IV insertion issues

  1. 0
    Hi all, I've been working in NICU for about 8 months now and I'm having issues with starting IVs.

    It usually goes like this: Insert, see flashback right away, remove needle, no more flashback, try to adjust catheter to get flashback again, FAIL.

    Or: Insert, see flashback, remove needle, attach flush, flush, VEIN BLOWN.

    It's usually the first scenario. Can some of you experienced nurses and IV insertion superheroes troubleshoot what exactly is happening when I get a flashback and then lose it? I've tried IVs with and without using a "tourniquet" aka rubber band, but that doesn't seem to make a difference. Any tips will be appreciated, thank you!
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  4. 15 Comments so far...

  5. 3
    What size cathalon are you usually using? I found that the smaller needles were wayyyyy more likely to give me a "delayed" flashback, and by the time that thick blood made it down to the chamber, i'd actually already gone through the vein, but, like you, i'd think, "Great, i am now IN the vein, there is my flashback"
    when it was just the delayed flashback which occurs more often with teeny tiny needles.

    Go up a size, see if that helps.

    some other things i found helped make IV's easier,
    include
    keeping a conversation going with patient, at all times. This keeps patient and you both relaxed. Interview the patient, find out what he is interested in, and act fascinated by that, learn from him, keep asking question on whatever it is that he is interested in. I am very good at getting people to talk, even quiet people, and lots of times, the person is so engrossed in saying their answers, as i am taping the IV in, they exclaim, "wow, that didn't even hurt!" cuz i used the most powerful of all meds----DISTRACTION.

    For hard to get pts, get a "chuck" (those blue bed liner squares, plastic on one side, papery on the other side). Lay the chuck with plastic side up, under the pt's arm. Do both arms, is not a bad idea either.
    Get a warm to almost hot wet towel, squeeze out excess water, wrap arm in that wet super warm towel, then wrap that chuck over the wet towel. Tape the chuck in place.
    Tape the ends very well, or use extra chucks or towels, or you'll end up with a wet sheet.
    ask patient to open/close fist off/on while his arms are 'soaking'.
    Put HOB up, if no contradictions to that.
    Find something to do for 5 or 10 minutes.



    Unwrap arm. Now, the chance the veins are bulging is increased.

    also, my own personal pet peeve about IV starts, is, never ever slap an arm, that drives me nutz to see anyone doing that. Not only is it useless, it hurts, it makes patient tense, and it reddens the skin so much, you might be obscuring visual cues.
    Instead,
    gently rub the vein, repeatedly, in downward way. INtermittantly, 'bounce' your finger on it, assessing how full it is, also helps dilate it.
    Keep running your finger down that vein, not only will that help dilate the vein, it helps you spot trouble areas like scars, curls, corners, hardened valves, etc. (THIS is when you begin your interview of the patient).

    Be a rubber, not a slapper, ha ha!!

    good luck!!
    Last edit by somenurse on Feb 11, '13
  6. 3
    Thanks Jean Marie! I actually work in Neonatal ICU though, so trying to have a conversation with a patient would only elicit a response like "Wahhhhhh!" LOL.

    I use a 24 gauge/0.56 length.

    About the delayed flashback, I guess you're saying that I've already gone through the vein when something like that happens? That makes sense.
    prmenrs, somenurse, and Luckyyou like this.
  7. 1
    Quote from champagnesupeRNova
    Thanks Jean Marie! I actually work in Neonatal ICU though, so trying to have a conversation with a patient would only elicit a response like "Wahhhhhh!" LOL.

    I use a 24 gauge/0.56 length.

    About the delayed flashback, I guess you're saying that I've already gone through the vein when something like that happens? That makes sense.
    OHhhh, yeah, with something as tiny as a 24gauge, oh wow, very hard to NOT go through the vein before you finally get the flashback. No wonder you are having this trouble. 24s are soo tiny, and blood is soo thick, that by the time you finally can see any blood in your chamber, you have gone through the vein. I was never that good at super tiny IVs, only thing i can think of, is advance super super slowly, thereby possibly increasing the chance,
    that when you see the flashback, you *might* still be IN the vein. Maybe going uber uber slowly might help.
    Advance a half of a centimeter, wait.....advance a half of a centimeter, wait....wait a good few moments, after each and every advance, give that blood enough time to display itself.
    Just sit there and watch and wait.....wait...count to 30 or something, after each advance, to make sure you ARE waiting long enough.
    yes, the coworker holding the arm will think you are nutz or spacing out, but, give silently counting to 30, after each and every advance, a try.


    With 24s, and sometimes, 22s, you will NOT get a flashback for some time....takes a while. So maybe waiting...waiting...advancing super slowly, might help you.

    good luck, i think 24s are THE hardest of all IVs to put in. It's not *you*, it's the bore you are using.
    Last edit by somenurse on Feb 12, '13
    champagnesupeRNova likes this.
  8. 0
    also, anytime you can get away with a 22 or even a 20 every once in a blue moon, do it. The bigger the bore of the IV, the easier it is to place an IV. (imo). I'm always surprised when i hear some coworker say something that indicates she thinks if a patient is hard to get, to use a tiny bore cathalon. I believe just the reverse is true.
  9. 3
    We always use 24's, on occasion 26 on a micronates or really hard stick. I don't recommend using a 22 or 20, even on most full termers that is big.

    It is hard to tell what you are doing without seeing it. Once you see the flash advance just a bit, take off tourniquet, take stylet out, advance catheter and flush. You can also try to float it in while flushing. We do have delayed flashbacks, but it doesn't mean you went the thru vein, remember a lot of these kids have high hcts, jaundice or low pressures. You should get some flash.

    Have the IV gurus watch and see what you are doing. It just takes practice and patience !
  10. 4
    @Jean Marie: Those are great tips for an adult pt, but it is very different for neonates.

    24g are standard, 26 for a baby <700 gm, very, very rarely a 22g only for a big (>4k) who doesn't have a high crit, which r/o most customers. We routinely give PRBCs via a 24g.

    Flush your catheter before you start-the blood will come back easier on the wet surface. If/when you get a flash, try to withdraw the stylet at the same time you advance the catheter. On some catheters, there is maybe 3mm of length between the tip of the stylet and the catheter, which is makes a big difference-the stylet can be in the vein, but the catheter isn't. If you've ever driven a stick shift, it's kinda like letting the clutch out and pressing down on the accelerator. I

    f you don't get a flash, you can try pulling the stylet back part of the way to see if blood follows. (W/the old Jelcos you could take the stylet out and replace it if you didn't get blood and try again, but the newer safety catheters, you can't do that.) If you see blood, advance the catheter while the stylet is still partially in the catheter; it's too flimsy on its own.

    Swaddle the baby well so you're not fighting extra arms and legs, have someone help comfort him/her if needed. Keep trying!! Even the best IV person has dry spells.
    rnkaytee, BNE103, champagnesupeRNova, and 1 other like this.
  11. 5
    What brand of catheter are you using? We switched to introcans so now I can take the flashplug entirely off and can get the flashback faster. Many products (cannulas) have a special feature as part of their structure that speeds up the flashback. What angle are you generally attempting your start? Are you dropping your angle to parallel to the skin and advancing your catheter a bit more after you do get a good flashback? If you can describe each step in detail I can tell you what step you need to improve, If I could watch you I could tell you right away so be as detailed as possible. The 2 most common mistakes are going in at an angle that is too high and the 2nd is failing to lower the angle after the flashback is seen and then advancing it a bit more before sliding the cannula off the needle and into the vein.
  12. 4
    If it makes you feel any better, I'm in my 3rd year in the NICU, and still (frustratingly) often have a hard time with IVs. Practice practice practice!
  13. 0
    Quote from NicuGal
    We always use 24's, on occasion 26 on a micronates or really hard stick. I don't recommend using a 22 or 20, even on most full termers that is big.

    It is hard to tell what you are doing without seeing it. Once you see the flash advance just a bit, take off tourniquet, take stylet out, advance catheter and flush. You can also try to float it in while flushing. We do have delayed flashbacks, but it doesn't mean you went the thru vein, remember a lot of these kids have high hcts, jaundice or low pressures. You should get some flash.

    Have the IV gurus watch and see what you are doing. It just takes practice and patience !
    Yes, that^^


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