Tuesday, June 08, 2010

IV Tips From the IV King

IV Tips From the IV King

Lots of times at work, others call me to start IV’s on patients who are “hard sticks.” I’m usually successful. Many doctors and nurses acknowledge that if I can’t get an IV on a patient, they need to put in a central line. I’m not boasting about my prowess with the needle, Lord knows there are days when I can’t hit the broadside of a barn with a 22 gauge. But I want to share some tips to help you, dear IV-sticker, to make your job easier and become your own IV king or queen.

I won’t go into the basics of IV-sticking. If you’ve read this far, you already know the basics of how to stick an IV into a patient. Let’s work on getting better at it. There’s lots of different “hard sticks” out there: diabetics, IV drug abusers, frail little old people, children, babies, cardiac arrest patients, CHF-ers and so on. Their veins may blow, they may be very deep and invisible, or very tiny. These tips will help on all those.

One of the first and most helpful things you can do to be a better sticker is to brush up on your knowledge of the vascular system, particularly the veins. “But everybody’s veins are different!” I hear you screech. True, everyone’s different, but we all have two arms, two legs, a stomach, a heart and a brain and they’re generally located in the same place between individuals, right? Our veins are no different. We all have a radial vein, an ulnar vein, a brachial vein, a cephalic, basilar, saphenous and external jugular and they all are placed in more or less the same location in our bodies. Sometimes you have to do a “blind stick.” If you know where a particular vein should be located, it will help in hitting that vein, rather than just sticking the needle into any old patch of skin and hoping. You may have to dig around a bit to get the flashback. Move the needle slowly so you don’t pierce through the vein. Remember that veins follow the bone, and everywhere in the body, the NAV rule applies- Nerve, Artery, Vein. Aim the tip of your needle a little lateral to a pulse point and you should find the vein. I also find that while the initial needle stick is painful, after a minute or two of digging around, the pain almost disappears, thanks to our amazing sympathetic nervous system. So don’t feel that you are torturing your patient if it takes a while to find the vein.

Some patients are severely edematous. The swelling makes it impossible to distinguish the feeling of a palpated vein from edematous tissue. With these patients, remember the veins will be deeper under the swollen tissues. Don’t be afraid to stick your needle in at a steeper angle than usual. Your flash chamber may fill up with interstitial fluid rather than blood, so if you feel like your in the vein but there’s no blood in the chamber, pull your needle out and see if the catheter bleeds. If you keep everything aseptic, you can reinsert your needle into the catheter and keep trying if you didn’t get it. Just be cautious of tearing the catheter with the needle. If you feel any resistance reinserting the needle, pull the whole thing out & start again.

People with tiny veins are another challenge. Yes, everyone likes to use big ol’ honking 16 and 18 gauge catheters. But Grandma with the tiny spider veins won’t be able to take that. I know you learned that big, long catheters can infuse more fluid and could show me the math to prove it. But in real life, a well-placed 22 gauge can infuse just as fast as a 16. So to hit Grandma’s tiny little veins, use a small needle. Feel free to poke one of the varicose veins just under the skin. Make sure you’re very gentle as you pierce. Often the vein will form a hematoma at the insertion site. If it does, don’t give up yet; keep advancing the catheter and infuse a little fluid. If it doesn’t expand the hematoma when you push the fluid, you can use the IV. Another tip is to insert the needle bevel-down when poking a small or fragile vein.

Some IV-stickers freak out when they have to stick kids. People - it’s not that hard! Kids whine less than adults do. And kids have young, strong veins. Please don’t use a crappy little 24 gauge catheter just because the patient is a child. 24 gauge catheters are too small to support their own weight. I’ve stuck 16 gauges in 2 year-olds with no problem. Kids generally have a fair amount of adipose tissue that can hide the veins, but use the same principles of anatomically finding a vein and you’ll be fine. Scalp veins are commonly used on kids and kids often have great foot veins. Remember, you can use any vein in the body for an IV. Don’t get stuck in the thinking of using only arms for IV’s.

Speaking of which, if you can’t use an arm for an IV for whatever reason, look up the arm towards the shoulder. Frequently patients with terrible arm veins will have terrific veins on their shoulders and upper chest. True, you can’t use a tourniquet, so the lack of pressure in the vein may not give you a flashback. But if the catheter bleeds when you pull out the needle, you’re golden. On those crazy-looking sideways veins, just make sure you stick in the direction that’s most towards the heart and you’ll get it in the right direction.

Lots of folks have valve-y veins. When the valve senses the foreign body of the catheter, they tend to clamp shut and you won’t be able to advance your catheter. If the vein is relatively straight and strong, use the needle to pierce through the valve, making sure to keep the tip within the lumen of the vein. It may take a surprising amount of force, but remember, it the valves are that strong, so is the vein. Don’t be chicken.

Lots of EMS services use the EZ-IO (intraosseous needle) on cardiac arrest patients as their first line of access. Call me old-fashioned, but you can’t beat a good IV, especially on a code. Folks, at least try to get an IV on a code. You’ll be surprised at how easy it is. The lack of vascular tone usually makes the veins engorge with blood so they stand out yelling “stick me, stick me!” The whole purpose of ACLS and IV access is to get the patient back, and if they regain a pulse, they’ll be in the hospital for a while. Your IV will remain in use for days, helping the patient recuperate. If you stuck an IO in, it’ll get pulled before the patients gets to the ICU. Please try to get an IV.

One last tip - EMS people, your IV’s fall into two extremes by the time the patient gets to the floor in the hospital. Either they A) last forever and are great for infusing fluids and drawing blood or they B) need to be pulled prematurely because they get infected. Please start your IV’s as aseptically as possible. Yes, I know the thinking “you can always give them antibiotics.” However, antibiotics don’t always work. Antibiotics also contribute to resistant infectious organisms. Also, insurance companies don’t pay for treatment of iatrogenic infections, you and I do. If you’re going to start an IV, do it right.

Thanks for reading, and good luck!


Jonatan said...

Hi Sean!
i loved reading your post!
as an Israeli paramedic i get that dilemma almost every day.
nowadays, whenever i get the feeling that an IV is going to be difficult, on an emergency code i usually go directly to IO. in Israel we use exclusively the Bone injection gun (B.I.G.) for IO access. i don't know if you know the device, but as an automatic devices i get a vascular access using the device in less than 40 seconds! this is much faster that every other method i tried ( including the EZIO). it is also much more comfortable for me to carry it in my vest.
as far as i know, most paramedics have a lot of patients that owes their lives to the B.I.G. as the paramedic did not waste valuable time searching for a vein.....
just something to have on the back of our minds......

Sean said...

Thanks, Jon! I have only vaguely heard of the B.I.G., never used one. But there are lots of readers that will be eager to try it now!

Grainne said...

Jonmedic101, can you send one to Sean?