the cannula
also some say that am really gentle others say am butchering them so the patients are not that good of a source of feedback on the technique
Another thing the person did here was to sit down and make both them self and the patient comfortable and steady.
Dang right! Would rather have a natural childbirth than have multiple failed IV attempts! Going to tell these tips to other providers who try this and fail on me! The warming worked for me.
i use US.
I wouldn’t be so sure that the theory behind triple tourniquets is science based - assuming the placement of the first one is at the correct pressure to stem venous flow then the other two are superfluous.
Agree
A few things you need to change. Reusable tourniquets should not be used as they spread bacteria from patient to patient. If you want to touch the vein after skin antisepsis then you must wear sterile gloves. There is no antisepsis if you retouch what you just cleaned with non sterile gloves. Also dragging your Angio cath across the wristband is total contamination, as is laying it on the skin prior to advancing.
I find the most useful technique is heat but those hot packs you “break” are damn near useless. I’ve used plastic bags filled with hot tap water wrapped in a pillow case and not only do I get 80-90% of my IVs like that, patient’s love them! Just DO NOT apply without some barrier/cloth between the bag and the patient’s skin.
Peripheral I.V. canulation is taken very casually due to over confidence.The assistant and the main procedurist must have patience and should not speak during the procedure.Also the height of the bed should be adjusted according to the procedurist's convenience.
Thank you for all your fantastic comments and support! If you or your nurses or colleagues are struggling with IV access, be sure to check out the new NYSORA IV Access App. Try it free for 7 days and share your feedback! Let's master IV access together! www.nysora.com/iv-access-app/
No pumping no fists anymore and no wrists
I don’t know where you’re practicing but our hierarchy would have a stroke if we started bending needles. 🤦🏼♀️
Triple tourniquet is a ridiculous notion. 3 is not better than one appropriately applied tourniquet. How could 3 tourniquets make any difference on blockage of venous return of blood, one tourniquet of light force, no warming, no exercise needed. I have over 30 years experience with IV access.. The person receiving the IV is the most important variable. When patients have a significant subcutaneous fat layer, in general, the IV access is more difficult, but not always.
Some people will need Doppler visualization of the deeper tissues to identify peripheral veins, it’s not rocket science, it’s visualization first, palpation second, and luminal size third that creates the ideal IV access subject vein.
HI Wildbill! Thank you for sharing. Indeed, we all do things differently; in the end - it is what works 4 you. Thank you for watching and do subscribe to the channel - we have a lot more coming up soon; let's share the experience, learn from each other, and all get better at what we do. Cool that we have this medium now to collaborate without barriers. Greetings from NYSORA!
You applied the tourniquet wrong
Either you are born skillfull or you don't 😂😂😂
I can hear the lab calling about hemolysis already. Get back in there and straight stick 'em nurse and step on it.
👍👍👍
This video could have been 10 seconds long. Lol
“3 tourniquets plus a little bit of warmth and a little bit of time will engorge the veinS a bit more. If you have trouble with the actual venipuncture, you won’t find any help in this video.”
Yeah… ultrasound
Just sono the hard patients 🤷♂
What about us I.V. drug abusers? Lol. I bet a lot of those 'likes' are people like me. Or for people in the "harm reduction" community
Hello… I am a Vascular Access Nurse and I assess every patient with my eyes and touch first while having a conversation about past history with IV access, good or bad. Based upon that initial assessment and conversation, I will either place the IV in a vessel I have found to be healthy and viable OR retrieve the US to visually assess what I have felt and determine if indeed that vessel is healthy enough to use. If so, I will use the US to actually place the line to increase success, decrease number of sticks, and use the correct device (short peripheral vs long peripheral) of the appropriate gauge. I do this for each patient and for patients known to me as difficult intravenous access (DIVA) I will go straight to US guided IVs or suggest the most appropriate device (Midline or central line). I hope that helped. 😉
Thank you for all your fantastic comments and support! If you or your nurses or colleagues are struggling with IV access, be sure to check out the new NYSORA IV Access App. Try it free for 7 days and share your feedback! Let's master IV access together! www.nysora.com/iv-access-app/
Why do health care professionals insist on maintaining techniques that are antiquated. Why would anyone attempt difficult access using a blind stick? Ultrasound allows visualization of the vessels during the cannulation process. Instead, we allow anesthetist and other clinicians to obtain access using a tiny catheter only to pass the problem on to the next person when that 22 or 24 Guage catheter goes bad (surprise!). Oh, don't ever place an IV on the inside of the wrist, it's just bad practice. Let's encourage each other to advance our practice, not maintain practices that have been evidence based to be poor.
You forget the home care nurse who does not have access to ultrasound. We have to use all the tips and tricks we can find even if some are antiquated
Thank you for all your fantastic comments and support! If you or your nurses or colleagues are struggling with IV access, be sure to check out the new NYSORA IV Access App. Try it free for 7 days and share your feedback! Let's master IV access together! www.nysora.com/iv-access-app/
I'm nurse in india all of these techniques are good but just not practical in low income setting healthcare
Again all these fancy techniques fall shy in hands of experienced nurse who pricks 30-40 arms a day
Thank you for all your fantastic comments and support! If you or your nurses or colleagues are struggling with IV access, be sure to check out the new NYSORA IV Access App. Try it free for 7 days and share your feedback! Let's master IV access together! www.nysora.com/iv-access-app/
*data theft is the most common invasive procedure in medical settings. you crooks.* also, who would want to learn annulation from another dr, no offense...but come on. -JC
Really?? This s nice vein that i can cannulate with my eyes closed without a tourniquet. This is a joke. Can you show us how you do that on a really obese patient with dark skin?? Someone that you can not even visualize the vein??
Hi Sam. Indeed, those patients require more time and additional techniques, some of which we have described in other videos. However, the vein in this video were not visible/palpable before application of the 3-ple tourniquet. Greetings.
Its not applicable for everyone, but my hospital has an ultrasound machine. With the help of coworkers and youtube, I learned to access deep and difficult veins
makes for a difficult video
Skin color has nothing to do with finding veins. You must find veins by touch not by sight.
@@RESophia 99% of IVs placed are veins that you can not palpate. In emergency room or operating room. So you just read a textbook or someone taught you that and you are repeating it?
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Poor medical practice on a number of levels. Do better, use ultrasound!
What about institutions without this capability? I work in a low resource setting and we have to make it work with what we’ve got which is not much.
@@MS-yu5cl are you able to advocate for training from the company who supplies your IV products?
Good
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Thank you for all your fantastic comments and support! If you or your nurses or colleagues are struggling with IV access, be sure to check out the new NYSORA IV Access App. Try it free for 7 days and share your feedback! Let's master IV access together! www.nysora.com/iv-access-app/
Good thx sir
Thank you for all your fantastic comments and support! If you or your nurses or colleagues are struggling with IV access, be sure to check out the new NYSORA IV Access App. Try it free for 7 days and share your feedback! Let's master IV access together! www.nysora.com/iv-access-app/