IV tips and tricks

veetach · Jul 5, 2004

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

I guess its all in the technique. I draw blood through 22's numerous times in one day and I have not had a hemolized specimen in over a year. If the patient is in danger of bleeding out, then we use larger bore (18's at the largest), and usually 2 of them.

I can give blood through a 22 in about 3 hours. I can also give D50 through one, without problems. IMHO if anyone puts a #18 or larger IV in me because I came in with abdominal pain, I would throw a fit!!!

All I am saying is, the trend (at least in our area) is away from the huge IV cannulas. Its worth checking out. Our hospital spent a lot of money on the study.

IBigger is not always better.

veetach · Jul 5, 2004

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.

Please dont generalize. "Giving blood through a 22 guage catheter is one of the most assinine things I have ever heard." How often do your paramedic students hang blood in the field? If you are going to hang blood to run over a period of less than 4 hours, you can do it through a 22. If you are going to pressure a bag in, obviously you would need a bigger catheter.

I think the lesson here is to determine the need. Not everyone needs a huge IV.

critcarenurse16 · Jul 6, 2004

A friend in nsg school had trouble remembering where her veins were once she had rubbed the site down with the alc pad, so our clinical instructor taught her to pick her vein, pick out where she is going to insert the IV and take the end of a skinny ball point pen (not the marking end) and make an indentation at the site (not enough to hurt the pt...), then clean. The indentation will stay long enough for you to stick. Good trick for beginners.
I clean the site with the alcohol pad then leave it on the site. Once you're ready to stick it remove the pad, let dry for a few secs and go.:)

tinytoons · Jul 7, 2004

oh, and if a heroin addict says "thats not a good vein" , they are right.

i agree... even with some patients like the sicklers, you should believe them when they say "that's not a good vein, try this one.."

flashpoint · Jul 7, 2004

ALWAYS listen to postitve advice like, "They usually have good luck with the one in my left hand." Take advise like, "They always have to call anesthesia to start me," with a grain of salt. I've been successful with a lot of "anesthesia starts."

I like to stick just above a bifurcation (sp?) because it provides a bit of an anatomical anchor.

Look and FEEL...don't just look...it's amazing what you can feel, but not see.

Don't tie your tourniquet too tight on patients with big ropes...you'll risk blowing the vein.

When you don't succeed the first time, try sometime different the second time...change arms, try a smaller cath, move the tourniquet higher or lower...

BTW...I learned on 18s and 16s...can't imagine using anything smaller for a patient who needs blood or a bolus or D50...

PA-C in Texas · Jul 9, 2004

I think the lesson here is that you need to guard against what you don't know. When someone walks into the ED, you don't know what is going on with them until you perform a physical exam and review the appropriate diagnostics. That generalized ABD pain could very well be an atypical presentation of a dissecting aortic aneurysm. Then how are you going to get a large bore cath when they have ruptured and are clamped down so that their antecubital fossa veins have magically disappeared? Are you going to be frantically calling for someone to come start a femoral while the patient crashes through the basement? Taking reasonable steps to prepare for the unexpected is just something that is appropriate when you don't know.

It might be appropriate for smaller guage catheters to be started in non-emergent settings where a patient's condition has been better defined.

Someone mentioned using a bifurcation as a natural anchor. I like to go in right below the bifurction and hit the vein where it splits rather than going on top of the vein. You might have to advance the needle slightly further to get through some valves, but its a pretty sure bet.

Sadie04 · Jul 9, 2004

[Q

Someone mentioned using a bifurcation as a natural anchor. I like to go in right below the bifurction and hit the vein where it splits rather than going on top of the vein. You might have to advance the needle slightly further to get through some valves, but its a pretty sure bet.

I agree, I almost always have success when I go in below the bifurcation

:)

mother/babyRN, RN · Jul 9, 2004

We had to learn how to put in an iv with the lights out in the room so you could feel the vein only...Interesting...I still turn on the lights...Also, if people remember granulex or the spray used for decubitus ulcers to increase circulation, that also helps...With autogard brand ivs catheters, you will not feel the pop we feel or felt with quick caths...I agree, so what if a topic has been discussed before. If it is an opportunity for learning, go for it....For my warm compresses, I place a heated face cloth or towel that has been warmed in the microwave or wrap it in a chux as one would for an iv infiltrate and leave the hand down....That usually works for me..AND, as has been said, if someone with bad veins or who is a difficult stick, I believe them...Even in labor and delivery where large gauge ivs are preferred, if I think I will miss with an eighteen I will go for a twenty and, by the way, for those of you using the autoguard brand, their twenty gauge is the size of our old eighteens..AND, if someone has difficult veins, the larger gauge needle can cause more damage, and I speak of autoguard because we use them now....So, I had to attend a conference...

mother/babyRN, RN · Jul 9, 2004

Actually, through the autoguard, blood runs as well as an eighteen or more....

mother/babyRN, RN · Jul 9, 2004

A lot of times blood "Hemolyzes" when the lab takes awhile to get to it....We hand carry our specs to the lab on babies or absolutely needed draws...Somehow they NEVER hemolyze then...And , if it is between four or five sticks or a perfectly good twenty gauge, I am going with the patient rather than the anesthesiologist preference. Unless of course, we need two sites or things are more serious....The patient comes first.

Calfax · Jul 13, 2004

My 20 yen......if a 22 g is all you can get, then use a 22g gage. Run in a little fluid then try again with a bigger needle. If you really need a largebore IV and they have no good access, I frequently have success with an EJ stick. But check with your department guidelines about putting one of these in first.

EJ's are really simple to do. If the patient's condition allows it, stand at the head of the bed and turn the patient head to the opposite side of the body where you want to place the EJ. This will flatten out the neck area making it easier to see the external jugular (or if you're in Michigan, the external "juggulo".....you down with the :clown: ?) Locate the external jugular (this is a fairly shallow vein and may or may not be distended depending on a variety of factors). It crosses the sternomastoid in the superficial fascia, traverses the posterior triangle and then pierces the deep fascia to enter the subclavian vein in the chest.

Again, if the patient's condition allows, placing the pt in trendelenburg position can distend the vein, making it more visible. Prep the site and insert the needle towards the heart. Then do the "dirty bird" cause you got a big ole line in that patient!

Now as far as getting lines into people, nothing' worse than spending an hour to get a good line and have the patient pull it out. What do you use to secure the site? Veni-gard? Op-sites? IV-loc? A big patch of tape?

What kind of splints do you use on pediatric patients? My hospital's kinda low-budget so I'm currently using the 3 popcicle and 4*4 guaze method and securing the whole mess above and below the joint/IV site with tape.

This was previously posted on an old thread too, but worth mentioning....you can use a little local anesthetic, buffered lido or EMLA cream to numb the pain of the IV stick and your patient will be very grateful for it.

Calfax · Jul 13, 2004

My hospital's kinda low-budget so I'm currently using the 3 popcicle and 4*4 guaze method and securing the whole mess above and below the joint/IV site with tape.

popcicle = tongue depressor, ahem.