Hello, good afternoon. This afternoon I'm gonna be talking about tubes, lines and drains. So hopefully by the end of today's lecture, we'll be able to list the different tubes, lines and drains that we most commonly use in veterinary medicine, understand the uses and the contraindications for each of those.

Know our role as veterinary nurses in the placement and the management of these, and also how to place them if that's applicable. And then we'll go through the implications of infection control practises. So firstly, I want to just discuss venous access.

So when we are looking at our veterinary patients, we really have 3 options to access their veins. So the most common would be our peripheral. We can then also think about placing something more central, so looking at jugular lines and also peripherally inserted central catheters, so our PIC lines.

When we think about peripheral peripheral catheterization, we have a good number of choices, so we tend to go for our cephalic veins, which are in the forelimb, or saphanous veins in the hind limb, and of those saphanous veins, we can use both our medial and our lateral veins. Pros for peripheral catheterization is that they are pretty easy to place. Everybody is trained to do those from the nurses to the vets.

They're very easy to manage. We have really good levels of patient compliance. We can easily change them.

So if we do have a problem with one vein or a catheter that's been in for a couple of days, then we can change that normally to another leg. They come in various sizes depending on the different patient sizes and also what we're requiring them for. And because of all of this, they are the cheapest option to us as well.

The cons of using a peripheral catheter is that they do limit us to the volume of fluid that we can give down them. So for a very big dog, if we are trying to fluid resuscitate that patient, actually we might look at having a different type of catheter in place, or if we're only able to place peripheral catheters, then maybe putting in more than one. We're also limited to the strength or the viscosity of medications and also patients that might be on multiple CRIs.

So if we think about a patient who might need a very strong glucose constant rate infusion, then actually a central line is going to be preferable to that, because you don't want to put anything too viscous through the peripheral veins. We also might have difficulty in placing these catheters in very shocky patients, really sick patients, and also if we're thinking a patient might require a blood transfusion, then we might want to think about placing either a second line because that has to be given alone, or placing something more centrally. Then if we're thinking about jugular catheters, we can leave these in place for longer.

So we have a wider sort of choice of sizes as well. And because of that, we can then give larger volumes of fluids and also medications down those. Depending on which catheter we've gone for, we have a choice of giving multiple constant rate infusions at once, and also the choice of giving a blood product alongside maybe fluids or parentinal nutrition.

And they also give us the opportunity to blood sample these patients without having to stick them with needles continuously. So ethically, if we've got a patient who we know is going to receive, multiple blood draws, then actually considering this is, is really important. The cons of placing a jugular catheter is obviously the skill required for placement.

So we need to know that we've got somebody who is skilled enough to do that and confident enough to do that. And they also do take more time to place. So because of that, the cost of these catheters is more expensive than a peripheral catheter.

To do with patient compliance, we often will need at least a sedation, if not an anaesthetic, unless the patient is really sick. So if we do have a sick enough patient, then maybe just some buterphennil or maybe methadone, if we've given that as analgesia might facilitate this, but, but generally they'll need some sort of sedation. We do have a lot of contraindications for placing jugular catheters.

One of the main ones being if we are concerned over coagulopathy. So if we think for any reason that this patient might have a clotting disorder, then obviously using a jugular catheter is really risky, if a patient had a pacemaker in place, amongst others. And then moving on to our peripherally inserted central line.

Again, similarly to the jugular lines, we can use larger fluid volumes, we can also give more medications and consider giving multiple CRIs and blood products. And we can also use these for blood sampling, and again, they come in good sort of choices of sizes and have good patient compliance generally. The contraindications of placing those are patient interference.

They don't tend to last as long as the jugular because of where we're placing them. And again, because of where we're placing them, there is a bigger infection risk because we're looking at these being in our back legs of patients. So, if we've got a patient with diarrhoea, for example, we really would try to not put a PICC line in their Sainous lane.

Again, the cost of these is increased because we might need a mild sedation to place them, and also just because of the equipment required and also the skills that is required to place them in the time it takes. So I don't want to bore you with placing peripheral IVs because I'm sure that we do this all the time. But just sort of a list, but we want to really make sure, I guess, that we're washing our hands really well, making sure that we've clipped a really large place so that we can see the vein and visualise that nicely, and, and then we can also do a good clean before we go on to insert that.

You want to choose a catheter carefully, depending on the patient's size and what we're we're using it for and make sure that we've bandaged it really nicely as well. Moving on to placing a central line, so there, there are a few different ways of placing these, and the one that we most commonly use in veterinary practise is the Seldinger technique. And as nurses, if we have had the right training, then we are able to place central lines.

So, it's just a really nice way of sort of expanding your skills. When we're gonna be placing these, we want to look at our patient positioning. So they either need to be in dorsal recumbency or a lateral recumbency, and we wanna make sure that their neck is really well exposed, and sometimes placing a sandbag or a rolled up towel underneath their neck really helps with placement.

You want to clip a really generous area over the jugular vein so that we can visualise this really well and make sure that we can clean this really well as well. So we wanna prep that skin surgically. You want to use a sterile technique, so making sure that you're using drapes and sterile gloves.

And the first thing you will do is insert the catheter into the vein. So this is not the jugular catheter that we'll leave in, but it, it normally looks like a peripheral catheter and comes in the kit that you get. So you insert that into the vein first.

Once that's in place, you remove the styler from the middle, and then you'll insert your guide wire into the catheter up to the desired length and that will again depend on your, the size of the patient really. Once you've inserted the guide wire, you'll remove the catheter that's in the vein over the guide wire and take that out, and then all that's left in the patient currently would be the guide wire. You place the dilator over the guide wire in this, it is quite tricky to get in, but that basically separates the vessel from all the surrounding tissues and just means that when you're placing the catheter, it should be going in pretty smoothly.

You then want to remove the dilator, and this is tends to be when it bleeds because you've separated all those tissues, so just using some sterile swabs to control any bleeding. And then you'll want to place the central line over that guide wire and insert that into the neck and hopefully because you've had the dilator go in, it should be fairly easy to do. You then want to remove the guidewire completely, flush all of those lines and make sure there's no air.

Some people will pre-flush the central line before they've placed it, and some people will just draw out the air once it's in place, and that's a very personal decision. And then you want to secure it with sutures and dress it in a sterile manner. The important things to think about when we're placing central lines is that we never let go of the guide wire, and especially when we're training to do this and sort of getting to grips with it, the guide wires can be really fiddly and there's a lot going on.

So even if you have somebody put on some sterile gloves, just so that their job is to hold the guide wire, then that's really worth doing, just really important, until you know that you're competent enough to do all of this and think about the guide wire. It's also always really important to have an ECG on your patient throughout these procedures so that you can just check that you've not inserted the catheter or the guide wire too far down. And if you do get any changes to your ECG, it's just often because you've inserted that guide wire too far, so just pull that back.

So placing PICC lines again, a very similar technique, we'll use the cell doing a technique, as we just discussed. We use either the lateral or the medial safurous vein, depending on what looks better on that patient. And again, just never let go of the guide wire.

I have seen patients need to have guide wire surgically retrieved, so just making sure that that is your number one priority. So then thinking about arterial lines, again, as nurses, we are able to place these when we are trained to do so. And the most commonly used arteries that we'll go for are the dorsal pedals, so just on the, on the back foot, the top of the back foot and the femoral artery.

As with taking a venous sample, you want to clip the area well with really clean blades and prepare the area with a good sort of Clorhex alcohol swab, but don't scrub. If you scrub, you can cause the artery to spasm and you'll have real difficulty getting that sample or placing that catheter. You then want to feel the pulse with your index and middle fingers, and then using that catheter with the bevel facing up, insert the style at a 45 degree angle and just watch that cub really closely for flashback.

As soon as you've seen that flashback, advance the catheter off the style it just really gently. And then you'll want to remove the styling and cap the end and then make sure that you're securing the catheter with strong tape. So, in our practise, we tend to use tensor plast, rather than sort of a drapo because it just seems to hold it in place better.

And then you want to attach your tee connector. You don't want to dress it and make sure you've labelled it so that everybody knows that that catheter is arterial, because we don't want to be using that for any medications or fluids, and just, yeah, to prevent any accidents. So then once we've got sample sampling catheters in place, so talking about our central lines, so either in the jugular or peripherally, or our arterial lines, we are able to take blood from these.

So just sort of a step by step, if we're taking them from a central vein catheter, then we pause any fluids or medications, clean the port of that catheter and using just saline, flush between 0.5 to 2 mLs of saline into the line, depending on the patient's size. So if we've got a small cat, we'll tend to just use 0.5 mL, but if it's a really big Labrador, maybe 2 mLs would be fine.

You then want to draw back on that same port to at least double the volume that you've just flushed in, and this just basically ensures that you have removed all of that flush and that the sample that you take is just gonna be purely circulating blood. You wanna then just hold that syringe and make sure it's kept sterile while you take the sample with a fresh syringe. And then you want to put that previous syringe with the blood and the saline back into the pool and return that to the patient.

You can then flush that with saline to clear the line and restart the fluids or the medications that they're on. We're taking a sample from an arterial line so that we can monitor oxygen status, for example, in our hypoxemic patients. The procedure is pretty much the same.

The differences would be that you have to be much more gentle because the arteries are at risk of spasmings. We don't want to do anything too, too haphazardly. And when you have Taking the blood and the saline back into that patient, you want to give it back via vein, not the artery.

So, otherwise, completely the same, but that syringe that you're giving back to the patient must be given into the vein. And it doesn't matter if you've got no central line. You can give that back into a peripheral line, but just making sure you're not giving that back into the artery.

Once you've done that, you can flush the arterial line with saline really gently and then restart the invasive blood pressure monitoring if that's what you have got on. So then moving on to management of venous or arterial lines. You want to make sure that in a healthy patient you are checking these lines at least twice a day, or more often if the risk is increased.

So maybe in an immunocompromised patient, or if in a patient who maybe is interfering a lot and, and is a bit of a worry. You want to try and use an AE tech technique, make sure you've got clean hands and wearing gloves and use sterile dressings for all central lines each day. When you're checking these catheters, you're checking that they are flushing so that they're patent.

They're drawing, if that's appropriate. So if you've got a multiple lumen catheter in a central line, for example, checking if all of those lines are drawing or if one of them maybe is flushing but not drawing, and just noting that down. You wanna have a look at the skin and make sure the skin looks really lovely and clean.

You wanna check the insertion site if you can see that to make sure that that looks really clean. That the vein or the artery is looking healthy and that there's no signs of phlebitis or infection. If your patient has got a pyrexia or any signs of infection, then you'll need to remove that line and place a new one.

But again, you'll need to check with your vet before you do any of that. So in our practise, if we have highlighted a pyrexia or a worry to do with a catheter, we'll always speak to the vet before we go ahead to do anything else. So then moving on to our urinary catheters, we have a variety of catheters to choose from in veterinary practise, and this will depend on again what we're using these catheters for.

We tend to use our our Foley catheters, so this one here on the left, because these are really useful in dogs. They come in a really wide variety of sizes, and as in dwelling catheters, they're really good because we can inflate this balloon while when the catheter is sat in the bladder, and that will sort of prevent hopefully any removal of this catheter. In our cats, it's slightly different.

So if we are unblocking a male cat, then we'll want to use a catheter that gives us the ability to place that catheter well. So a catheter that has a stylelet through the middle, and also a catheter that then enables you to flush through that. So if you are unblocking a cat that maybe has some crystals or stones, that we're able to sort of pulse that saline through in order to clear the blockage and place the catheter.

If we are just using a catheter to drain a bladder in a dog, then we might just use a large dog catheter and just remove it after we've done that. So moving on to placement in the dog. You want to clip the area to make sure that we're able to clean that really well with diluted hippie.

You want to wear sterile gloves and make sure that everything that you are using is kept sterile. And you'll want the person that's restraining the patient to extrude the penis. Using lubricant, you'll want to insert the tip of the catheter and you want to advance it the whole way.

And in male dogs, you will find that initially it's fairly easy to insert here, and as it hits this U bend, you'll feel some resistance. And again, once it's round this U bend, it will go pretty easily back into the bladder. Once you have urine flowing back, you'll want to attach the syringe or the connect the closed circuit, the drainage bag, in order to start collecting the urine.

And if you're leaving this catheter in place and you've used a Foley, then you'll inflate the balloon so that it stays in place. So to place a catheter in the bitch is a slightly more tricky task, and the first reason is because they don't tolerate it as well. So they will need either a light sedation or anaesthetic in order to be able to place this well.

You want to clip and prepare the area but not scrub it as much as to make it sore, and then you'll want to use a sterile placement, so making sure you're wearing sterile gloves and that all of your equipment is kept sterile. There's two different ways of looking at these. So the first one would be to use a speculum, which again is only really useful in larger breed dogs.

In smaller dogs it's quite tricky, or just going blind. If you're going blind, then using your non-donament hand, you'll want to insert your index finger and feel for the papilla, which tends to be, if you're looking at the dog, as is in this picture, the papilla would be sort of at the 7 o'clock mark. You use that finger then to block the hole to the cervix and then using your other hand, insert the catheter along the underside of that finger and follow the path down into the papilla.

Now hopefully if it's all going in the right place, that catheter then just kind of feels like it's disappeared into the tissue. If you can still feel that catheter or you can feel it sort of twisting inside, then you want to remove and try again. Once you've got that in place and you know that you've got good urine flow back, you want to inflate the balloon and attach the collection system.

Placing a catheter in the male cat again requires some sedation or a GA, especially if this patient has been blocked, they tend to be quite angry and and sort of sore. You want to clip and prepare that area, and using your non-dominant hand, you'll just use your fingers ventrally and dorsally to extrude the penis. You then want to insert the tip of the catheter and then pull the skin forward to help straighten out that urethra.

Once you've done that, it should be fairly easy to insert the rest of the catheter into the bladder unless there are stones or crystals, in which case you'll want to flush saline in order to remove those. You then attach your collection system and suture the catheter in place. And then depending on the cat, will depend on sort of how well they tolerate keeping that bag in place.

But some cats would be tolerant of having that tape to the tail, sometimes just using a syringe. Really you need to work out what works well for your systems that you're using and the cats that you've got in practise. So then moving on to managing urinary catheters.

They should always have a closed collection system if they're in dwelling. This will limit the risk of them getting a UTI or urinary tract infection. It also enables us to measure accurately their urine output, and it also just keeps our patients happier and cleaner because none of them want to be covered in urine and especially cats will really suffer if they feel that they're getting dirty.

All urinary bags really should be double bagged again for sort of infection control purposes. And we tend to clean the system, so from down from the insertion site, wherever the catheter is, down to that bag, we'll do that every 4 hours, just with a really dilute hippy solution, just to make sure that all of that catheter is staying as clean as possible. Once our patients are getting better, or for whatever reason, if they're more mobile, then we really want to think about removing urinary catheters at the earliest opportunity because the longer that they're left in the the increased risk they have of developing a UTI.

Contraindications for urinary catheters again are the risk of UTI patient interference. So now just having a look at faecal catheters. So these really are, there's not a lot of data on faecal catheters, especially in veterinary medicine, and so these really are only used at sort of the vet's discretion.

However, if we are able to use these, then they are huge time savers. And what we tend to do in our practise is to use a large bore foley, although you can get ready-made catheters designed for this for humans, but large bore foleys seem to work really well in our patients. Sometimes you want to think about inflating the balloon far more than is recommended for if that Foley was being used in the bladder, just because obviously the colon can expand much further.

So just considering that, and maybe that patient might tolerate more fluid in that balloon and hopefully it would stay in place longer. If we are doing this, then we want to make sure that we deflate, move the catheter and reinflate that balloon really regularly to avoid any pressure necrosis of the colon. But if they work, then they're great, they keep the patient much cleaner, it keeps them really comfy, they don't get upset sort of having all these baths, and it saves us a lot of time and sort of bathing time, especially when we're really busy in practise.

The other consideration is that if our patients really have terrible diarrhoea, then actually we can then accurately monitor their outs for their diarrhoea, instead of just sort of guessing how much fluid we think they're losing. Moving on now to wound drains, so, firstly, we'll look at passive drains, and these do not use any suction to draw fluid from the wounds. The most common one that we use in veterinary practise is our Penrose, and that's because they are very easily available.

They're normally made out of silicone or a polypropylene, and they're just soft tubes really, that can be cut to different lengths, and they come in a variable sort of sizes in diameter. These are normally used in surgical wounds or where we think that fluid is accumulating. And they work by capillary action, they work by gravity, and also fluctuations in pressure gradients due to body movement.

So the pros of these passive drains and these pen roses is that they are cheap and they're very widely available. They come in a variety of different sizes and you can cut them down as well, so they're really good for varying different wounds. They're really well tolerated, they don't seem to cause any pain, and they're very easy to remove.

There's no sedation required. You can just nick the suture that you've used to keep it in place and pull that out. The patient can go home with the draining come place and then in place and then come back for that removal.

The cons are, is that they are not appropriate for having in abdominal or chest cavities. There is a huge infection risk, and I know that when I used to start sort of practise as a student nurse, it would be quite commonplace to leave these without dressings on, but it is really important that we dress them appropriately so that we don't have any infection tracking back up into that wound. And obviously because we are not collecting this fluid in any way, we can't really accurately measure output.

The second type of wound drain that we'll look at is our vacuum drains, and these tend to be our Jackson Pratt, which is really common. These work on a grenade mechanism, so they are, they just tend to be a grenade or a ball that you basically squeeze all of the air out, fold as many times as you can. I think it's 5 times that they recommend.

And then the vacuum that that creates basically pulls fluid from whichever area it's in and collects it in the chamber. The tubing that is inserted into the cavity is, is this tubing here, and it can be cut back and you can see that it's penetrated the whole way along, so you can see all these little holes. The pros of these are that they are easy to place and remove, again, you don't need sedation to remove these.

They're easy to use, so as long as you have had relevant training, they're fairly easy to manage. They collect the fluid, so we can measure drain output, which is also very handy. And they can be used in the abdominal cavity, so patients maybe that have had aseptic peritonitis will have these, and they're just really good to manage.

Because effectively they are a closed system, they do have a lower infection risk than passive drains. The cons are that the patient can't go home until until they've been removed. It's not possible to send these patients home and expect that an owner is able to drain these.

And there is a worry about patient interference because of the size of them and just the way that they are. It tends to be quite difficult to secure these in any sort of good fashion. So sometimes patients will wear a big vest that will tie it up to, but if a patient's small, especially, they are just really clumsy to secure.

So if your patient's up and about, there are risks associated with that. If we're gonna be draining these manually, then we always want to wear gloves. We want to make sure that we're cleaning around where we're, we're draining us from, so in this drain here, you can see that there's a little port here for your syringe, so you want to just give this a really good clean before and after.

And you want to use a sterile syringe to draw that fluid out and then reset the drain by squeezing out all the air again. The 3rd type of drains that we are gonna be talking about is our thoraccostomy tubes, so our chest drains. And again we use two different types in veterinary practise commonly so we've got our rocca or our mealer types.

You can place chest drains either uni or bilaterally depending on the presenting complaint of the patient. But I would always consider instilling local anaesthetic Done as part of a multimodal analgesia protocol. So speaking to your vets about that.

And especially if we're using trocars as they tend to be much bigger drains and cause much more pain. Again, depending on why the patient has these drains will depend on what we then want to do about draining them. So a lot of our patients will have intermittent drainage, and some of our patients might require continuous drainage, for example, if they've got a continuous pneumothorax.

So our trocar, our larger ball catheters, they don't tend to be too flexible, and in order to place them they'll require a full anaesthetic or a heavy sedation just because they are very painful. And they are placed with using an over the needle placement. With our mealers, we have a range of sizes.

They are a very small and flexible catheter and they do require some sedation unless the patient is very sick, in which case they have been tolerated. And these are a singer technique much like our central lines that we talked about previously. So this is just a picture of a trocar, you can see that this needle in the middle is really quite large and that is why they are so painful to place.

As compared to the Miller type catheters, which are placed in the Seldinger technique, and you can just see that they're much smaller and sort of much better tolerated. So then we'll just think about how we're gonna manage these chest drains. So if we are looking at doing intermittent drainage, which is what we would do with any patient that sort of has a fluid collection.

We want to make sure we're wearing sterile gloves, that we use needle-free ports rather than three-way taps. You can use three-way taps, but I just think that people get very confused with them, and the risks obviously with people getting confused with a three-way tap on a chest strain are obviously very high. So just trying to minimise those those concerns.

Using sterile syringes and an alcohol swab and then you'll also want something to collect that fluid in, especially if it is fluid that you're collecting. You then want to use maybe saline for flushing or lavaging if a patient maybe has a pyothorax, you want your lavage using some warm saline. The other way that we can look at draining our chest drains is by continuous suction.

In order to do that, we've got two different types of machine that can help us. The first one is called a thoraceal, and these require a suction machine to be attached to those at all times to give us that suction. It will measure using a bubble chamber, so for patients with continuous pneumothorax, we actually can't measure accurately that air output.

We can only look at how many bubbles are coming up in the chamber, which, as you can imagine, is very subjective. With a Topaz canister, it really accurately outputs all of the, it really accurately logs all of the outputs, whether that be fluid or air, it will tell you, as in this picture here. So this picture is describing that this patient has a 2110 per minute output of air.

There's a choice of canisters depending on how much fluid you're expecting to accumulate, and the patient is able to have more mobility because they're not having to be attached to suction machines, you can take the patient out on walks. The connections for both of these must be really secure again, if you have any worries about them becoming disconnected, you then have a worry about causing a pneumothorax. You want to consider patient compliance and also think about expenses versus time and patient safety.

This is a picture of the thoraceal, so you can just see here that this bit would be attached to the patient. If you had any fluid accumulation, it would come up in this chamber. This chamber here has some bubble has some water at the bottom, so some saline here and this is where the air is sucked into and where you would measure your bubbles.

And then this chamber is filled depending on how much pressure you want to suck onto that chest. With the Topaz canister, they are, you can just see they're much smaller, so this tends to be about 1/3 of the size of this thoraceal, and this is where this would attach to the patient, and all the suction is sort of the mechanism is inside the machine so you don't require a suction machine to be attached. Now we're just gonna be thinking about our feeding tubes.

So first kind of feeding tube that we think about are the ones that we can place as nurses, so our nasal esophageal or our nasogastric tubes. These are really good to place in conscious patients, they're very useful for anybody who is at a very high anaesthetic risk, so really sick patients or patients who have cost concerns. We can just use some local anaesthesia to place these, measure to the desired distance, and then using lubricant, just insert them.

Once they're in place, you want to secure them either with sutures or butterfly tape, or maybe a finger trap suture and again, that really depends on what you prefer to do. There's no sort of better, better way of placing them. They can be used for both nutrition and gastric emptying, so patients maybe who have sort of reduced mobility of the gastric tracts, and maybe a parvo puppy would be very useful to empty that stomach if it was filling up the fluid a lot.

And they tend to be able to be place conscious, but if the patient is really struggling initially with that, then even just some burophenol or maybe some methadone, if they're on that anyway for analgesia, is useful to facilitate it. So moving on to our esophagostomy tubes which are placed by our surgeons, these require the anaesthetic to place and because of that there is associated cost. However, they can be left in place longer term, they tend to be really well tolerated, we can just bandage them out of the way and the patient can just forget that they're there.

They are a larger bore than those nasal esophageal or nasogastric tubes, so we have a wider choice of diets. And actually this maybe sometimes will negate the cost because with the smaller tubes, the nasal esophageal and the nasogastric, they are quite small and actually we tend to have to use specialised diets, if they are going home with those. But with our esophagostomy tubes, we have a sort of more of an option to maybe blend cheaper diets to get that down.

Because they're a bit wider, we can give medication down them too, so as long as the medication is able to be crushed and that can also be given. And they can also go home with them in place. So managing any feeding tubes, so with our, our nasal tubes, they will require flushing really regularly, especially if we're not feeding down them very often.

Patient compliance, so sometimes they sneeze a lot and that really can't be helped, but if they are scratching at their faces, then just placing a buster collar is really useful. We want to be able to remove these before discharge, it's not really possible to send them home with them in place, because they probably will just remove them. With our O tubes or our duunal tubes, again, we want to flush them if we're not feeding them down regularly, and we want to check that stoma cytes at least once a day.

We want to ensure that we're handling this stoma and cleaning the stoma at least once a day when necessary and and using gloves when we're doing that. And if we are sending these patients home, then actually we can teach owners to feed them down. So if we've got a patient who we think is going to be a longer term patient that maybe won't be eating for a while, then sending them home is sometimes the best thing for them so that they feel more comfortable and maybe they'll start eating sooner.

So the next tubes that we'll think about are our tracheostomy tubes. So hopefully when we are going to be placing our trait tubes, it will be in a controlled manner. And as nurses, this is not something that we will be doing generally in practise, but I think it's really important that we understand how they are placed so that we can assist with them really, so that we can assist our veterinary surgeons in placing them, and also in case there is a time where there's an emergency so that you know what to do, because if it's a life or death situation, then it's something we should understand.

So if we're thinking about placing these trait tubes then we want to think about our patient positioning. So we want them in dorsal recumbency. And again, similarly to the jugular catheter, maybe having a rolled up bandage or or maybe a sandbag under their neck will also help.

You want to find the midline cervical trachea, and this will be in the middle between the larynx and the thoracic inlet. You want to clip and prep that really well, so do surgical prep on that area. And then you want to make a midline skin incision.

Then you'll want to do blunt and sharp dissection of the muscles, which will expose the trachea. And using self retraining retractors, gelpies, you'll hold that area open so that that trachea is well visualised. You then want to identify the tracheal rings and make an incision between the tracheal rings of no more than 30% of the circumference of the trachea.

And then place stay sutures placed cranially and cordially to the incision. So that's sort of round the ring at the top and the ring at the bottom of that hole. You then place your tracheal tube and tie using umbilical tape onto those little wings so you can just see that they, they usually have these little wings at the side.

And using umbilical tape you want to tie so that there's a quick release knot around the back of the patient's neck. When you place the stage sutures and once everything else is in place, you'll want to label these so cranially and cordially. In this patient, it says up and down, and that just makes it really clear if there's any emergency and we need to be able to bring that trachea to the surface to reintubate them, that we can pull up and down so that we can expose that quickly.

So once you've got a patient with a trach tube in place, we need to know how to manage them. And we'll want to be able to clean that stoma really well, especially sort of acutely so as this wound is a surgical wound, at least for the first week, we'll wanna make sure it's really, really clean. With brachycephalic, which tends to be the patients that we most commonly place these in, we want to monitor the noise and actually we can get a really good indication of, of when our patients might require interventions by listening out for any sort of tube sounds.

If we've got really good air flow through those tubes, it's normally pretty silent. So if you hear any rattling, then it might be that that tube needs cleaning or suctioning. Our trach tubes are available to us within a cannula, and I've got a picture of that that I will show you.

Unfortunately, they don't come in very small sizes, so for our brachycephalic patients, we tend not to be able to have them available. For any patient that has a larger tube, the inner cannula is really useful because it just means that you don't need to suction the tube. You can change the inner cannula really regularly instead.

Nebulation is a consideration of these patients as well, especially depending on maybe why they've got the trait tube in place. If you've got any patient with a trach tube, you want to be prepared for any emergencies. So I've had patients remove their own trach tubes by accident, or, you know, maybe an obstruction with saliva or mucus, in which case you need to be able to change that tube really quickly.

So making sure you've got a tray next to that patient's kennel with a new trach tube available in the same size or smaller. You want to know about your stay sutures and know what they are labelled, have some spare gloves next to them as well, and also make sure that you've got oxygen nearby. If we're thinking about suctioning these patients, this is really a decision that's made patient by patient.

It isn't standard protocol for us to suction or trait tubes, but we really do assess the patients whether they clinically require it. If we are going to suction a patient, we want to pre-oxygenate them for a few minutes first and use a sterile suction tip every time. I've written no vacuuming, so I've seen a lot of people vacuum tubes for various reasons.

But if you do do that, then the the suction tip through the inside of that trach tube will cause just really micro abrasions. And the more micro abrasions that there are, the more fluid build up that there'll be inside that tube the next time. You want to make sure that you're not suctioning further than the trach tube, so not sort of hurting the trachera at all and only doing this when clinically indicated.

And this is just a great picture that shows and describes that in a cannula. So you can see that this is on the outside of the patient. You've intubated into the trachea here, and then these in a cannula can just be sort of clicked out of place and replaced really easily, which is just really nice to minimise the interventions that you need to do.

Well then just have a look at oxygen cannula. So in our patients that may require more oxygen than we can provide sort of through a mask or nasal prongs, these are really useful. Again, as nurses, we can place them.

We want to wear gloves, to make sure that we've used a local anaesthetic and using lots of lubricant and measure the tip of the catheter to the from the nostril to the medial campus, and that's just as far as they go. When that patient's then have that local anaesthetic in place for a minute or so, you'll then insert that into the nostril. It's really well tolerated and when they have been fully inserted, just suture them into place depending on your preferred suturing technique.

So now just having a quick think about our infection control practises. Daily check. So we wanna make sure that with all of our tubes, lines and drains, we're checking them really regularly.

At least once or twice a day and more often if we think that that patient is at increased risk. If we have to clean any insertion sites or stoners, then we want to make sure we're using a very mild, heavy solution and wearing gloves. And when we're redressing any of these, using the appropriate dressings.

So for anything that is discharging a lot, using something very absorbent, or maybe a primapore if it's looking really good. If anything requires neck wraps, so anything that's got a central line or an esophagostomy tube, then just making sure we're aware about the tension around that patient's neck and how comfortable that patient's going to be. And then thinking about our patient tolerance or interference.

So maybe we're thinking about putting a catheter guard on a peripheral catheter if they, if they like to chew, using a buster collar, and sort of dressings that are appropriate for that patient. If we have dirty tape, if we had a catheter that looked like this and we've got some blood spills, then ideally we'd want to really place a catheter in a different leg to avoid any infection risk. But if that wasn't possible, then we could clean that and take all the tape down and sort of redress it properly.

If you have any swelling above catheters, then just making sure that that catheter is really patent and that we've not got any extravasation of fluids or medications. And if we've got swelling below, it tends to be because maybe the the tape is a little bit tight or the bandage has been too tight, or maybe that patient arrived quite dehydrated and now that they're evolemic, we just need to rebandage and retape that catheter. If we have any pyrexia or we're worried about inflammation or phlebitis, then having a conversation with that vet to make sure that they're happy, but actually replacing them if we can in a different leg and removing the worrisome catheter.

So with our infection control, we want to always be wearing gloves for the majority of these things, but making sure that we always have good hand washing and hand rubbing practises because gloves can't replace having really clean hands. We want to be barrier nursing, so for patients that may be at risk, so maybe if they're immuneocompromised, if they've not had all of their vaccinations, and also for patients that are potentially infectious as well. We also want to think about room cleanliness and kennel cleanliness and our cleaning equipment as well.

So thinking about actually when was the last time I cleaned the mop handle? When was the last time I cleaned the mop bucket. We use all of this equipment for cleaning everything else, but actually how often do we clean the cleaning equipment?

And also having a look at cleaning checklists, if we've got a good hospital protocol for cleaning checklists, making sure that they're done every day or every week, depending on what things that we are needing to do in our hospital and what equipment we have. And doing regular checks, so some practises will do regular swabbing to check for any infe infectious problems such a buildup of bacteria, but just making sure that we're really at the forefront of infection control. So hopefully after today, you now feel more confident in listing the different tubes, lines and drains that we use in practise and the pros and cons for each of those.

As veterinary nurses, understanding our role in the placement and management of these, and how to place them if that's applicable, and also the importance of having really good infection control practises. Thank you for listening.