18 gauge insertion

[Murse7]

Not sure if this is where I should put this, but I work in the ER :)

I'm pretty good at starting IVs with 20s and 22s, but for some reason, whenever we need an 18 gauge (vomiting, fluid loss, etc.), they never work (i.e. I never get a flashback). Is there a different technique you all use with 18s? Maybe my angle is too much...but is it that much different from the angle you use with a 20? It's just frustrating, b/c I have a really good vein, and I don't get it twice, and this has happened with 2-3 patients so far. Any help would be appreciated.

[vamedic4, EMT-P]

An 18 is a large bore catheter, and while it doesn't necessarily require a different technique...it can be too much for even people with "good" or "great" veins. Many times we may WANT to put in something that large but simply can't, our patient's veins simply won't hold up to the stick - especially if they're dehydrated, feverish, or in any other way physiologically compromised by illness.

From my experience, I have watched veins literally disappear once you insert the needle. I firmly believe that once there is trauma to the outer layer of skin - the body in many cases immediately reacts. This causes ..perhaps, vasoconstriction or some other vein "movement".and can make a target you had your sites on just seconds earlier - unable to be found. You hate to dig around but you find yourself doing so because you don't want to go through finding yet another vein and having to stick the patient yet again.

If indeed your veins are disappearing on you...try this: once you have the catheter in the skin, release the tourniquet for a minute if you can. Then tie it back and see if you can again palpate the vein. It's worked for me many times.

Good luck.

vamedic4

[AirforceRN, RN]

Physiologically I can't think about what the problem would be...especially if you aren't even getting flash. I would say maybe psychological? Personally, I think 95% of IV problems are psychological. I know if I miss 2 or 3 in a row, I'm screwed for the day but if I get the first 2 or 3, I'm set. Keep trying...be positive.

[BluntForceTrauma]

Pt's vein may just not be able to handle an 18GA IV, no matter how big and juicy the vein feels. Next time that happens, try a 20GA instead.

[rgroyer1RNBSN, BSN, RN]

I use the bp cuff you may try that, pump it up, stick, if the vein disappears, release some pressure on the cuff then pump it back up, has worked for me all the time. But then again your pt. just might not be able to handle an #18g.

[SDS_RN, RN]

I'm pretty good at starting IVs with 20s and 22s, but for some reason, whenever we need an 18 gauge (vomiting, fluid loss, etc.), they never work (i.e. I never get a flashback). Is there a different technique you all use with 18s? Maybe my angle is too much...but is it that much different from the angle you use with a 20? It's just frustrating, b/c I have a really good vein, and I don't get it twice, and this has happened with 2-3 patients so far.

Oh I'm so glad that I'm not the only one. I have a terrible time getting 18g in. Sometimes I work on SDS and they want 18g in and anesthesia will be p***ed if you put a 20g in. When I do the 18g's I can get flashback but I can't get it to advance completly so if there are any tips on advancing the 18g I would appreciate that as well.

[johnnrachel]

Physiologically I can't think about what the problem would be...especially if you aren't even getting flash. I would say maybe psychological? Personally, I think 95% of IV problems are psychological. I know if I miss 2 or 3 in a row, I'm screwed for the day but if I get the first 2 or 3, I'm set. Keep trying...be positive.

I completely agree!!!!!!!!! I try to go after each stick with the attitude... I WILL GET THIS STICK!!!!!!!!!! When I feel pressure from family watching or a constantly complaining patient I most certainly always miss!!!!!!!!:lol_hitti:hhmth:

[eandgsma]

I'm in L&D and all we use are 18g IVs. I feel like I'm going to break the needle with a 22! We are usually working with "healthy" pts with extra blood running through their veins so I don't really have any advice. I guess one reason may be that you are going through the vein because it is a larger needle than you are used to? As another poster said, it could just be psychological as well since you see a large needle as compared to what you are used to using. The others have posted some great advice though!

[greenjanell]

no matter what the patient is in the ER for, unless it is a child or otherwise completely unnecessary, i ALWAYS start with an 18G because then you get used to putting them in, and when the time comes that you actually need one (GI Bleed, Trauma, disecting AAA (which usually gets a 16G or bigger)), you have the ability and confidence to do it. I always tell the new ER nurses this because its practice for the real need. so keep practicing, eventually it will become second nature.

[VivaLasViejas, ASN, RN]

I'm just happy to know I'm not the only one who had trouble w/ 18G angiocaths. In my med/surg days I could get a 20 or 22 in almost anyone, but 18s were troublesome for me and I remember being successful with only a few of those.

That's what I love about allnurses---I'm always learning something new, even though I'm a 'used' nurse!

[Djuna]

I must be a weirdo because I have no problems with the 18g and I miss them with the 22g. 20g is a no brainer so I usually go for that size unless I really need a bigger cannula.

[Nacki, MSN, NP]

I used to have the same problem with the 18 gauge. I found that it really was a simple solution once I figured out what the problem was, another nurse pointed it out to me...

For some reason when they manufacture the 18g the cath seems to be stuck and won't advance and will blow the vein. When you first open up the package twist the cath around the base of the needle and then insert into the vein. It works everytime.