AC IV starts

Specialties Med-Surg

Published

I need some advice or tips on AC IV starting. As a floor nurse I rarely even try to use the AC vein do to patient comfort or depending on the patient some never keep there arm straight. But there are some times when you really need to have an AC IV and sometimes I have trouble with them.

I would say I am actually pretty good/decent at starting ivs and I am successful a good amount of the time. I usually start them in the forearm- just seems to always be my go to spot. I don't usually like the hand or wrist because I feel like they can be easy to loose depending on how much the patient is moving or how orientated they are.

I know the AC is the biggest vein and seems like it should be easy to get but the few times I do actually try there I seem to miss them way more than when I use the forearm for some reason. I don't know if I just need more practice with them to get comfortable. But I have trouble deciding where to start my stick because at times I feel like I feel different veins going in different directions in the AC. I also don't know if I'm going in at the wrong angle.

Any tips from more experienced nurses or ER staff that do more AC insertions?

Thanks

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I am not that experienced but I have had a lot of success with the teaching I received from several experienced ER and ICU nurses.

Basically what they showed me is approach at a 45 degree angle, once you receive blood return stop and advance the catheter. I have seen a lot of nurses that like to insert a large portion of the needle before they start advancing the catheter and I think that is what causes many failures on attempts that would have otherwise been successful.

For me personally I deal with a lot of patients with DTs and so getting a good line for ativan push is imperative. I have found the best places the start lines are not the AC per se but there is usually a good vein to the left or right of the AC. My absolute favorite spot is the bicep. I'd say about 50% or more of patients have a nice straight vein running up the bicep. That is my go to spot for anyone on restraints.

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Specializes in Oncology, Ortho/trauma,.

make sure the arm is completely straight have their arm hang off the side of the bed or prop their arm on pillows for a more angled attempt. once you grip the arm and pull skin taunt with the non sticking hand keep it there and don't move the arm or the veins position will move. They are deeper than the FA. make sure you are using an appropriate gauge needle for the size of the vein, practice practice practice!

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By referring to the "AC" keep in mind that there are actually several vessels there and many times, is not the largest vessel, just a shallow larger vessel.

Vessel variation in patients can be astounding but typically the "AC" vein is the median cubital vein. Often times this vessel will present at a significant angle. Using large-bore catheters will often compress this vessel prior to puncturing the vessel, by the time you puncture the vessel your bevel has actually gone through both walls and in buried in the opposite wall (ever get blood return but can't advance? This is why.)

When inserting the IV imagine you are inserting into a straw. Puncture the vessel and then immediately drop the angle of your catheter and then advance.

The vessels within the AC area tend to be heavily used and typically have a greater than normal build-up of scar tissue. The more scar tissue will result in a greater resistance and then a greater chance of over-penetration. This is most likely why the OP does so well with (lightly used) forearm vessels.

Take a table straw, tape it to your desk and attempt to insert an IV into it. You may find that the same motion as the "scoop method" that was taught for recapping needles may actually help you cannulate these vessels.

Asystole RN, CRNI, VA-BC

Vascular Access Nurse

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Thanks for the tips.

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Just started an AC line today that made me proud. It was a restrained alcohol withdrawal patient. I found a fat vein just above and slightly adjacent the AC, at the base of the bicep. I had just started to stick the patient when another nurse came in the room. She saw the patient (agitated alcoholic) and what I was doing and started putting on a pair of gloves. As she was donning her gloves I struck gold and retracted the needle. Blood started flowing like a midsummer fire hydrant despite my fully depressed thumb on the catheter.

Her reaction was priceless. "oh my god. are you sure that's a vein [as opposed to an artery]? If he pulls that out he is going to die [bleed to death]."

That feel was priceless.

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Specializes in Hospital Education Coordinator.

as a former Pedi nurse I rarely if ever accessed the brachial or apical veins near the AC. forearm was preferable except for infants, and then I accessed the scalp vein (forehead). Kids just use their arms too much

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Specializes in Pediatric/Adolescent, Med-Surg.
Just started an AC line today that made me proud. It was a restrained alcohol withdrawal patient. I found a fat vein just above and slightly adjacent the AC, at the base of the bicep. I had just started to stick the patient when another nurse came in the room. She saw the patient (agitated alcoholic) and what I was doing and started putting on a pair of gloves. As she was donning her gloves I struck gold and retracted the needle. Blood started flowing like a midsummer fire hydrant despite my fully depressed thumb on the catheter.

Her reaction was priceless. "oh my god. are you sure that's a vein [as opposed to an artery]? If he pulls that out he is going to die [bleed to death]."

That feel was priceless.

As an ER nurse I can say that there are plenty of times that you are in a big juicy vein, or you are using an 18G or larger that it can be hard to fully clamp off the catheter. I have developed a trick of putting a 4x4 right under the catheter if I anticipate this happening, so that there is no mess.

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Specializes in Emergency Department.

I'm a Paramedic. I've used the veins in the AC area many times... however, that's actually not my favorite place to start a line. One big tip I have is to palpate the veins and actually trace their path up and down the arm from where you think you'll insert the needle. This way you know where that vein actually goes, not just where you can see it. The "scoop" method is pretty close to what I do, only I make it into more like a 3D S curve. Just to keep from puncturing both walls, I normally puncture the skin just off to one side of the vein, opposite where I'm pulling a little traction on the skin as described above. This is done using the scoop method just so that I get under the skin and I've flattened out the angle so that I'm not going any deeper than I have to. Then I angle the needle toward the vein and using the same scoop movement, just in a different plane, I puncture the vessel and enter it while "shallowing the angle", watch for the flash, pause, advance if necessary another 2-3 mm and stop. At that point, I advance the cath into the vein. Then I put my 2x2 under the hub to catch any drops of blood, make sure my IV tubing is very close by, put a little pressure right at the tip of the cath (not on the tip), pull the introducer needle, safe it, grab the IV tubing and insert it into the hub in one smooth movement. Normally, I'm able to contain blood loss to just two drops.

After that, it's just a simple matter of securing the site. My disclaimer: I haven't started a line in quite a while, but I still remember how to do it. When I'm let loose at IV starts in nursing school (that module comes in a few months), I fully expect to be a bit rusty at it, but hopefully I won't be too horrible at first! ;)

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I think the biggest mistake people make is a 45 degree angle… I'm an ER nurse so I start IVs all day long in ACs, and I will typically go in at a 30 degree angle. If I use a hand, I almost scrape the skin getting access (and typically with forearms). The AC typically has good veins and you should be able to feel where they go. If you feel it going sideways, stick sideways. I've had plenty of AC IVs that are basically pointing towards the pt's body. I see the new nurses are EMTs in training go straight up with their needle no matter what way the vein is going. And their biggest issue is almost always the angle. I drop down the angle of the needle AS SOON as I get a flash back. If for some reason you go through, pull it back. Fish a bit. I've initially missed plenty of IVs in the AC but I know that thing is in there and find it. Also, a lot of times you need to pull up a little on the vein with the needle to feed the catheter in. It seems to happen more in the AC than in other areas… I think just from hitting the wall of the vein, that'll help open it up.

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One big tip I have is to palpate the veins and actually trace their path up and down the arm from where you think you'll insert the needle. This way you know where that vein actually goes, not just where you can see it.

This ^^. You may need to go kind of sideways. Some people's veins don't really run up and down. This way you know the angle of entry.

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Isn't an IV on the antecubital incomfortable?

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