IV advice?

[Porta]

Regardless of the skin thickness, visualize your target as the inside of a small piece of hollow pasta. You aim for the middle of that lumen and go from there. You start out with a shallow angle and after you have entered the skin, aim for that lumen and just go for it!

Good analogy!

 

[bigbaldguy]

One thing no one ever really told me in a way I understood was you don't start right in the vein. You start a bit down from it and kind of tunnel up towards it so you don't go through it on entry. Like a gofer who starts out making a new tunnel but then joins that tunnel with an existing one. I was starting mine way too far up. Also I was under the impression that going fast makes it hurt less. It does make it hurt less but you're more likely to miss. Better to drag the pain out an extra 3-5 seconds then to have to try 3 or four times. Now I advance the needle nice and slow and I haven't missed one since.

Hope this helps.

 

[the_negro_puppy]

I still believe site selection is really important. Spend the extra minute or two to have a look at all your options. Find the best vein, don't just settle for the first one you see because you feel rushed. By doing this I virtually get most IV's on first attempt, makes for a happy patient.

- Use traction, pull the skin as taught as possible. This can help with loose skin and prevent veins from rolling away.

- Go in at a shallow angle. Many books say 45 degree then lower but I have never done this. I generally go in at as shallow angle as possible.

- Tapping veins lightly does actually make them more engorged and easier to stick. I use this often. Make sure you are dangling their arm if possible, allow gravity to pool blood in the veins.

- Pt's with chronic health problems usually know where their 'good veins' are. Ask them where they normally receive blood draws etc from.

I always go for the forearm if possible. Seems to hurt less, doesn't prevent use of the hand and wont get kinked by bending at the elbow.

- Practice makes perfect. The only way to get better is just do it over and over again.

 

[Porta]

One thing no one ever really told me in a way I understood was you don't start right in the vein. You start a bit down from it and kind of tunnel up towards it so you don't go through it on entry. Like a gofer who starts out making a new tunnel but then joins that tunnel with an existing one. I was starting mine way too far up. Also I was under the impression that going fast makes it hurt less. It does make it hurt less but you're more likely to miss. Better to drag the pain out an extra 3-5 seconds then to have to try 3 or four times. Now I advance the needle nice and slow and I haven't missed one since.

Hope this helps.

That's actually one thing I was messing up, I was way too high. The IVs that I had success with, I think I was lower and was able to get a little more wiggle room.

Thank you!

 

[Porta]

I still believe site selection is really important. Spend the extra minute or two to have a look at all your options. Find the best vein, don't just settle for the first one you see because you feel rushed. By doing this I virtually get most IV's on first attempt, makes for a happy patient.

- Use traction, pull the skin as taught as possible. This can help with loose skin and prevent veins from rolling away.

- Go in at a shallow angle. Many books say 45 degree then lower but I have never done this. I generally go in at as shallow angle as possible.

- Tapping veins lightly does actually make them more engorged and easier to stick. I use this often. Make sure you are dangling their arm if possible, allow gravity to pool blood in the veins.

- Pt's with chronic health problems usually know where their 'good veins' are. Ask them where they normally receive blood draws etc from.

I always go for the forearm if possible. Seems to hurt less, doesn't prevent use of the hand and wont get kinked by bending at the elbow.

- Practice makes perfect. The only way to get better is just do it over and over again.

Thanks!
I wish we had more ED time. I start ride time in a few weeks and I know it's going to be a lot harder in the truck than a stable environment like the ED.
But it's not like I'm the first student to ever be intimidated by sticks.

 

[wildmed]

I usually stop with 2 tries and will allow an attempt to go for 30 sec, this is variable depending on how badly I need a line. If a pt is crumping, Im not going to stop until I have access of some sort.The best trick I have ever learned was from a flight nurse when I was a new ED tech. Instead of advancing just the angiocath once you have a flash; pull just the needle tip back into the catheter so its no longer exposed, and advance the entire unit. This keeps the cath ridged and allows you to have better control while your advancing into the vein, without causing damage to it. It works great for those fragile old veins that have been wrecked by heparin as well as tiny peds veins with strong valves. I also am a big fan of hands for a 1st try because you can hold traction easily, they are usually easy to visualize, and you are leaving superior options for access incase you loose a line. Obviously if your needing to drop bilateral 16-14 this should not be your 1st option. Also don’t forget the “handcuff" vein, many people forget its there, but it can be a great option.

 

[Porta]

Handcuff vein? Do you mean this guy?

 

[VFlutter]

http://m.youtube.com/watch?v=_-9tTq53XH8

We had one of these on our floor for a while. It was useful but they decided it was not worth the cost at the time. A decent understanding of common anatomy and thorough palpation did just as well.

 

[wildmed]

The “handcuff” vein is the basilic vein. Its located on the posterior portion of the forearm a few inches distal to the elbow. If your having a hard time finding something, look at your own arms, circulatory anatomy may be slightly different between each person, but the general lay out is the same. Once your confident in your skills it also pays off to be creative,don’t get locked into the arms or EJ as your only two options. I’ve started lines in upper arms, breast tissue, scalps (Neonate),feet, and legs that remained patent for days .

 

[Porta]

The “handcuff” vein is the basilic vein. Its located on the posterior portion of the forearm a few inches distal to the elbow. If your having a hard time finding something, look at your own arms, circulatory anatomy may be slightly different between each person, but the general lay out is the same. Once your confident in your skills it also pays off to be creative,don’t get locked into the arms or EJ as your only two options. I’ve started lines in upper arms, breast tissue, scalps (Neonate),feet, and legs that remained patent for days .

Ah, okay. I actually got an IV on that my last rotation. How difficult are EJs? I watched my preceptor try and get one (or two rather) on a woman and it seemed that it would have been easier if he had gone for a vein in one of her breasts or go IO - he stuck her twice with no luck. If you need a central line but can't get an EJ, would an IO be your best bet after that?

 

[JDub]

Ah, okay. I actually got an IV on that my last rotation. How difficult are EJs? I watched my preceptor try and get one (or two rather) on a woman and it seemed that it would have been easier if he had gone for a vein in one of her breasts or go IO - he stuck her twice with no luck. If you need a central line but can't get an EJ, would an IO be your best bet after that?

Neither an EJ or an IO are central lines.

If you are in the field, most providers attempt to go for an EJ last, so yes a IO would probably be your only option at point. I would say if you keep looking you could probably find a vein to place an IV in.

If you are at the ER and you attempt an EJ as a last resort and cannot get it, then a doctor will probably place a central line such as in the Internal Jugular (IJ), Subclavian or Femoral.

 

[Porta]

Oh, okay, thank you for the correction. I was under the impression they were considered central lines.

 

[Akulahawk]

Oh, okay, thank you for the correction. I was under the impression they were considered central lines.

Depending upon where you work, an EJ could be considered a central line or a peripheral line, as far as IV access is concerned. Where I did my ED clinical rotation, they considered the EJ as a central line but the local EMS agency considered it a peripheral line. Just know what your employer considers as a central vs peripheral line. Follow their rules as to what you can place and you'll (usually) have their backing when it comes to IV lines placement.

 

[JPINFV]

Wait... a regular peripheral IV being considered a central line? There's a rather large difference between size, technique, and function of a central line and a peripheral IV, regardless of location.

 

[Porta]

My scope only allows me peripheral lines, which includes an EJ. However, at the ED, the EJ was referred to as a central line.

 

[Akulahawk]

Wait... a regular peripheral IV being considered a central line? There's a rather large difference between size, technique, and function of a central line and a peripheral IV, regardless of location.

Yep. Some places consider an EJ to be a central line. That was pretty much my argument as well when I found out that those places don't consider EJ's to be a peripheral line. :blink:

 

[hogwiley]

When I was in the hospital not too long ago I had students sticking me like a pin cushion. First in the ER there was a student medic. Then later up on the floor and needed a second one started, I got to have a student Nurse do the honors. Later when that line went bad I had an RN start one who was as bad, if not worse than the students, and she left one at a weird angle that hurt like a SOB, but I wasnt about to ask her to take it out and put it somewhere else. I'm a fairly muscular skinny little guy but apparently im a hard stick.

I can tell you none of them followed the 2 sticks your out rule. I finally had to ask if I did something to these people to make them hate me. I told them next time they needed a line Ill stick the damn thing myself.

 

[blachatch]

I usually stop with 2 tries and will allow an attempt to go for 30 sec, this is variable depending on how badly I need a line. If a pt is crumping, Im not going to stop until I have access of some sort.The best trick I have ever learned was from a flight nurse when I was a new ED tech. Instead of advancing just the angiocath once you have a flash; pull just the needle tip back into the catheter so its no longer exposed, and advance the entire unit. This keeps the cath ridged and allows you to have better control while your advancing into the vein, without causing damage to it. It works great for those fragile old veins that have been wrecked by heparin as well as tiny peds veins with strong valves. I also am a big fan of hands for a 1st try because you can hold traction easily, they are usually easy to visualize, and you are leaving superior options for access incase you loose a line. Obviously if your needing to drop bilateral 16-14 this should not be your 1st option. Also don’t forget the “handcuff" vein, many people forget its there, but it can be a great option.

This sounds like a great idea I might try next time.. to prevent damage to the catheter when trying to advance.

 

[AtlasFlyer]

When I was in the hospital not too long ago I had students sticking me like a pin cushion. First in the ER there was a student medic. Then later up on the floor and needed a second one started, I got to have a student Nurse do the honors. Later when that line went bad I had an RN start one who was as bad, if not worse than the students, and she left one at a weird angle that hurt like a SOB, but I wasnt about to ask her to take it out and put it somewhere else. I'm a fairly muscular skinny little guy but apparently im a hard stick.

I can tell you none of them followed the 2 sticks your out rule. I finally had to ask if I did something to these people to make them hate me. I told them next time they needed a line Ill stick the damn thing myself.

When I was in the hospital in 2005 having my 2nd baby I had a student attempting to start my IV. I admit I have scrawny arms, but this girl could not get the thing started. It was AWFUL. I was already on edge because the baby was being induced 4 weeks early for failure to thrive, and I was quickly reduced to tears by this student sticking me over and over and over and over and over again.

She finally left, in tears herself, and had a supervisor come in and get it going. I felt bad for her, and I know students have to learn on someone, but please not repeated attempts on someone who's already pretty upset.

 

[jorgito]

two tries sounds good;however, on the field its a different story. You try as many times as you need to, even the most experienced miss, so keep trying. Practice makes perfect.