IV cannulation and IV infusion

 Parts of IV Cannula

 Color coding of IV cannula

HOW DOES A 3 WAY STOPCOCK WORK - https://youtu.be/4TXQyv5_lGI

Usual sites of cannula insertion 

Dorsum of hand (Most commonly done), forearm, dorsum of foot in paediatric patients

Order of preferred vein for cannulation - the more distal the better, the straighter the better, the lesser on the joint the better. Your very last option on the arm should be the antecubital vein. 

REQUIREMENTS:

An appropriate size iv cannula (blue used usually for adults), a tourniquet, sterile gloves, alcohol swab, 3-way stopcock attached to 5ml syringe filled with normal saline (keep the 3- way such that one side-port is open and one is closed, as shown in the image below), dressing for the cannula.  If blood collection has to be done – vacutainers.

 

PROCEDURE: 

1. Wash hands and wear sterile gloves. 

2.  Apply a tourniquet proximal to the site of cannula insertion and ask the patient to close and open the fist a few times to make the veins visible. 

3.  The selected site is cleaned with an alcohol swab. 

4.  The cannula is opened from the sterile pack and held with two wings together with the bevel of the needle pointing upward. 

5. The vein to be punctured is steadied by slightly stretching the skin over it (also helps to see the direction of the vein clearly) and the skin is punctured with the cannula keeping the cannula at about 15 degrees to the skin. While doing this, decrease the angle between it and the hand (tilt needle upwards slightly) so that the vein is not counter-punctured. 

6. The needle with the cannula is advanced through the subcutaneous tissue into the vein.  As the cannula enters the vein blood will be seen flushed into the distal end of the cannula. 

7. The needle is further advanced few millimetres inside the vein. 

8. The cannula is held steady. The needle is withdrawn slightly and the plastic cannula is advanced into the vein over the metal needle. The metal needle and the tourniquet are removed. 

9. Blood collection from the open end of the cannula can be done at this point if it is required.

10. ** FLUSHING THE CANNULA – Immediately, the open end of the cannula is connected to the 3-way stopcock which is already attached to a 5ml saline syringe. Flush the cannula by injecting the normal saline.

11. ** ‘Turn off’ the 3 way (by aligning the blunt end of the 3 way knob with the iv cannula end), detach the syringe and close the ports of the 3 way stopcock with the caps.

12. The cannula is secured in place by an iv dressing.

** = DONE DIFFERENTLY FROM WHAT IS SHOWN IN THE VIDEO. 

PRACTICAL TIPS & TRICKS

1. As is mentioned before, keep the saline filled syringes already attached to the 3-way stopcocks during emergency. You won’t have time to attach them midway during the procedure. 

2. Tourniquet usually not available, so use a glove instead. 

3. During blood collection from the open end of the cannula, to prevent blood spillage between successive collections in different vacutainers, maintain a slight pressure with your hand over the end of the cannula which is entering the vein. This will prevent the blood from coming out. 

4. Remove vacutainer caps and keep the bulbs ready to collect blood in. Won’t have time to open and close each. 

5. During summer due to sweat, the iv dressing is more likely to come off and displace the iv cannula. Which will lead to repeated iv cannulations. So, make the cannula extra secure by additionally using micropore tape to keep it in place. 

6. Before putting IV sticking, put sanitiser on your gloves so that the sticking doesn't stick to your gloves.

7. Lower down the hand to be cannulated to make the vein more prominent.

8. Cannulate at the bifurcation point of the vein preferably (to prevent vein from rolling).

9. Vein may be tapped to make it more prominent (as it warms the area and releases vasodilators).

10. While stretching the skin over the vein, do it so by using your non-dominant hand's thumb placed below the patient's knuckle ridge.

 

VIDEO LINK:

https://youtu.be/h8DlRtqgh8c  (HAS SOME DIFFERENCES FROM WHAT IS DONE IN KEM HOSPITAL where I study. Those steps are highlighted above)

 

SETTING UP AN IV INFUSION 

Flow controller/Roller ball clamp: controls the rate of flow

Uppermost position: fastest flow

Lowermost position: CLOSED – no flow

REFERENCE VIDEO LINK:

https://youtu.be/Siy2cEMICE4

PROCEDURE OF SETTING UP THE I.V. INFUSION:

1. Collect all the requirements – bag containing the fluid/drug to be administered, iv set, pair of gloves

2. Explain the procedure to the patient and gain their consent

3. Check the fluid bag for any cloudiness or particulate matter present; do not use the bag if any such impurities are present

4. Remove the outer packing of the bag and hang it up on a drip stand

5. Wear sterile gloves

6. Open the iv set and keep the flow ‘off’ using the roller-ball clamp on the line

7. Remove the cover from the port on the bag containing the fluid/drug by twisting and breaking it off. Insert the spike (piercer) into the port, without touching the end of the spike

8. Half fill the drip chamber by squeezing it. Insert a needle at the top end of the bag and let it remain there.

9. Then release the roller ball clamp to allow the fluid to run through the giving set. Let the fluid come out through the open end of the line. Ensure there are no air bubbles in the line (to prevent air embolism). 

10. Attach the luer lock connector end of the iv set to the 3 way stopcock attached to the iv cannula which is already inserted in the patient’s arm

11. Set the infusion rate (as per instructions from the resident) by adjusting the roller ball.

Stopping the i.v. infusion:

1. Adjust the roller ball clamp to turn off the flow

2. Before disconnecting the iv set from the iv cannula, ‘switch off’ the 3-way stopcock

3. Disconnect the iv set from its insertion into the 3-way stopcock

 

 

Written by our guest author Mitali Shroff

Illustrations by Devi Bavishi
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SCHIRMER'S TEST

The Schirmer test is used to test aqueous tear production. 

The test is performed in dim light with fans switched off.

Whatman filter paper no.41 is used with a dimension of 5 mm x 35 mm.

1. The test is performed by instilling a topical anaesthetic.

2. The 5 mm tab is folded at one end and then the bent end is placed at the junction of the lateral 1/3rd and medial 2/3rd of the lower conjunctival sac.

3. The corners of a soft tissue paper may be used to wick all liquid from the inferior fornix by capillary attraction without any wiping or direct irritation before the paper is placed. 

4. The patient's eyes are then closed for 5 minutes, and the amount of wetting in the paper strip is measured.

5. Less than 5 mm of wetting is abnormal; 5-10 mm is equivocal.

VIDEO LINK

https://youtu.be/cF2wocf6XWQ

Written by our guest author Jignesh Bhadarka

Illustrations by Ayushi Gupta
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Incision and drainage

 Incision and drainage (Hilton's Method)

 

REQUIREMENTS: Written informed consent, sterile gauze pieces, povidone-iodine, ethanol, sterile drape, syringe with needle filled with local anesthetic drug, scalpel with no.11 blade, 2 sterile syringes or 1 sterile syringe and 1 sterile swab, pre-labelled containers (for sending the sample for microscopy and culture and sensitivity), artery/ sinus forceps, roller gauze

• Area of abscess is cleaned with povidone iodine followed by ethanol and draped
• Local anesthesia (generally lignocaine) is injected
• Stab incision along long axis of abscess with no.11 blade is made over the most prominent part of the
swelling where the skin is red, thinned out & pointed OR over the most dependent part of abscess (to allow easy drainage)
• Skin incision is generally made along the Langer’s lines (vertically on limbs and horizontally on trunk) and it should be parallel to neurovascular bundle
• Squeeze out the pus
• Sample is collected by a syringe/ swab for microscopy and culture & sensitivity in a prelabelled sterile
container
• Explore the abscess cavity by introducing sinus forceps/ finger in the abscess cavity and breaking all loculi
• Base of the abscess, if unhealthy, is curetted
• Oozing of fresh blood indicates completion of process
• Cavity is irrigated by normal saline followed by antiseptic (e.g. Povidone-Iodine and H2O2)
• Pack the cavity with roller gauze (soaked in Povidone-iodine) and remove it after 24-48 hrs
• Keep the abscess open and do regular dressing. Allow healing by secondary intention
• Advice to patient: Keep the area clean and dry

 

Alternate day dressings (generally). Analgesics SOS.
Antibiotics and Tetanus immunization as indicated.

TIPS & TRICKS:
1. Incision should be large enough to allow artery forceps to enter. If required, extension of incision in the same axis may be done or a cruciate incision can be made
2. Sometimes a counter incision can be made in a the independent part to allow gravity- assisted drainage
3. Overpacking of abscess cavity should be avoided (to prevent ischemia of surrounding tissue)

Abscess at special sites:
I. For breast abscess, needle aspiration is done rather than incision and drainage. If it has to be done, incision should be radial
II. For some abscess like axillary abscess, drainage should be done under general anesthesia
III. Gluteal abscess requires a cruciate incision and de-roofing
IV. Tubercular lymph nodal abscesses are drained by non-dependent aspiration (To prevent non-healing of incision site)

 

VIDEO LINK
Equipment required: 2:28min
Preparation: 3:39 min
Procedure: 4:46 min to 7:27 min
https://youtu.be/MwgNdrA18fM

 

Written by our guest authors Tushar Mahajan and Anveshi Nayan

Illustrations by Devi Bavishi
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Common steps to minor procedures

 

Steps common to all minor procedures

A) Pre- procedure:

1. Correct documentation with clinical photograph 

2. Informed written consent

3. Universal precautions  

4. Cleaning with betadine and spirit (or any other antiseptic) 

5. Infiltration of local anesthesia—Lignocaine with or without adrenaline. Check for the effect of anesthesia by gently poking the same needle in the periphery of the bleb raised by local anesthesia administration

B) Post-procedure: 

1. Dressing, antibiotics, TT injection when indicated

2. Advice to patient: The biopsy site should be kept clean and dry for a few days. The bandage should be changed at least once a day and should be changed if it should become wet or damp. Once a substantial scab has formed, or new skin begins to grow over the area and bleeding has stopped, the bandage can be removed

 

PRACTICAL TIPS AND TRICKS: 

1. While infiltrating, try to elevate the lesion by raising a wheal which allows the lesion to prop up

2. Keep a formalin filled pre-labelled container ready for putting the specimen in after its removal

Excision of Sebaceous cyst/ Dermoid cyst

EXCISION OF SEBACEOUS CYST/ DERMOID CYST

  

 

Steps common to all minor procedures 

REQUIREMENTS: Written informed consent, local anaesthetic in a 2 or 5 ml syringe with needle, sterile gauze pieces, povidone-iodine, ethanol, sterile drape, scalpel with curved no. 15 blade, artery forceps, toothed forceps, needle holder, suture, dressing material

• Palpate the cyst and surrounding area to confirm its exact location and punctum
• Curved no. 15 blade is used to make an incision
• The longitudinal direction of the ellipse should be along Langer’s lines (vertical in limbs and horizontal on trunk)
• The width of ellipse = approx. 1/3 rd diameter of cyst and length considerably longer
• First incise the skin up to the subcutaneous tissues
• Then, using blunt and sharp dissection, identify the plane between the cyst and surrounding subcutaneous tissues
• Then, separate the superficial 25% of the circumference of the cyst with blunt dissection
• Now press the normal surrounding skin and soft tissues on both sides gently with the thumbs, first in
one direction, then at 90 degrees to the previous direction
• Around 80-90% of the cyst emerges from the incised area
• Gently lift up the incised ellipse of skin and attached cyst with forceps, and separate the deep pole of the cyst from underlying tissues using blade

  

 

GANGLION CYST EXCISION

It is similar to the above procedure, while bearing following in mind:
1. Careful dissection away from the tendons should be done
2. Feeding vessels to the ganglion need to be ligated
3. Special care should be taken not to injure major vessels like radial artery
4. The stalk of ganglion cyst should be traced and if arising from joint capsule, some part of joint capsule will have to be excised

PRACTICAL TIPS AND TRICKS:
1) While infiltrating, try to elevate the lesion by raising a wheal which allows the lesion to prop up
2) Keep a formalin filled pre-labelled container ready for putting the specimen in after its removal
3) Incisions should be made with the belly of blade

VIDEO LINK:
Excision of sebaceous cyst/ dermoid cyst: https://youtu.be/On9iKyDmtk8
Excision of ganglion cyst: https://youtu.be/KqOSb0TC8Ss

 

Written by our guest authors Anveshi Nayan and Shrishti Patil

Illustrations by Devi Bavishi
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Pap Smear

PAP SMEAR

Pap smear should be obtained before per speculum/ per vaginum examination done by the doctor.

Although there exist guidelines regarding cervical cancer screening, in most of the government hospitals in India, pap smear is done for every female who visits the Gynecology O.P.D. 

It should be avoided in a female who is menstruating or has copious vaginal discharge.

PROCEDURE

- Take verbal consent of the patient and follow aseptic technique

 

- Any vaginal speculum can be used. Insert the closed speculum with its blades facing the lateral vaginal wall. Then rotate it by 90 degree and open it

- Use Ayre’s spatula OR Cytobrush to obtain the sample from inside the external os. Also obtain one sample from ectocervix using opposite end of Ayre’s spatula

        - Take a pre- labelled slide and make 1 smear each of the two samples (one obtained from inside the external os and one from ectocervix) as follows:

 

 

- Place the slide in a jar containing fixative (generally 95% Ethyl alcohol) and fill the required forms

VIDEO LINK:

https://youtu.be/PlAoDirRqC8

Written by our guest author Hemant Kadam

Illustrations by Devi Bavishi
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Skin biopsy techniques

Skin biopsy techniques 

 

Types 

1. Shave biopsy 

2. Punch biopsy

3. Incisional biopsy

4. Excisional biopsy  

 Steps common to all minor procedures

 

SHAVE BIOPSY 

1. Stabilize the lesion between the thumb and forefinger in a direction perpendicular to Resting skin tension lines

2. A vertical cut is put at the periphery of the lesion using 11 or 15 No. scalpel blade attached to No. 3 BP handle

3. Blade is held parallel to the skin surface and then passed through the lesion through the cut that is already made at the periphery 

4. The blade is advanced through the lesion by a smooth sweeping stroke rather than a sawing motion while grasping the lesion with forceps

5. Hemostasis is achieved by firm pressure or with the chemicals
   

6. The procedure can also be performed by using halved razor blade or curved scissors.

7. Antibiotic cream applied and a gauze dressing is given

 

 

PUNCH BIOPSY  

1. Routinely a 3-4 mm punch is chosen

2. Traction given in a direction perpendicular to long axis of resting skin tension lines  

3. Punch is held vertically, and a steady pressure is applied

4. Punch is rotated in a clockwise manner till the punch reaches the subcutis. At this stage there is feeling of give away

5. Punch is withdrawn

6. Tissue cast is lifted with fine forceps while avoiding crushing and damage to epidermis. It is then cut at the base with scalpel blade as shown in figure

7. On releasing the tension, the circular biopsy defect relaxes into ellipse

8. The wound may be sutured for better healing with interrupted sutures for cosmetically important regions, but otherwise only dressing is generally done

 

PRACTICAL TIPS AND TRICKS: 

 Approximately, ½ of the blade of skin punch should be visible when it reaches the subcutis. 

 

  

INCISIONAL BIOPSY 

1. In this type, biopsy is performed from active edge of the lesion in a wedge shape including the normal skin. Alternatively, it can be performed by using biopsy punches of size 5 mm and above 

2. Area is kept taut and scalpel with No. 15 blade is held like a pencil

3. Begin the incision at the apex holding the blade perpendicular to the skin 

4. As the incision progresses blade is angled to 45° to cut the tissue with the belly of the blade

5. At the end of the incision again the scalpel is lifted vertically to prevent the excision from extending beyond the end point 

6. Wedge of tissue separated from underlying tissue with scalpel or dissecting forceps

7. Interrupted suture taken for larger and deeper defects suturing is done in two layers

 

 

EXCISIONAL BIOPSY Different techniques are been used to excise lumps from different parts of the body and different types of the lump. Separate document for the same has been sent.

 

Written by our guest authors Mohit Jain and Kritika Bhatia

Illustration by Devi Bavishi
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Skin tag removal

 

Acrochordon (Skin tag) removal

METHODS

• Cryotherapy

• Surgical removal (Usually done)

• Electrosurgery

SURGICAL EXCISION

 

REQUIREMENTS: 

Written informed consent, 2 ml syringe filled with local anesthetic and attached to a needle, scissors, toothed forceps, sterile gauze pieces, ethanol

PROCEDURE:

• Area over and surrounding the lesion is cleaned with ethanol

• Local anaesthesia with 2% Lignocaine with or without adrenaline is given

• Acrochordon is held with the forceps and the base is cut using a snip scissor or blade

• After achieving hemostasis (by applying pressure or aluminium chloride), antibiotic ointment applied

  
  
  
   
  
  Written by our guest author Kritika Bhatia
  

  Illustration by Devi Bavishi
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Preoperative patient preparation

Pre-op washing: 

Using soap to physically remove dirt and remove transient microorganisms from the surface of the skin.

A regular soap is enough for cleaning, patient is not required to use costly antiseptic soaps.

Pre-op hair removal: Hair should be clipped not shaved

INTRA-OP SKIN DISINFECTION:

SCRUB AND PAINT

Things to keep in mind while cleaning:

• Clean the areas in a circular motion going outside from the center

• Always prep from "clean to dirty" areas, starting with the incision site

• Pour the antiseptic on the gauze

• After contact with peripheral or contaminated areas of the prep site, discard the sponge/applicator and use new sponge/gauze to clean new sites (e.g. cleaning the umbilicus, inside the vagina)

• Do not "back track" over an area that has already been prepped with the same prep sponge/gauze

• Prepped area should extend to an area large enough to accommodate:

1) The potential extension of the incision 

2) The potential for additional incisions 

3) All potential drain sites

 

 

DRAPING:

The purpose of draping is to eliminate the passage of microorganisms between nonsterile and sterile areas.

(1) Handle the drapes as little as possible

(2) Hold the drapes high enough to avoid touching nonsterile area but avoid touching the overhead light

(3) Hold the drape high until it is directly over the proper area, then drop (open fingers and release sheet) it down where it is to remain. NEVER ADJUST ANY DRAPE. If the drape is incorrectly placed, leave it in place and place another drape over it

(4) Do not let the gloved hand touch the skin of the patient

(5) If a hole is found in a drape after it is laid down, cover the hole with another drape or discard the entire drape

(6) If the end of a drape falls below waist level,or gets contaminated,do not handle it further. Drop it and use another drape. If in doubt about sterility, discard the drape

Written by our guest author Swapnil Bhagat

Illustrations by Anveshi Nayan
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