ivs

[emtcutie]

So i've done about 20 ivs, and i'm still so-so at starting them. I am getting frustrated because i see the vein, i feel the vein but it feels like i miss more than i geth them. Any tips for getting a good stick?

Edited March 29, 2011 by emtcutie

[island emt]

In order to assist you we need to know what technique you are using to start them now.

Choice of vein, ie back of hand, wrist , forearm , AC, EJ.

Do you jump right in with a big gauge catheter to the AC or do you take the time to get a nice flowing 22 or 20 ga in the hand? Are you jumping at the first vein you think you can get or are you checking all options.

Are you starting IV's because you can ?

Or because you have come up with a treatment plan that requires fluid resuscitation or medication administration?

When you miss, is it because you didn't get access to the vein with flashback?

Or are you missing because of holding technique?

Don't take these questions as an attack on you or you new skills.

Most of us have gone through a period of misses over the years.

Many times it's a combination of pt's with crappy veins and a lack of confidence in your skill, mixed in with a little bad technique.

Most of these can be corrected, but there will always be patients with crappy veins. Thats when you need to look at the places where everybody else hasn't.

Don't fall into the mantra of every PT needs a 16 ga in the AC. Can't remember the last time I did a 16 or 14, it's been years.

The bigger the bore the greater the chance of blowing the start.

The majority of the IV's I start are small ga in the hand unless it's big time trauma or a potential arrest situation.

[emtcutie]

In order to assist you we need to know what technique you are using to start them now.

Choice of vein, ie back of hand, wrist , forearm , AC, EJ.

Do you jump right in with a big gauge catheter to the AC or do you take the time to get a nice flowing 22 or 20 ga in the hand? Are you jumping at the first vein you think you can get or are you checking all options.

Are you starting IV's because you can ?

Or because you have come up with a treatment plan that requires fluid resuscitation or medication administration?

When you miss, is it because you didn't get access to the vein with flashback?

Or are you missing because of holding technique?

Don't take these questions as an attack on you or you new skills.

Most of us have gone through a period of misses over the years.

Many times it's a combination of pt's with crappy veins and a lack of confidence in your skill, mixed in with a little bad technique.

Most of these can be corrected, but there will always be patients with crappy veins. Thats when you need to look at the places where everybody else hasn't.

Don't fall into the mantra of every PT needs a 16 ga in the AC. Can't remember the last time I did a 16 or 14, it's been years.

The bigger the bore the greater the chance of blowing the start.

The majority of the IV's I start are small ga in the hand unless it's big time trauma or a potential arrest situation.

Usually I go for the AC, i try to look at both arms before i stick them. And i almost always go with the 20 gauge, unless it's truama and i go with an 18 or if they have small veins for some reason i go with a 22. I've been doing alot of my clinicals so pretty much all patients get iv's. When I start them i get like bubbles of blood, but i can't advance the catheter, i thought maybe i was just hitting valves, but i keep doing it. I know i need to work on my angle because my first couple of iv's I blew.

And don't worry i didn't take it as an attack, i need all the help i can get, because i am really getting frustrated.

[island emt]

OK : thats a start.

Have you studied a good A+P book to learn the venous pattern in the extremities?

You can practice on anyone by simply holding their hand and feeling for veins , then looking for them after you feel them.

The more people you do this exercise on will give you confidence in your ability to find them. practice this simple vein finding drill on as many folks as you can. Skinny folks and well padded folks , A carpenter with big muscular forearms and a little old lady with tissue paper skin and aged veins are all very different in feel and how deep the mass is on their arms before you get to the vein.

A nurse that taught me many years ago in a day surgery unit, taught me to place your tourniquet then close your eyes while running your fingertips up the hand + arm. FEEL them and be one with them first.

Then when you have made the determination of which vein feels good , look at it for size and valves, bifurcations and scar tissue. Then decide what size catheter you feel comfortable in that vein.

Bigger is NOT always better.

I'd rather get a good secure 22 flowing in the hand to gain fluid access and then after, if I feel the need go for something bigger further up the arm.

The problem with always going for the AC is if you don't get it then you have wasted that site and need to go find something else. The AC is good if it is prominent and yes it's a big vessel, but thats where all lab techs go and many folks have developed scar tissue from repeated cannulation there.

I worked with a lot of newbies over the years who were taught to go big and go to the AC because it's easy, but not every pt needs big needle or big fluid. The other problematic issue with the AC is the PT needs to keep their arm straight or it will occlude the flow and it can kink the indwelling catheter causing shear, which is a big no no.

Do your prep of the site and then tell the pt to expect a little sting as you make your approach. That way they are less likely to flinch and pull away as your making the skin poke. Contain the vein above & below with your other hand while making the approach. One steady advancement until you feel the catheter enter the vein and then lower your attack angle to allow the catheter to advance. You should see a good flash in the chamber before retracting the needle back leaving the plastic catheter in place.

What type of Catheters are you using?

Some places are using the push button retractable units which I personally find cumbersome. We use the J&J manual retract caths which are shorter and fit in the hand better.

More to come later.

[emtcutie]

i'm pretty good at finding the vein, it's just like i said im not able to advance the cathater. And yes they taught us go with the big ones. As for the cathater, my area only has the push button retractables. I've done the blind find where i close my eyes and find a vein, its harder i find for me in the older people and dehydrated. If i can't find it at all i let my preceptor start the line not me.I do also warn my patient so they are less likely to pull away (although that doesn't stop some people).

[emtannie]

i'm pretty good at finding the vein, it's just like i said im not able to advance the cathater. ...

It sounds more like this is a technique issue.

I don't know what kind of catheters you use... but it really doesn't matter... take a piece of IV tubing, tape it to a table, get a catheter, and practice starting the IV into the tubing, until you are comfortable with how you want. You need the muscle memory so you are comfortable with your technique. It sounds screwy, but it works!

I know initially, a lot of instructors tell their students to go for the big veins because they are supposedly easier. As you get more comfortable and more confident, as island stated, you may want to consider smaller veins in the arm or the hand. Yes, we may need IV access on a patient.... but not all those patients require large volume boluses into large veins. We may only need to give a medication, or draw blood, or give a small amount of fluid... and, if they are going to be in the hospital for a while, and are mobile enough to move on their own, it may be more comfortable for them in the long run to have the IV in the hand or forearm, so it doesn't constantly cause issues whenever they bend their arm.

Don't feel bad about missing some IV's... everybody has their misses..

[Lone Star]

I know my 'problem' is mostly with technique, and the fact that I'm out of practice. Part of my technique issue is that my 'angle of attack' is probalby too shallow and that when I was learning how to do them, one hand was in a cast.

I'm pretty sure that once we start doing them in class, I'll get better (can't get much worse, can I?)

Would the tubing that is used for air pumps in fish tanks qualify as 'iv tubing'? One would probably have better luck getting their hands on that as opposed to true 'iv tubing' or the extension oxygen tubing.

The biggest question I've got is this:

We're taught to start as distally as possible, and work proximally, yet I find many medics going straight for the AC. Sure, it's a bigger target, but it's NOT proper technique. Additionally, if we're going to follow proper technique (starting in the hand when appropriate) do we HAVE to apply the tourniquet above the elbow, or can we apply the tourniquet distally to it?

[Dustdevil]

The problem you describe seems to most often be the result of timidity. You have a good eye and feel for the vasculature, but aren't being definitively assertive with your sticking motion. Consequently, you're simply not penetrating deep enough. The bevel is in, but the Teflon has not yet cannulated. So even though you're getting blood flow, the leading edge of the catheter is outside of the vein, and in fact is pushing the vein away as you try to advance it.

In the martial arts, we teach not to punch or kick at your target, but to punch or kick through your target. This same technique is also an essential part of a successful IV strategy.

Don't push the needle to the vein. Quickly shove it into the vein. The cannulisation should be accomplished with your first motion, at the same time you are pushing the needle in. Then your second motion is to bury it to the hub. And at that point, it shouldn't be any trouble.

[spenac]

One should feel the vein more than see it. In theory you should be able to start an IV in a dark room. I found that while doing my assessment I will feel for veins while talking to patient and not looking. When I feel a good vein then I will look but in fact could do w/o looking. Sometimes because knowing where the veins should be I can palpate a good one yet not see it and that is where I go. I leave the AC for last resort in most patients. The forearm has one of the straightest veins, limited valves, is not positional, and it is usually big but is hidden in many patients so you will have to rely on touch not sight. I have found when I rely on my eyes to find the vein I miss more often.

Kind of like Dust said don't be easy just place it. Remember it doesn't hurt you and if they need an IV the brief pain they have is a justified means to an end.

Edited March 31, 2011 by spenac

[emtcutie]

Thanks this has all been really helpful. My next shift is saturday in the e.r so i will put this to use.