I am trying to give saline IVs to a patient with delicate veins that are difficult to begin with -- but I insert either a butterfly needle or a catheter, get flashback, advance the needle, and the IV starts just fine -- but then stops after only a small amount of the saline goes in (first the drip slows, and then it stops). A couple of times it was obvious the needle blew out of the vein, but the other times, the drip just stopped with no explanation (and the tubing, bag, etc., were all fine upon removal). I don't know what I'm doing wrong. Can anyone tell me possible scenarios where this would happen, and fixes? I'm trying to learn -- thanks.
Jan 5, '14
How old are your pts? If they're geri, might you be in a really sclerotic vein?
And I don't mean to offend you (as I have REALLY seen this happen), but you did remove the tourniquet, yes? Seriously, I've been there, done that! And boy, did I feel DUMB! In the excitement of getting the flash, I started threading and advancing and forget the tourniquet...
Jan 5, '14
1. Get the vein as full as possible bfore the venipuncture. Use a medical warm pack. In the elderly or with fragile veins a tight tourniquet is not the best way to go..better to fill the vein up with dependent positioning and heat.
2. Use the smallest cannula that will meet your needs. If the vein and or skin are fragile you can try a bevel down stick to minimize a through and through puncture.
3. Hand Flush with a prefilled NS syringe. Use more if needed until you are certain it is not infiltrated. I have trained my fingers so that I can feel the flush going into the vein. I place all my fingers along the course of the vein starting at least from the length of the catheter. So if the catheter is one inch long I place my fingers from 1 -4 inches above the insertion site and flush. It requires a very light touch.
4. Are you infusing by gravity? If so the line could just be backing up with blood and clotting off!
5. If you are in the vein and have had a successful stick it would not just STOP for no reason. I suspect that you may be placing the IVs in anatomical locations that allow you to administer a certain amount of IV fluids that may make it difficult to detect an infiltration. I think they are infiltrating and then when the fluids builds up in the tissue enough it stops or slows. This is not always the case though and you can have a large amount of IV fluids infiltrate,even by a gravity system. You may also have a mechanical occlusion or a combination of both. What sites are you choosing and do you see a pattern so I can help you with more directed advice. Give me more detail,,how long does the IV run for and are you flushing before you hook up the bag?
6. Looking at the tubing or bag is not going to tell you much because the problem is at the insertion. You are no longer in the vein,partially in the vein or it has become occluded. Run through your exact technique with me in as much detail as you can and I can pinpoint what the problem is and then I can assist you more specific help. it is critical that you properly assess whether you have a successful cannulation before you proceed and that comes down to proper technique, skill and assessment.
Jan 7, '14
Hi there, thank you both for your helpful replies. The patient I'm referring to in particular is receiving IVs at home, and is bedbound and very frail, with cold extremities, arguably poor circulation, but not geriatric -- just someone with poor veins who has had a history of infusions and blood draws so those could have resulted in issues. Yes, I'm removing tourniquet, though I can't say I have never made that mistake : ) I may be tightening it too much based on what Silver said -- I also have not tried doing bevel down so can try that. These are simply slow drips of regular saline, so nothing exotic, and I am doing weekly in-home drips as a private nurse per doctor's orders to help hydrate patient and improve hypovolemia issues, so am sometimes using butterfly needles (I am using 23 or 24G or else the same gauge in cannula for a longer drip. I am hooking up the bag immediately, and generally the patient is not getting multiple bags but if so, flush between bags. I have not been hand-flushing with a syringe since the hook-up is immediate, but that is also a helpful suggestion. I have been warming the site but that has not helped much. Any other suggestions definitely appreciated but these already are useful things to try. Thanks!
Jan 7, '14
If this pt is a chronic, long-term client and is expected to have continued IVs and labs, might an infuse-a-port be worth the consideration? Permanent long-term access that makes things easier. And just routine maint care.
I would consider one for myself or my family if the need arose.
Jan 7, '14
Yes...... I was just going to say you need to call the MD and tell him or her that you can no longer can obtain venous access due the poor quality of his veins and you need an implanted venous port placed (be assertive). Many do not know the problems we face and just keep ordering IV therapies not realizing what we face and what the patient goes through. In the meantime you need to flush after you place it to verify patency every single time. You think you are in the vein and hook up the IV fluids and they drip awhile and then stop because you are not in the vein or never was so it is critical that you check this before you add the fluids and the way to do this is with the flush and proper assessment. If you are using the ACF area you may need to flush more since there is a lot of space for infiltrated fluids to go before you may notice an infiltrate.
Jan 14, '14
Checking placement of the PIV is important for many reasons, for you do not want your pt to have an IV related complication. Continuous long term sticking also puts pt at risk for an infection. Talking to the Dr. About a tunneled picc or a port could benefit the pt in this situation and less likely for infection in our long term pts.
Jan 15, '14
try a BP cuff upside down and inflate to just below the level of the diastolic...then crimp off the tubing with a kelly clamp so it stays inflated ...plan to release immediately after you have threaded the catheter . This is because it really distnds the vein and while you are advancing after hitting the vein and then threading the remainder of the catheter all the while some blood is leaking from the insertion site. So you have to be efficient and somewhat fast if the veins and skin are frail. You may see a bit more brusing at the site if you arre slow and only inflate the cuff as much as you need to access the vein.