Question on your IV method?

[trevor1189]

Just curious what your method of establishing an IV is?

Any IV access or venipuncture for labs I've seen as been low angle from the start, yet many teaching materials seem to say puncture at 45 degrees, when blood flows, lower the angle.

 

[Sasha]

It depends on the person. Deeper veins require bigger angles.

 

[trevor1189]

Ok, thank you. Since I am no where close to being able to establish IVs, this was just a curiosity question. But Input is still appreciated.

I know a lot of times what is taught in classroom seems to be different than what is taught in class so I thought I'd ask.

 

[Onceamedic]

For the most part, I am a "slow and low" gal. As Sasha states - sometimes I increase the angle for the deep ones. Generally, the most critical thing for me is to visualize or palpate the anatomy of the vein. I have seen many students get good flash and then fail to advance the catheter because they are not pointed in the direction of the vein.

 

[trevor1189]

Ok, I have seen people go the "low and slow" method and still screw up but it just seems like there is less of a chance of infiltrating the vein using this method rather than the 45 then low method.

Also have read and heard from medics, don't go by the looks, go by the feel. Seems to hold true. I have heard phlembotimists from the red cross tell me they could stick a straw in my AC's even though they aren't really visible after palpating my arm.

 

[HotelCo]

Other

I go "low and fast" I guess, when I'm going through the skin I go through it fast, it's less painful that way, but once the needle is in the skin, I advance slowly.

 

[trevor1189]

Good deal, I really appreciate the responses. Keep'm coming!

 

[Wee-EMT]

I like both. I prefer the 45 degree angle, but also do the "low and slow" method. Like mentioned before, it all depends on how the veins are, the juicier the better!

 

[trevor1189]

I like both. I prefer the 45 degree angle, but also do the "low and slow" method. Like mentioned before, it all depends on how the veins are, the juicier the better!

My appologies for lack of options in the poll. If none fit you like in the case of Wee-EMT, just post your method.

Thanks a bunch!

I posted this just to learn about IV methods, so the more info the better, even if it doesn't fit in the poll.

 

[lightsandsirens5]

Although I am not ILS yet, we are being taught the "low and slow" as you call it. Although like Sasha said, deeper veins require greater angle.

 

[trevor1189]

Although I am not ILS yet, we are being taught the "low and slow" as you call it. Although like Sasha said, deeper veins require greater angle.

Thank you, proper wording isn't my intention. As long as you understand what I mean that is fine.

 

[Hastings]

My partner taught me to bend the IV catheters into an angle before insertion. Scared me to death when he did it the first few times. I was horrified. But alas, it works well.

I don't suggest anyone else do it. I certainly don't. Too scared.

 

[trevor1189]

My partner taught me to bend the IV catheters into an angle before insertion. Scared me to death when he did it the first few times. I was horrified. But alas, it works well.

I don't suggest anyone else do it. I certainly don't. Too scared.

That's a new one... :unsure:

 

[Onceamedic]

I certainly would not bend a catheter in any way whatsoever. Those things can break off very easily. If he/she puts a plastic embolism in a patient because of stupid *** individual god look at me ain't I smart cowboying tactics I hope they crucify him/her.

 

[ffemt8978]

My partner taught me to bend the IV catheters into an angle before insertion. Scared me to death when he did it the first few times. I was horrified. But alas, it works well.

I don't suggest anyone else do it. I certainly don't. Too scared.

That technique used to be prevalent years ago, before safety catheters, but it should not be used anymore. Like Kaisu said, if you do it and your patient develops ANY problems with the IV site you are going to be in a heap of trouble.

 

[MasterIntubator]

I'm an other....

If you are interested in fine tuning your skills in IV stuff when you become ALS , one of the best things you can do to get familiar with it, is play with the stuff. Get yourself a catheter and safely play with it, notice all the anatomy of it, study the differences from a 14 gauge to a 22 or 24 gauge. Each size will give you a slightly different approach on the technique you use.

( terminology -
Stylus= the metal needle that actually does the penetration and adds rigidity
Sheath or Catheter= The plastic based part that goes over the stylus, which can be made of many materials from polyurethane to teflon
Flash chamber= Where you see the blood when you are in the vein.
Bevel= The tip of the Stylus, which has the cutting edge to penetrate the skin. Used in terms such as... bevel up or bevel down. The sharp end.
Bevel indicator= Many catheters have a marking or indicator on or near the flash chamber indicating whether you are bevel up or down while you are in the skin )
Hub= The portion of the sheath closest to you, and what you hook the rest of your IV stuff to.

Now, hopefully knowing the terminology will help with the mental picture... If you compare a 22 guage ( small cath ) to a 14 gauge ( big cath ), there are differences in the bevel, and the distance from the end of the sheath to the end of the bevel. This determines my decision how far I may advance the catheter once I get a "flash" ( visible blood in the flash chamber, indicating you are in the vein ), and how much I need to advance.

If you play with some old IV tubing, you can almost visualize what would be going on within a vein. Notice that you may get blood flash, but only the bevel in the vein.... causing a sheath hang if you chose to thread at this point. Advance the whole assembly a little further, and you get the sheath within the vein wall. Advance the whole assembly too far, and the tip of the bevel can poke thru the opposite side of the vein, causing a hang up. Most folks chalk it up to "Valves". ( thats another theory ).

Reducing your catheter assembly angle will help prevent poking thru the other side of the vein.

When I stick, I choose to use a low angle, and stick fast thru the skin at a predeterimined length based on what I see and feel in the vein. Once I get a flash, I thread in. I do not advance anymore, unless I am using big catheters, just because the rate of "hang ups" by the sheath go up due to sheath to tip of bevel difference. I also do not retract the stylus until the hub is fully seated against the skin. The stylus gives you rigidity while advancing the sheath. If you take that away, as you advance the sheath, your chances of buckling the sheath have gone way up.

Some shallow veins, I have done sticks with the bevel down, helps prevent double wall punctures. I also increase my venipuncture angle as well with this. This takes some practice.
I also use BP cuffs for my tourniquet. I have better pressure control, plus I can grab a BP quickly and get right to stickin. I inflate to the pts systolic, this gives me the best back pressure. Geriatrics, I use less pressure ( until the vein feels spongy... not rock hard. ( side note.... you gotta check your equipment, if you have a leaky cuff, it will slow you down. I always know where my leaky cuff is..... in the back up unit. ).

So many techniques.... so many variations. These are the ones that have granted me great success. When you clinb that ALS ladder, I hope you are as passionate and learn what is best for you. Take all these ideas on this post and play away. You will find your niche.

As far as bending the catheter for a better angle, I have only done that with vacutainer systems, or just by pulling blood via syringe... and that is to make up for any angle issues the larger syringes create. I would be leary of how you do something like that with a catheter, especially the technique you use to make your bend, if contaminate the sheath ( phlebitis, although the stats are low for in field folks ), but more importantly... causing a nick or burr in the sheath. Not to mention, that cancels out any reason to re-insert the stylus. ( I know what the books say, but many of near impossible lines were saved by rotating the stylus for a bevel down position to re-insert the stylus to re-seat the sheath. The bevel rides down the sheath - vs - bevel up where it punctures the sheath. Try it with some training caths. Place a slight bend in the sheath, re-introduce the stylus both bevel up - then bevel down. Pretty neat trick when that 1 in 1000 comes around and it works ).
We tried to create a plastic embolism in the lab, it never happened. Even when we went beyond extreme sheath shredding. Those sheaths are tough. Try that too... give one a rip, not easy. And we have not been able to find any documented cases of such with todays caths ( 80's on up ). What we did end up doing was shearing the vein wall more, creating a bigger hematoma.


----excerpt from my soon to be book... "... And why do I care how it works?"

 

[irish_handgrenade]

i dont know about you guys, but my technique is simple: I grab an arm or leg, say a prayer, close my eyes, and then I just simply stab repetedly in an overhead method until there is "blood flow".B) lol no really I'm a low and slow kinda guy.

 

[trevor1189]

I'm an other....

If you are interested in fine tuning your skills in IV stuff when you become ALS , one of the best things you can do to get familiar with it, is play with the stuff. Get yourself a catheter and safely play with it, notice all the anatomy of it, study the differences from a 14 gauge to a 22 or 24 gauge. Each size will give you a slightly different approach on the technique you use.

( terminology -
Stylus= the metal needle that actually does the penetration and adds rigidity
Sheath or Catheter= The plastic based part that goes over the stylus, which can be made of many materials from polyurethane to teflon
Flash chamber= Where you see the blood when you are in the vein.
Bevel= The tip of the Stylus, which has the cutting edge to penetrate the skin. Used in terms such as... bevel up or bevel down. The sharp end.
Bevel indicator= Many catheters have a marking or indicator on or near the flash chamber indicating whether you are bevel up or down while you are in the skin )
Hub= The portion of the sheath closest to you, and what you hook the rest of your IV stuff to.

Now, hopefully knowing the terminology will help with the mental picture... If you compare a 22 guage ( small cath ) to a 14 gauge ( big cath ), there are differences in the bevel, and the distance from the end of the sheath to the end of the bevel. This determines my decision how far I may advance the catheter once I get a "flash" ( visible blood in the flash chamber, indicating you are in the vein ), and how much I need to advance.

If you play with some old IV tubing, you can almost visualize what would be going on within a vein. Notice that you may get blood flash, but only the bevel in the vein.... causing a sheath hang if you chose to thread at this point. Advance the whole assembly a little further, and you get the sheath within the vein wall. Advance the whole assembly too far, and the tip of the bevel can poke thru the opposite side of the vein, causing a hang up. Most folks chalk it up to "Valves". ( thats another theory ).

Reducing your catheter assembly angle will help prevent poking thru the other side of the vein.

When I stick, I choose to use a low angle, and stick fast thru the skin at a predeterimined length based on what I see and feel in the vein. Once I get a flash, I thread in. I do not advance anymore, unless I am using big catheters, just because the rate of "hang ups" by the sheath go up due to sheath to tip of bevel difference. I also do not retract the stylus until the hub is fully seated against the skin. The stylus gives you rigidity while advancing the sheath. If you take that away, as you advance the sheath, your chances of buckling the sheath have gone way up.

Some shallow veins, I have done sticks with the bevel down, helps prevent double wall punctures. I also increase my venipuncture angle as well with this. This takes some practice.
I also use BP cuffs for my tourniquet. I have better pressure control, plus I can grab a BP quickly and get right to stickin. I inflate to the pts systolic, this gives me the best back pressure. Geriatrics, I use less pressure ( until the vein feels spongy... not rock hard. ( side note.... you gotta check your equipment, if you have a leaky cuff, it will slow you down. I always know where my leaky cuff is..... in the back up unit. ).

So many techniques.... so many variations. These are the ones that have granted me great success. When you clinb that ALS ladder, I hope you are as passionate and learn what is best for you. Take all these ideas on this post and play away. You will find your niche.

As far as bending the catheter for a better angle, I have only done that with vacutainer systems, or just by pulling blood via syringe... and that is to make up for any angle issues the larger syringes create. I would be leary of how you do something like that with a catheter, especially the technique you use to make your bend, if contaminate the sheath ( phlebitis, although the stats are low for in field folks ), but more importantly... causing a nick or burr in the sheath. Not to mention, that cancels out any reason to re-insert the stylus. ( I know what the books say, but many of near impossible lines were saved by rotating the stylus for a bevel down position to re-insert the stylus to re-seat the sheath. The bevel rides down the sheath - vs - bevel up where it punctures the sheath. Try it with some training caths. Place a slight bend in the sheath, re-introduce the stylus both bevel up - then bevel down. Pretty neat trick when that 1 in 1000 comes around and it works ).
We tried to create a plastic embolism in the lab, it never happened. Even when we went beyond extreme sheath shredding. Those sheaths are tough. Try that too... give one a rip, not easy. And we have not been able to find any documented cases of such with todays caths ( 80's on up ). What we did end up doing was shearing the vein wall more, creating a bigger hematoma.


----excerpt from my soon to be book... "... And why do I care how it works?"

Very nice post. Thanks for going into all the details.

 

[marineman]

My method is based on the individual, and how deep the vein is. Like others said deep veins require higher angles. Another reason I use the higher angle is you pierce the skin quicker making it less painful. Especially on patients with tough skin I will take a fairly high angle and pierce the skin right next to the vein then try to fish it into the vein. I have never understood low and slow, other than for the rhyme, go fast to pierce the skin then you can slow down getting into the vein but if you mess around with it too much you will make it more likely to roll.

With experience everyone learns what works for them and what doesn't, my technique may not work for you and yours may not work for me.

 

[omak42]

i pretty much use a hybrid of the too....I go lower than a 45 degree angle but usually try to go faster. slow is more painful for the patient usually and you "roll" more veins that way. if you go slow you will kinda nudge the vein out of the way, whereas fast you will puncture it. however like said above.....it differs by patient/scenario