Hi everyone, my name's Sophie McMorran. I'm a registered veterinary nurse and a veterinary technician specialist or VTS in small animal internal medicine. I work for a referral hospital called North West Veterinary Specialists, which is part of the Linnaeus Group, where I make up part of the internal medicine department and I'm one of 4 head nurses.

My areas of interest are endocrinology and emergency medicine. So today I'm gonna talk to you about gaining IV access and fluid therapy. So IV cannula placement is something that we all do on a daily basis as RVNs.

However, it doesn't mean that we should become complacent, because it certainly is not a benign procedure. So we need to stay up to date with our techniques and make sure that we're giving the patient everything that we can to give them the best chance, because if we do relax, then the patient can be compromised and infections and complications can occur, which can be serious. So we do place them routinely and we place them every single day.

They're recommended for all patients that are hospitalised, so if any patient is ever admitted to the hospital, it should be sick enough that it requires an IV catheter, so place one in all of those, and also any patient that's undergoing a sedation or a GA. Now the most common thing that we'll place them for is for fluid therapy, but we can also use it for blood sampling or administering important medication. And most commonly we place them peripherally, so the cephalic vein in the forelimbs is the most common site that we use, and then secondly the tephenous vein.

Now both of those are really great vessels to use, and we need to talk about how we can best access those, which vein we should choose when and what happens if we don't have access to those two vessels. So in the emergency case, every emergency ideally needs an IV cannula. So once we've done our initial assessments, we've performed a CPR, we've performed any CPR if we need to.

The next step is gain IV access in these patients so that we can stabilise them. We can give them fluid therapy rapidly if we need to, and we can give emergency drugs, it's really, really important in your emergency patients. Ideally, we want minimal restraint, so if the patient is recumbent, we can place it while it's late in lateral recumbency, and we want to try and cause as little stress as possible, especially in the patients who are critical.

Any stress can tip them into a really compromised state, so we want to minimise stress, especially in our cats. And IVF tests we can administer many different things, so crystalloids, colloids, parenteral nutrition if the patient's been anorexic for some time and can't eat via mouth, maybe it has injuries to the mouth or or that area. We can administer anaesthetics to anaesthetize the patient through the IV and we can do .

We can administer any emergency medications, so if the blood pressure does drop or if the heart rate drops, they become really bradycardic, we can give drugs to support their cardiovascular system, and then most importantly, CPR so we can give emergency drugs as and when we need to. So they are really important. It's important that we can place them quickly and successfully so that we all always have access as and when we need to.

So when we talk about fluid therapy and vascular access. We need to make sure if our patient is hypovolemic or if they have any perfusion deficits, then that fluid is going intravascularly. So we used to give subcutaneous fluid quite commonly and thankfully this is being phased out.

An IV cannula is really easy to place and it will really support that patient's vascular system. Subcutaneous fluids will not improve a patient's intravascular volume, so we need to get IV access in these patients. And it's also important that we get used to placing IV catheters in different recumvencies so they can't always just be sat in sternal recumbency.

If a patient crashes under an anaesthetic and the IV blows, we need to gain another IV access quickly. If they're in dorsal recumbency, you need to place that IV catheter in that recumbency, so you need practise. And equally in lateral recumbency, if the patient has collapsed, maybe it has a spinal injury, it's been hit by a car, we may not be able to move that patient.

So we need to practise, practise, practise, and use our stable patients to pop them into different recumbencies so that we can try and gain IV access. It will build our confidence and just help with those emergency situations for as and when we need them. And also if the usual routes are not available.

So if the patient has really poor skin or really horrible skin condition on both four limbs, we may need to go to that sofina vessel. If we're not used to placing it, then we need to be up in our practise, because practise makes perfect. Try all of the different techniques, try the different vessels so that if the time comes that we need it quickly in an emergency situation, we're confident and we can go for it.

So before we place an IV catheter, there are different factors to consider. So the patient size is a really important one and one size does not fit all. So years ago when I used the locum, I went to many different practises.

Most of them were really good with IV cannula placements. Some of them did have. Protocols in place that was kind of a one size fits all, and they will place a blue catheter in every single patient regardless of size.

That's not the best practise and we should be changing according to every single patient. If you have a patient over 25 kg, we should be going for more of a green rather than a blue. And we need to make sure that the ball is appropriate for the size of the patient, so.

Also, if we have patients like rabbits, I know so many practises that will only place a yellow catheter into a rabbit ear, even if they have a giant rabbit, you can place a blue catheter in the ear of a rabbit. You need to assess the size of the vessel and assess the size of the patient, and then make your decision accordingly. That's the most important thing for the patient and it will allow you to gain IV access and administer fluid therapy as quickly as you need it according to that patient size.

And also we need to look at the patient's temperament. So if they are really anxious or they're foot shy. Venus vessel may be more favourable.

And this will allow somebody else to restrain the head away from you, so it's safety for you as well. And they can do it studdle, so you don't need to touch the pole, you don't need to restrain the leg. You can just pop the ivy cannula into that sofina vessel while they're being distracted.

You can even feed them treats from the front if you want to, and the sovious vessel may be a much better option for any anxious patient. So take all of these considerations on board. And assess how quickly you need it.

So if you need the IVA test really quickly, then absolutely go to your most confidence in your most commonly placed site. Look at any injuries or edoema, is there any risk of contamination? So is the patient in for a salivary mucous cele and they're dripping saliva right the way down the front, contaminating all of their chest and their forelimbs?

If so, use a hind limb. Do they have ear disease and they're scratching their ears with their dewclaw, which is right next to an IV catheter. We don't want things like pseudomonas to be passing over into the IV catheter site, which can put our patient at greater risk.

So any patients with ear disease, especially if it's itchy, place it in the back leg. And then staff experience also comes into this. So this is where it's really important for, while you're practising, use those stable patients, try a different positions, gain confidence in the stable patients, because if you do have a really collapsed patient, you don't want your least experienced staff member trying to gain IV access because it could be life changing for that patient.

Only when they're confident enough. Should they be then trying IV access in all collapsed patients, so use your staff experience levels and grab the most experienced member to place it in those really poorly patients until the other staff members are up to that level. OK, so what equipment may we need?

So you can see the image of this swab cap at the top, and these are really useful. They're really cheap and it's a small cap that is impregnated with surgical spirit. So they're useful for when you're walking your patients, you can just pop one on the end of the T connector and then you're not risking contamination from the outside environment.

And the most important thing is once you've used this, and you've connected it back up to the IV catheter, that it's disposed. We don't keep these and use them for a second time. And we quite often use a clean litter tray, so we have yellow litter trays which are quite shallow and they're only used for patients GA equipment to be prepared and our IV catheter equipment can go in there as well.

So they can be cleaned and disinfected between every single patient. And in order to plate an IV catheter safely and to prevent any contamination, it starts from the very beginning. So there's no point having an excellent IV cathetic care protocol in place for once it's cared for if somebody is placing it with dirty hands because they haven't washed them, they haven't worn gloves, they haven't used an attic technique at the beginning.

And maybe they've been using, they stuck their tape to the bin or the wall ready to place it on the IV catheter. If you have one of these trays, it'll give you a plate to stick your tape and to have everything contained in a nice, clean, fresh area so that it's already there for you to place your IV catheter. So we should be wearing gloves, ideally and Whether you use a bong or a T connector is up to you and it just depends what the patient is in for.

If it's in for a quick half an hour sedation for a procedure, we may just need a bone. If it's a hospitalised patient, then the T connectors are really useful because they mean you don't need, usually you get needle-free T connectors and you don't need to keep inserting a needle in which can contaminate the T connector and the IV line. You can just use the end, the tip of a syringe and they're really useful so that you can disconnect and reconnect with the other things that you may need to give such as different fluid therapy bags.

And then we just need some dressing material as well. So I don't usually enclose the foot. I think it, it upsets the patient more than it has to.

So I just put a loose bandage around the actual IV site itself and make sure it's. Tight enough to provide the protection it needs, but loose enough to not cause any complications and any swelling. And then in your collapsed patients, so if you have any, a tricky, a collapsed cat, for example, with any tricky veins, the medial to finous vein is absolutely ideal.

So this is great for if. Somebody else has tried IV access, it's really tricky, and you've used up the sofius and the cephalic veins. Then you can see here the sofius vein.

I don't have an image of the latter medial sofius, but it's just on the inside of the leg, and it runs alongside in a similar position to where this vessel does. You can see it quite obviously because it's quite superficial, and you can just plate your IV cannulate in there. It can be a little bit more tricky to tape in and secure, so it's great for your collapsed patients, but they may well pull it out or it may slip out a little easier than what the other sites may do.

Once they start to become a little bit more conscious and a little bit more alert, hopefully by that time you should be able to gain IV access in one of the more common veins. But that can be a go to vessel in any collapsed cat, because even if the peripheral, the other more common sights are really tricky to see, then this one is so superficial, you can usually see it straight away. So that is a great vessel for instant IV access.

OK, so to prepare the site, we need to wash our hands, and we should be doing this between every patient. We need a large area to be clipped and ideally clip off the wings, . Clip off any of the excess hair, so even if it's a particularly if it's a long-haired patient, you can do a 360 degrees clip so that you're not contaminating any of the sides of the tape with the fair.

You want to visualise and I find it really useful to feel the vessel prior to placement. But a tip for this is make sure you're feeling the vessel prior to cleaning it, and once you have cleaned it, you don't touch that area again. So have a really good feel, have a good look to see where about on the vessel looks best for placement, and then once you've cleaned it, don't touch that area and just maintain a sepsis because we're then contaminating that area again as soon as we touch it.

Now we want to ideally place distally if we can, so the furthest down the leg that we can, because then if it does blow or if we don't gain the IV access, we can then try again a little bit closer or a little bit further up the vessel so it just gives us an extra chance. Once the IV cannula is in, we want to advance it, ideally a 30 to 40 degree angle, and really important to make sure that the bevel is up. So the bevel needs to be placed facing you.

We don't want to be placing it with the bevel facing downwards. And it just allows us to know exactly where the IV is going. We can see the bevel, so we can see the base of the the needle itself, and we know exactly where we're placing it.

And one of the important take home messages is always, always apply a layer of tape underneath that IV. I used to work with a veterinary surgeon who always, he was quite old school, he used to always place the IV and then he'd tape over the IV cannula. The next time you get that patient out of its kennel ready for its GA, you guarantee that IV will be on the floor, because there's nothing to anchor the tape to.

It prevents it from slipping out, so place a layer underneath that IV and then it gives just some anchorage to the rest of the tape so, one underneath and then the rest over the IV itself. So when we're taking the IV it should be clean and dry. It shouldn't be contaminated with any fur, and if you do have a patient who bleeds excessively, ideally use a dry swab and just get rid of any of that excess blood.

Anything that's contaminating that tape can contaminate the site itself, and especially if this IV needs to be in for 3 days, if it's a hospitalised patient, we want it to be clean and fresh and dry. So just clean the sites before we place any of the tape. And we tend to place a comfort swab underneath the IV catheter and that's just a small gauze swab, so you can cut a normal sized one into quarters or you can buy the small ones.

We just put a little slit up the centre and then place it underneath the actual bung itself. So put one layer over, tape it in, and then underneath the bung just place that comfort swab. It just gives that extra level of comfort.

If they're feeling that the IV cannula or the bone is rubbing, they're much more likely to interfere with that cannula. So all of these little things will just help with the care and the maintenance, and the patient tolerating that IV cannula, especially if they are long stay patients. And then just secure it in as you can see in this image with just a small amount of soft ban and then a cohesive layer over the top.

So place it nice and gently, we don't need to have any tension on this. The more tension that we have, the more likely we are to see a swollen pore the next day. And then you can just place a piece of tape over it to say your initials, who's placed it, and the date, and also ideally what day it is.

So if it's the 25th of the 9th, which it says on this piece of tape, you can put day one or day two so that you know when it's been placed and what day you're on. And then once the IV cannula has been placed, we need to make sure that we're caring for it appropriately. So ideally twice a day, we should be undressing and looking at that that IV cannula site.

We need to look for any areas that may suggest phlebitis, so any swelling, any redness, any pain. Does it seem painful when you touch it? Is the patient moving their head around and licking the site?

Has the IV slipped, can you see the IV catheter itself? If so, you need to remove it and place a new one. And is there any perivascular leakage?

Is any of the fluid coming out of the site or are there any swellings above the site where it could be going subcutaneously? And we need to check the site itself, so make sure we're not just looking at it through the dressing, take that dressing off. Look at the tape, is the tape still nice and clean and dry, or have they urinated on it, have they slobbered on it?

If so, take it off and just place some fresh tape and give the area a nice clean. Now before we administer any medication or fluids through any of the access ports, we should be cleaning them ideally with alcohol. And then allow that to dry before we go administering any fluids or medication.

And we should be flushing IV cannulas with normal saline every 4 hours and just record that on the hospitalisation sheet. So in the box where we have fluid therapy going along to 24 hours on the hospitalisation sheet, we just have a small box automatically every 4 with an F next to it, which indicates flush. So you don't have to go right in a lot of things.

You just tick that you flushed it and put your initials next to him. If you do flag any complications, then write that on the notes, make sure it's written on the hospitalisation records and on the computer. So what you've found, is it red, is it swollen, but it's still patent and it looked OK, but you want to just keep a closer eye on it, so to check it again in 4 hours rather than waiting, so that you're only doing it twice a day.

And say what site as well. Is it above the line or is it beneath the line? So the more specific you can be, the least chance of complications, and the more we can closely monitor the patient's IV cannula.

And when we flush the IVs. It's useful to be aware that human patients have mentioned that they feel a cold sensation and an unpleasant smell or taste when their IV has been flushed with IV saline, which is quite interesting. And it's something that we can bear in mind for our nauseous patients in particular, if we're flushing their IV cannula with saline and they're going to get an unpleasant smell or taste, this may upset our patients.

So for those, we could try administering it a little bit more slowly. Now you can see on this image we have a sticker which says do not flush. Now these are just really useful to mention because you can buy these from MVS or any of the other wholesalers, and it just alerts people to say there may be a drug in that line.

So if you're about to administer something like paracetamol as an Ebola, don't use this line. If the patient's on potassium, for example, you can just place the sticker next to the bone, which people are likely to give give medication through, just as an extra warning to say don't flush through this line, give it through the other port via the the IV catheter. So really, really useful, definitely handy to have in, and this is also one of the swab caps that I mentioned that impregnated with surgical spirit as well.

OK, so once you've checked your IV cannula, you're happy with it. It seems clean and dry and patent, we need to redress it and it should be clean, fresh dressing twice a day. Now IV cannulas can be maintained for a maximum of 3 days in the hospital, and there have been studies to show that over 3 or 4 days can contribute towards a greater complication risk.

In humans, so that's why ideally we want to keep, we keep an eye on what they were on, whether we're on day 12 or 3, and when we get to day 3, assess is the patient likely to be going home? Does it need removing, or do we need to remove it and place a new IV catheter? And in order to maintain the IV for those 3 days, all of these, all of these things contribute towards us being able to maintain a nice patent IV with minimal complications, because if we don't take all of these steps, the chances of us maintaining that IV for 3 days is slim.

And we tend to say the placement day is day 0. And we monitor, we record the day and the date, each time we plate it and each time we change the, the dressing itself. And then other Ways that we can look out for signs of complications is regular temperature check, so the patient should have a temperature check at least once a day.

They're spike in a temperature and it's not linked to their condition, we don't know why. We need to look at, could that be linked to the IV cannula. If so, we could be starting with signs of phlebitis, and we need to visualise that IV cannula and maybe remove it and culture it, which I'll talk to you about in a moment.

So, complications that can occur, there are many, and I have found an NHS visual visual infusion phlebitis score or VIP score, which is available online. They use it in the NHS for humans and it's really useful. So it shows you what signs to look out for and when we should be acting, what we need to do, and when we need to remove the IV cannulus.

That's a really useful resource that you can use. We need to be checking if it's red, if it's painful, if it's smelly as well, if there's any discharge there. And also quite commonly we might see swollen pores.

So if you do have a swollen pore, it's important to remove all of that dressing, and ideally remove the tape as well. So cutting the tape just to allow a little bit less tension doesn't work. I've tried it and the pore still remains swollen.

So we need to remove that tape and we need to check the IV site itself. And if it's still patent and you're happy with it, place more tape but just place it nice and gently so that there's no tension there at all. And maybe put the patient down to have physio on its paw 2 or 3 times a day so somebody can just gently massage that pore to try and redisperse any of the the swelling.

And the most important thing is to make notes on the patient's records so that if it does need changing and you have notice for this in one area. If we need to change it again in the future, we don't go and place it in that same site. And as you can see by this image, this is a act that was in for spinal surgery.

You can use the ears of these patients. Look how small his legs are. So.

We're likely to be able, we're likely to have complications if we try to place an IV in those legs. Some people absolutely love placing IVs in the legs of taxis and any of the other smaller legged breeds. I personally love to place them in the ear.

I think they're well tolerated as long as you don't do a really bulky dressing. And it's nice and easy. It's great.

Usually if they're foot shy, it's, it's an ideal place to, to place it. And then it's out of the way for if they do need something like spinal surgery, it won't get in the way of any of the diagnostic imaging. So if you do think that there's a complication there, we may need to culture the the IV tip.

So if we do need to do that, which we should be doing it ideally if we have a pyrexia of unknown origin and it's not linked to the patient's condition otherwise, we don't know what's causing the spike in temperature and if it's red and swollen and especially if it's smelly. So just carefully undress and remove that catheter. With sterile scissors, you want to snip the actual tip itself into a sterile universal pot and make sure you're not touching any of the inside of that pot with the scissors or with the rest of the catheter or with your hands.

Seal the pot and just label it to say it's an IV IV cannula tip and we want to send it for culture. It will just culture any specific bacteria to let us know what's grown there. Where that complication could have come from if it is this site that has the complication.

And what treatments we can use, so it gives you a specific antibiotic that will be useful for this specific bacteria. Now this is also useful for things like pseudomonas. If you do have any patients who have ear issues and then they've spiked the temperature, this may pick up on things like pseudomonas as well.

And it's useful for us to reflect on these cases if pseudomonas is found in the IV of a patient with ear disease or skin disease. Maybe put it as a routine that it goes in a hind limb in your practise to try and reduce that complication risk. And then when we're maintaining that catheter, there's other factors to look at, so.

Do we disconnect the fluid therapy or do we leave it attached? So I think this depends on the patient. So as you can see, there's a patient here with the urinary and the faecal catheter bag.

We're walking this patient regularly and we have a fluid therapy bag attached as well. The chances of somebody becoming entangled, whether it be the patient or us, is quite high. The chances of one of those being pulled out because you can't possibly keep your eye on all of them at once, is quite high.

So in these patients, I think definitely disconnect the IV catheter. Every time you do disconnect that IV cannula or the fluid therapy, you are. Increasing the risk of introducing bacteria.

So we need to make sure we're wearing gloves, ideally place a cap of some sort over the bone. So if you have the the swab caps, they're ideal, but if not, place a bong over the end, then make sure you're not contaminating it. And then also cover the IV itself, if you have maybe a patient who has A spinal injury and they can't cock their leg, and it's a male, they will urinate standing up.

There's a high chance it's going to hit that IV cannula in the front leg. So just cover it up if that's the case, and make sure that we are we are putting a bung on the ends of those T connectors so that we can protect it and just keep it as clean as possible. And look at the weather, if we're gonna get a really soggy dressing, the chances are if it's moist and warm, it's gonna grow bacteria.

So all of these factors come into play. And we should treat all of them individually. And then when we look at fluid therapy, we need to assess the patient's dehydration.

So in order to do this, just perform a physical examination. We know that dehydrated patients or hypovolemic patients may have a tachycardia to compensate. They may have alterations in their blood pressure, so maybe they're hypotensive, so they might have a low blood pressure.

So perform your physical exam and then gauge where you think this patient is on a dehydration scale. There's also other things that we can do to assess hydration, such as your PCV and your total protein. We know that with dehydration, the PCV in total protein is likely to go up together.

Because the fluid is reduced in that protein, so it's just the serum or the plasma that's reduced, so the protein and the total protein appears higher. And lactate is also a really useful tool, especially if you have one of the small handheld monitor the devices that you can use in-house in your lab. So lactate becomes increased with a lack of perfusion.

So if you have maybe dehydration, which is stopping fluids from being perfused to certain tissues, that affects the oxygen delivery. And when that occurs, your lactate will start to creep up. With dehydration, that's why you may see an increase in elevated lactate.

So once you start to administer fluid therapy, that lactate should come down. And all of these tests are really quick and easy and cheap to perform in-house, so they can be repeated to assess the successfulness of your fluid therapy. Is it effective enough?

Is our rate high enough? Are those values coming down and responding to our fluid therapy treatment? And when we look at fluid therapy, we, if you look at shock in a textbook, it will say, 0, 60 to 90 mL per kilo.

That may be the case, but now there've been studies to say you don't just give that volume, you are much more likely to have a successful outcome for each patient if you administer each bolus at a time. So we give a 10 or 20 millo bolus depending on the patient, and then we assess all of those vital signs. So perform a TPR has the heart rate come down.

Has the patient's demeanour improved? Has the blood pressure improved? Are the are the pulses now feeling better quality?

If so, we know that our fluid therapy may be affected, effective, and then if we still need more fluids, you can give another bolus of 10 or 20 mL per kilo and just keep on giving and reassessing, giving and reassessing, because that's the most important thing to assess the effectiveness of these fluids and to prevent over infusion, particularly in those small patients. And especially in cats because we can overinfuse them very easily and very quickly. And then we need to calculate our ongoing fluid rate.

So once we feel like we've corrected the hypovolemia, what maintenance rate are we going to put them on? Are we going to just give 4 mL per kilo, or do we need a higher rate of maintenance? And then look at any ongoing losses if we are still vomiting and we're losing lots of fluids through diarrhoea, for example, then we need to factor that in as well.

We don't want to just have this patient on a maintenance rate if we have further ongoing losses, so calculate those in and all of these will help us, well, will prevent us getting a dehydrated patient later on. And then just keep on monitoring that response to fluid therapy. So that's the most important thing that you can do for your patients.

Now, when we come to choosing what fluid therapy to use, crystalloids is the most common fluids that that's used globally, and it's the first line that we go to in the intensive care unit. So crystalloids are just a solution of ions which freely move through permeable membranes. So they do have ions and they do have some of them have electrolytes so that they can support the patients deficiencies that they might have, and they are quite close to the patient's plasma.

So the two most common crystalloids that we use are Hartmann solution and normal saline. So Hartman's solution, also known as lactated ringers, has a closer tenicity to plasma than normal saline does, and it also contains buffers and electrolytes. So it's really useful for those patients who may be losing electrolytes through.

Vomiting and diarrhoea or maybe they're not gaining them because they're anorexic, so this is the go to fluid therapy. Whereas normal saline is more acidic than the plasma, so it's actually quite an acidic solution. So I think the pH is around, I'm sure I read it was 5.4, which is quite acidic.

So we don't want to give this to your everyday patients. Hartman's is a great go to for everyday patients. Normal saline should be used in a more specific way.

So maybe patients with low sodium levels, like your ad. We can use normal saline and it's also also useful for those patients who we shouldn't be given any potassium containing fluids. So maybe the patient has a hyperkalemia, so a high potassium value.

Then we can give normal saline in those instances. And the chloride level is considerably higher in normal saline than in plasma. So in human patients, it has been shown to increase patient's chloride levels and they are doing studies to look at whether that can be detrimental.

So we need to assess the patient's assess the patient's status and look, are they in shock? If so, what type of shock is a cardiogenic shock because they have a cardiac issue and the heart is struggling to pump that fluid around the body and that's why perfusion is being compromised. Or is it because of hypovolemia?

In that case, we definitely need to give fluid therapy. And what's causing the hypovolemic shock? Is it a patient that's been hit by a car and we need to restore, maybe they've had a large haemorrhage, we need to restore that fluid.

So if we can look at these, sorry that the quality of this table is not great, it didn't work very well when I expanded in. But if we can grade the level of shock, so maybe it's we're sat in the severe hypovolemic grade, we can then start to reassess whether our treatment is having a benefit. So are we now reassessing and we're only classed as moderate, or then we're entering the mild hypovolemia stage, and we know that we can desperately use these tools to assess our treatment and are we doing.

And as we mentioned earlier, the shock rate of fluid therapy should be given in bolus. That's much more beneficial to the patient. We may consider colloid support if the patient is really hypovolemic and if we feel that that is necessary.

And the most important. The thing when we're administering especially fast and high volumes, is to monitor cardiovascular parameters and do it regularly. We don't just link the patients up to fluid therapy and leave them because their their needs may change, and that's our responsibility as a nurse to be assessing those parameters regularly and altering accordingly.

Now, before we end, I just wanted to pop in a slide about whether we use normal saline or a heparin solution to flush our IV catheters. So heparin, as we know, is an anticoagulant, and it's commonly used across human and veterinary, the veterinary field. Now we use it because we believe that heparin prevents the formation of clots or a thrombus in the IV catheter.

However, there have been recent studies of the literature where they've reviewed 10 different studies, and what that says is that it's not fully documented whether normal saline is more effective at maintaining patency and reducing complication risks. So, if there's no proven benefit to using heparin. Why do we use it?

So we, there's many different reasons to support the fact that we should just use normal saline, and that's because of one efficiency. So it's more efficient. We can just draw up a syringe of normal saline and use that to flush the IV.

It's cost effective. Why use an expensive drug when we don't need to and it's not proven to have any benefits? And then finally, it avoids errors.

So heparin is on the list of high alert medications. Now this is a a list which is put together in the human field and it's a list that shows you. A list of drugs which has a very narrow margin between the therapeutic range and the toxic range.

So any mistakes that are given, if too much heparin is given, it can very quickly tip over into a toxic or a dangerous range. So why use this drug if we don't need to? So the studies say there's no proven benefit, so normal saline should be the go to fluid therapy, sorry, the go to flush, flush your IV catheters and maintain patency.

OK, full of lots of different techniques. I hope you've found it useful. I hope you can utilise it in practise.

Thank you very much from me. If you do like internal medicine, please follow my Facebook or Instagram page called Veterinary Nurse Medicine Geek, and I'm here to answer any questions.