IV tips and tricks

Most people don't realize or even think about what's on an IV catheter. When you're removing it, there's probably few days worth of biologic detritus coating that catheter. When you remove it, putting pressure on it would strip the catheter of all that schmutz and expel it into the patient. Additionally, there is a real danger that if the person who put in the catheter had partially transected it, putting pressure on removal may complete the transection and you'll have a catheter tip embolus (in this case apply tourniquette right away, then call for help).

Elbow, or antecubital vein IV's have be a patient's bane of existence since the invention of IV's. However, in the emergency setting, it is absolutely the best place for the following reasons:

1. it's not a long term solution, so it's no big deal
2. it's a big vein, it allows for good blood draws at the time of insertion, allowing for one stick does all.
3. it's a big vein, good for variable required rate contrast injection.
4. it's a big vein, meaning it's normally a size 20ga cath, allowing blood transfusions.
5. it's a big vein, meaning you can't miss.

For the few hours of inconvenience in the ER, it is by far, the best site, bar none.

Ralph

Good answer our facility they only require a #18 in AC for ct chest otherwise they are ok for #20's on CT's elsewhere. Per our CT tech: The reason for the #18 angio for a CT chest is that they shoot 120 cc at a rate of 4cc/sec over contrast is 115 cc at 2cc/sec in less then a minute. If you do not have a big vein and a big needle the pressure can blow the vein.
My previous facility in the ED,except in a code the only time you can use the AC is for a chest CT, and after 3 failed attempts anywhere else. they reccommend you start on the hand or wrist first. When you do use the AC you must document why because the IV will report you and you will have to explain otherwise. (do not think I agreed with this in the least I just had to follow protocol.)

I can only add my 2 cents, but these are a few things that I've picked up in the last couple of years that have made it so much easier for me.....
-On the little old ladies with extra skin, hold it taut! I have so many students who have problems with those IVs, simply because they don't pull the skin.
-If you absolutely must go for the AC in a kid, have your holder put one hand on the forearm and one on the upper arm, and pull back a little. Not enough to hurt, but it keeps the kid from rolling his arm.
-We had a 21 m girl last week who had great veins, but was the strongest 21m old I've ever seen! We tried to let mom hold her, but the kid was coming off the table and was still able to pull her hand back, and she d/c'd her line. We finally decided to bear hug her, and have someone else hold the forearm. (Does this make sense?) It worked like a charm.
-I second the trick of advancing a little more on adults after you get your blood return - that way you can be sure the needle is in the vein instead of just nicking the top.
-Advancing with the needle in (but not all the way) helps you get through valves; also the saline flush trick.
-On peds, I've found it is best to go low and slow. Once you get that blood return (which may be just a drop), pause, take a breath, and then advance your catheter slowly. For some reason, that little pause helps to not blow the vein.
-When a parent tells me I "only have one stick" I smile and say "Thank you for telling me that" (as long as they are not mean about it) and excuse myself for a moment. Step outside the room, take a breath, and then go back in and stick. Half of peds sticks is mental, and having all that pressure on you makes it ten times worse.
-I also lay down ground rules with parents as I'm setting things up. Mainly, I welcome parents in the room, but they need to conduct themselves in an "adult" manner. I ask any other family members to leave (grandparents, siblings, family friends, etc) unless they seem to be huge support systems for the parents/child. I welcome the child to be held in mom/dad's lap IF they can keep a good hold on the baby. Otherwise, I don't ask parents to be my second holder - i.e. holding the kid down on the bed; I hate the idea of a kid feeling this pain and looking up and to see his mom holding him on the bed. I also don't mind if parents want to stroke the kid's head or hold the other hand, but the second they're in my face or causing more drama, I ask them to sit or step out. Mainly, they need to facilitate, not hinder.
-On the same note, if mom/dad is going to step out for a procedure, make sure they go to the WR. I've come out of a few rooms to find a parent in tears outside the room - they stood there and listened to the kid screaming and crying, and instead of seeing what was happening, they imagined it - which is always so much worse!

These are just a few things I've picked up. I'm nowhere near an expert, but they've helped me out a lot.
Great thread, I've learned a lot!!

Something else you can do is have an assistant place one open hand under the elbow and push the elbow up and toward the body with the palm of their hand while their other hand takes the wrist and rotates the forearm outward and into a position of pronation (with the inner part of the forearm facing upward and slightly out). They have to be gentle and not very aggressive as they could injure the joint. This puts the arm in hyperextension and locks the elbow very much like a splint would do so the arm isn't going anywhere. It also gives the person doing the sticking excellent access to the antecube.

Like the bear hug solution for squirmers!

this is a very helpful thread.

Yes THANK YOU (former Heroin addict here who really does know which vein is best to use ) sorry I know that tip was given a while ago but I just had to concur with it. A number of times I have had a Nurse or a Doctor who need to draw blood or give medications to me IV and I tell them which vein to go into and they ignore me completely, pick a different vein and then end up rather annoyed and embarrassed when they have trouble and return to the initial vein I first pointed out.

Thanks for reviving an old thread. Just in time for my venipuncture lab coming up.

I also thought it was called the "interns vein"


There's also often a rarely used vein on the back of the forarm - you end up like standing on your head practically to insert the IV but its always a good place to check, often overlooked.

For tough IV starts, there is always the "wing and a prayer" approach that often works for me, and many other ER nurses I know. But, for REALLY tough sticks, we often now use our bedside ultra sound machine. It works great!!!: Find the vein, keep the probe over it gently and watch the screen while you guide the cannual into it.

Everytime I'm ready to say I've seen the whole of this site, I find a gem. Thank you for starting this thread and for the wonderful advice I've read so far! I cannot begin to say how greatful I am. I'll be starting IV's this semester, and though I wasn't freaking out just yet, I have found some easier techniques that will help me to probably not freak out at all. Thanks again!!!