tips and tricks for difficult IV starts?

[amzyRN]

My IV skills have improved a lot. My timing has improved too about 3 minutes to establish IV access and obtain labs. For me, that's a big improvement. I still have a hard time if someone is difficult. I don't mean the impossible, like the IVDU with no veins. In those cases we get a PICC nurse to do it with ultrasound or EJ or IO. What about the in-between cases, fragile veins with lots of valves. Veins that hide under tendons. Infants where the veins hardly show (I try to go in the hands now but most of the time I have to get someone else)

I want to get really good with my IV skills. I enjoy that part of my job a lot.

[chul_soo]

In the pediatric world, IV lights (Vein finders) are the go to option. US is slowly starting to creep in.

I only got better by watching other people better than me and by doing them myself. When at all possible set everything up because toddlers can be a hand even with a good holder... I also use a LED flashlight as my vein finder. From neonates to small toddlers, I'm able to see veins in their hands. I did a little demo and posted it on YouTube.

PSA: Never use an otoscope! They get real hot and cause burns.

[isis07734]

If ppl keep coming to you saying I got a flash or I got it! But it blew.. lessen the the turniquet pressure.

[RobbiRN, RN]

Along with the really good advice listed above, two last ditch tricks for me are:

1, raising the stretcher, letting the arm hang over the side, and soaking as much of the hand and forearm as possible in really warm water for about 5-10 minutes. This is time consuming, but it is way more effective than a simple warm pack and it softens the skin. Take a look at your own veins before and after your next warm bath.

2, Try looking at the shoulder area just above the armpit. Most people don't go this high and the veins are often close to the surface and in good shape. I can almost always get a #24, sometimes up to a #20. You can you use your left 4-5th fingers for slight pressure proximal to your site to get back pressure into the vein or sometimes pull the sleeve up on the gown and twist it for a tourniquet. Let the patient hold it if they are able to help, freeing both of your hands. You need to stabilize the surrounding tissue well. These tend to depress into the soft tissue and spring back when you get through the skin making it easy to go through them and out the backside. A shallow, slower entry improves your success rate in this region.

[iluvivt, BSN, RN]

I do not believe that US will be the gold standard for accessing veins but rather another tool in the orificenal.I have been placing IVs for 38 years now with most of them by visualization and palpation and a lot of tricks that I have learned and invented to stabilize veins.USGPIVs still have a high failure rate with almost 50 percent of them failing within 24 hrs.Mine ,started the traditional way last significantly longer. I can always tell my co=workers who had the shift the day before me because I spend all day restarting US IVs.These are very experienced nurses.They fail for a variety of reasons and even when we think we have corrected the factors that contribute to this our failure rate in the first 24 hours remains high. I still want it in my toolkit but I will only use it on rare occasions.Granted,I am known for my talents in placing PIVs when noone else can get it and I learned at a time when all you had was your palpation skill,aiming skills and stabilization skills so I understand the need for US.The other issue with USGPIVs is that by the time an infiltration or extravastion is detected it is very advanced.

[Guest374845]

We've published that failure rates decrease as IV length increases. When we go back and QC USGPIVs placed in our department in patients who are still admitted, they're often still being used beyond 4 days because they still flush and draw back and no other access is obtainable. If your failure rate is truly that high, your program really needs to be reevaluated.

[iluvivt, BSN, RN]

We do use longer catheters.We have 1 3/4th inch and 2.5 inches.They still fail in fleshy areas. That is why I use the cephalic vein if I can't get it by palpation as I get a longer dwell time on the ra5te occasion I use US. Our nurses all have 20 plus years as IV clinicians.

[SoCal Nurse]

3 minutes is just fine. Take it slow with the harder cases, better to take an extra minute and get it in than not. If you don't get flash, just stop, take your time and go real slow while you "fish around". I always ask my pts' where the best place is to go. Position that arm low and heat it up with a few warm packs wrapped in a warm blanket if possible. If there is no latex allergy those wide penrose drains make EXCELLENT tourniquets, and you can always inflate a bp cuff to 30 mg pressure (many auto cuffs have an IV setting to do that). In short, take your time and go extra slow, ask, heat and position, tight tourniquet, and oh yeah, an Accuvein is great if you can get one.

[offlabel]

Ultrasound

[offlabel]

USGPIVs still have a high failure rate with almost 50 percent of them failing within 24 hrs.Mine ,started the traditional way last significantly longer. I can always tell my co=workers who had the shift the day before me because I spend all day restarting US IVs.These are very experienced nurses.They fail for a variety of reasons and even when we think we have corrected the factors that contribute to this our failure rate in the first 24 hours remains high. I still want it in my toolkit but I will only use it on rare occasions.Granted,I am known for my talents in placing PIVs when noone else can get it and I learned at a time when all you had was your palpation skill,aiming skills and stabilization skills so I understand the need for US.The other issue with USGPIVs is that by the time an infiltration or extravastion is detected it is very advanced.

The closer the tip of the catheter is to the point at which it entered the vessel, the sooner the IV will fail. Your u/s guided IV failure rate is because the veins that are being accessed are too deep for the catheters being used and the tip is too near the venipuncture site. For deep IV's you need very long catheters. I use a 10 cm femoral artery catheter but an extra long angiocath or whatever works too.