Venepuncture in general practice. (1954)

each year the importance of the intravenous route for drug administration is emphasized this route is of a special value to the general practitioner for the injection of small amounts of solution or the withdrawal of blood samples one example used here is the administration of a few milliliters of anaesthetic solution to the ambulatory patient the main object of this film is to show how venipuncture can be practiced in safety without risk of para venous infiltration arterial injection or other local complications the simple equipment necessary to a consistent a safe technique would also be discussed the film is for those with little previous experience of the method it does not deal with prolonged administration the injection of veins not superficial and palpable or any technique more suitably within the province of the skilled general anesthetist the largest challenges required will be of 20 milliliters capacitor the smallest 1 milliliter they're the majority of requirements will be met by the middle sizes of 10 5 and 2 millilitres the size most used is 10 milliliters here is a common type with metal head and central nozzle with it a safe technique is well nigh impossible the needle cannot be aligned with the vein as it could we're an eccentric nozzle use this disadvantage increases when attempting to enter a small or mobile bay the greatest disadvantage of both syringes however is the difficulty of checking the intravenous position at any moment during the injection it is essential for safety to be able to confirm this position by free withdrawal of blood from the vein here as can be seen after each successive withdraw greater quantities of blood cloud the solution obscure the reading and cause further delay a close-up using instead a glass syringe shows what could not be seen inside the metalhead syringe using this all glass syringe blood need be withdrawn to the nozzle owner and is returned at once to the vein without entering the main reservoir this nozzle test can be made as frequently as desired throughout the injection there are several makes equally suitable so long as the plunger battle and nozzle are accurately ground to preclude leakage always specify the American lower fitting as a lower glass nozzle is much more robust than the popular record size shown below the syringe is light and is well balanced when fitted with a fine gauge needle so that a more delicate technique is encouraged much weight also is saved by the avoidance of a heavier metal plunger and metal head fitting when learning none but adequate superficial veins palpable pulseless and healthy are attempted fine gauge needles with long fine bevels can be placed directly into such veins in one movement the arm grip is removed before commencing to inject good quality syringes with airtight plungers are essential or instead of blood being withdrawn from the vein air may be drawn past the plunger if resistance is encountered if no blood appears the syringe is moved slightly backward and forward and the test repeated until satisfied the point is free within the vein the blood withdrawal safety check can be made as often as desired with a pause of about two seconds as chef the speed of injection allowed by this fine gauge needle is adequate here is a speed of 1 milliliter in three seconds higher than will ever be required in normal practice the larger needle is one sometimes used for intravenous injection its puncture hole is many times the size of that made by the fine needle which is 26 gauge with the fine needle the additional delicacy of a fine bevel point will also be appreciated this fine long bevel is still shorter than the short patent bevel of the needle shown above the additional strength is not required with injecting superficial veins the larger bore also is unnecessary as has been shown indeed using the fine needle the speed of injection is not only adequate but is tinted a regulation when learning or when attempting to enter a small thin vein a short bevel needle of similar gauge is useful with it the safety margin is raised even higher at the expense of a less delicate puncture here the difference between a long bevel and a short bevel is shown by larger models the short bevel has a shoulder which is cut away in the long bevel pattern which separates the tissues more smoothly and without the slight trauma of the punch effect sometimes caused by the shoulder the short bevel in fitting the needle to the city the bevel should be down not up the reason for this is most clearly explained by a diagram let us suppose that it is required to inject into a vein as small as the needle in what position could this be achieved with the bevel up it is impossible withdrawal of blood will indicate an erroneous intravenous position and injection will result in per a venous leakage either below or above the base this complication is then not apparent until the tissues are visibly raised in a wheel it can never be left to such a chance with the bevel town the whole lumen could be accommodated in practice the needle will move chiefly in its long axis through the superficial tissues and into the Vale look at the comparative safety margin in each respective position the vein used will be many times the diameter of our needle so that the danger of achieving this half in half out position is small even so it is further minimized many times by adhering to the bevel down position level up leveled up when putting the intravenous needle to the cyllage it is most important that it be given an extra half term to avoid risk of dislodgement during injection in this instance the precaution was omitted the operator does not know that the needle is not firmly fixed it is not dislodged by removing the cotton row making the venipuncture or withdrawing blood however as soon as the injection commences the needle is dislodged the solution and blood spill out the anesthesia is interrupted the patient disturbed and much embarrassment caused this will never happen if the needle is firmly affixed do handle the delicate needle points with care after such treatment only the hub is of use when sealed it will make a nozzle cap needles are kept in sterile cotton rolls to protect the points and to disclose any snags when the needle is removed the solution is heated to blood temperature before use and for this heating a nozzle cap replaces the needle Kara's handling when cleaning is also a major cause of damaged needles after use first the city which is flushed out with water then the needles in practice this is usually done under running water here it is on the table merely for demonstration at this stage the airtight fitting of the plunger within the barrel can be tested remember the extra half turn when fitting the needles to prevent the accident risk just see especially with the fine gauge needles it is necessary to draw air through the bore to ensure that it is clear it is obvious how much simpler it is to check at a glance the mechanical creminis of an all-glass syringe then one which has metal fitments after checking the parts are wrapped in gauze ready for sterilizing and the filament was inserted in the needles great care must be taken to achieve reasonable safety from infection though boiling is shown autoclave or dry heat sterilization is essential for cotton rolls and gorse many slips can occur filling needles and files may be overlooked cotton rose may be used from packaged once but no longer sterile needles may be fitted to syringes with wet fingers with constant vigilance dry clean fingers are sometimes used as shown here but this method is not foolproof sterile forceps would be better it is useful to have some sort of stand or holder for the ampules when mixing the solution ampule should be kept dry and not left immersed in germicide prior to use before opening the necks are again cleaned with an antiseptic it is worth noting that the glass necks of some ampules may be more resistant than others to the saw and cut fingers are best avoided by not being held directly over the ampoules the liquid is transferred to the pyro ampule by means of a filling needle and the solution thoroughly mixed with a syringe this filling needle is three and a half inches long and will reach to the bottom while the twenty milliliters and pool the largest used note the extra support being given by the two fingers to ensure that the needle is not dislodged by the repeated pumping of a plunger during mixing after mixing the required amount of solution is withdrawn and the filling needle firmly replaced by the intravenous needle any air bubbles are expelled the required amount of solution confirmed the cotton rail replaced the reading fredita checked and the syringe is now ready for use no part solution which has been standing should ever be used without full knowledge and control three rules will avoid risk of little complications given adequate sterilization and equipment attempt none but visible palpable veins check the intravenous position whenever in doubt if there is the slightest pain on the injecting stop and stop immediately if you are not certain you do not inject for an injection occupying more than a few seconds a comfortable relaxed position alone will provide a steady base on which to control the movement of the needle point this is impossible if the patient does not stop clenching the fists or if an unbalanced knee allows a sudden movement at the wrong moment with both patient and operator comfortably relaxed a prolonged steadiness can be maintained nothing less will suffice during a slow injection into a rather mobile vein certain steps will soon be followed automatically the patient clinches the fist which is then held still the skin of the area is cleaned the upper arm is ripped the vein selected the skin stretched distally the actual site of injection is selected and sprayed with ethyl chloride to obtain the needle prick should this be a small thread-like vein in loose tissue both grips are moved as close as possible the two fingers stretch at either side of the vein fixing the tissues without occluding the flow for a tiny vein a short bevel needle will be used there is little bleeding from the puncture but pressure should be applied for a few seconds immediately after withdraw to avoid any hematoma from leakage finally ya is shown the sequence in close up after the puncher the arm grip is removed though the needle point be quite still this may cause movement of the tissues and the vein therefore a second check is made at once before starting to eject this simple withdrawal tests can help to eliminate all local complications associated with venipuncture but personal responsibility and care are the main keys to success with a special role if you are not certain you do not inject you