IV tips and tricks

thanatos · Jul 4, 2004

Nurses eat their young is ad nauseam- seems like you have it down pat though?

Easy there. All I am saying is there this has been discussed numerous times. Every few months someone posts requesting tips on IV starts, and I was just pointing the OP toward a gold mine of information. I have posted on some of those previous threads and was attempting to not repeat myself or have others do the same.

veetach · Jul 5, 2004

any patient, and i mean any patient who has even the slightest chance of being a surgical patient, be it an AP or abd pain or trauma, should have a large bore iv 18g or less. the anesthesiologist will put a second larger line in if you dont.
anyone receiving anticoagulant clot busting therapy like TPA or equivalent should have three lines, one 18 or 16 gauge for blood draws before the med is given. pop away.
even if you dont know what you are doing, try and make it seem like you do. be professional, dont let your hands shake, and read your patient. their eyes can tell you alot.
TIE THE TOURNIQUETTE TIGHT. DONT FORGET TO TAKE IT OFF!
good luck if i think of more, ill post it later.

I beg to differ about the sizes of cannulas listed above. It used to be a trend years ago to throw the biggest IV into the patient that they can handle. Not so anymore. Chances of phlebitis increases with increased sizes of IV cannulas.

I cannot imagine putting 16ga IV's into a patient in an emergency room. If this patient is a victim of multiple trauma or multiple GSW or stab wounds maybe. Usually those come in with larger bore IV's anyway.

Our hospital has now become very adamant about not starting large bore IV's. Even our pre op patients go in with a #20 in. I can give any med (including blood) through a #22 if I need to, and believe it or not. A #22 is the recommended size to prevent phlebitis. We use #20's for CTA of chest and cardiac caths, and sometimes you cant even get a #20 in them. Go with whatever you can get.

TraumaInTheSlot · Jul 5, 2004

I beg to differ about the sizes of cannulas listed above. It used to be a trend years ago to throw the biggest IV into the patient that they can handle. Not so anymore. Chances of phlebitis increases with increased sizes of IV cannulas.
I cannot imagine putting 16ga IV's into a patient in an emergency room. If this patient is a victim of multiple trauma or multiple GSW or stab wounds maybe. Usually those come in with larger bore IV's anyway.
Our hospital has now become very adamant about not starting large bore IV's. Even our pre op patients go in with a #20 in. I can give any med (including blood) through a #22 if I need to, and believe it or not. A #22 is the recommended size to prevent phlebitis. We use #20's for CTA of chest and cardiac caths, and sometimes you cant even get a #20 in them. Go with whatever you can get.

what if your patient drops their pressure? can u fluid resuscitate through a 22g? itll take at least an hour or two to get the liter of ns in.

if you draw blood through a 22g, it will hemolyze frequently.

i know, id rather have the large bore in me, until they had a diagnosis on whats wrong with me. always prepare for the worse when there is a vague complaint like cp or abd pain that can be one of a million things.

blood through a 22g? are you kidding? ive seen it done, but always after lying that the transfusion takes 4 hours when it actually took 5.

i respectfully disagree. ivs get phlebitic because they are in bad spots and the catheter moves in and out. id rather have a phlebitic patient than a dead one. 18g is not that big

Fergie · Jul 5, 2004

I am shocked that the thoughts have changed on IV needle sizes.

Old school maybe, I would never even consider giving blood with any thing but an 18 gauge or larger.

I would like to see more studies on this. I always go for a 18 gauge, don't even consider a 20 or a 22.

Maybe it depends on the acuity of the pt? Or as previously stated the policy of the hopital?

obliviousRN · Jul 5, 2004

For those older patients with the "rope" veins, I often find they blow when you use a tourniquet. We've taken to using a BP cuff slightly inflated (60-80) on these patients and haven't had a problem since. It's an excellent technique taught to us by one of our paramedics.

also works well on infants/toddlers too.

SmilingBluEyes · Jul 5, 2004

I may be an experienced nurse, but I am always thrilled to learn new things. You guys are so smart, and I am by NO means a venipuncture expert. I learned a couple things today....

presC. · Jul 5, 2004

hi traumaintheslot,

good advice! but i always experienced bulging of veins whenever i remove the needle on the cannula. whether g18 or 22? eventhough there's a backflow.

thanatos · Jul 5, 2004

Using a b/p cuff for your tourniquet is an excellent technique w/ veins that blow and also when you don't see anything. I've had veins pop up w/ the b/p cuff that didn't w/ the standard tourniquet. I'll take their b/p manually and then keep the cuff inflated a few points higher than their diastolic. Works like a charm...just make sure to check the pressure frequently, most of our cuffs have slow leaks. Although I don't use it myself, I've seen people use 2 tourniquets w/ good success.

Also, don't forget the basics: on hard sticks, wrap their arms in warm blankets, and have the patient hang their arm off the side of the bed. Make sure you take your time (if possible) when looking for a vein and don't forget the basilic vein hidden on the back of the forearm. In a pinch, don't forget knuckle veins and the inner wrist (my least favorite).

PA-C in Texas · Jul 5, 2004

When I used to be a preceptor for Paramedic students, I always taught them that a successful stick is most often the result of picking the right vein. Veins that you can see pretty well are usually thin and superficial. It's the veins that you can't see that usually provide the best sites. I am personally a big fan of the posterior aspect of the forearm. You usually cannot see those, but they are well-anchored.

My preferred back-up site for fluid resuscitation is the saphenous vein. Certainly not practical for long-term use but they will usually hold a 14 guage catheter.

As for catheter size, I always use an 18 or larger unless one cannot be successfully placed. Anything smaller is simply worthless in a patient who might need fluid replacement or blood products. Giving blood through a 22 guage catheter is one of the most assinine things I have ever heard. If they are losing blood, they could very well be losing it just as fast as you are giving it. And if you want to be stuck doing vitals every fifteen minutes for several hours, you can have it.

A 22 guage might be fine for a drip on the floor or in ICU. However, from the standpoint of emergent care, it is very appropriate to try at least an 18.

thanatos · Jul 5, 2004

agree w/ above poster about the size of the catheter. I almost always use an 18g on adults, sometimes 20g. I'll go w/ a 22g only if I have no other choice. the one time you start a small IV on pt because you're trying to be nice, is the pt that crashes on you or goes to surgery and needs blood. I'll use a 16g or 14g w/ bad GI bleeds and traumas. If you're concerned about the increased discomfort of the larger bore IVs (and you have time), first infiltrate bicarbonated lidocaine into the site.

catcolalex · Jul 5, 2004

I was taught upon my arrival to our SICU, that we do not put in anything smaller than an 18, there is nothing smaller even stocked routinely. i cant see any reason to even try to get by with some measly 22. if the pt only can support a little 22, then the pt may need a CL, at least in the ICU. Why waste 4 hrs to infuse 1L fluid bolus when the pt needs that liter in 10-15 min. 22's are for premies

presC. · Jul 5, 2004

thanks a lot for sharing that technique. i'm learning a lot and i'm enjoying...

:)