tips and tricks for difficult IV starts?

  1. 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.
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    About amzyRN

    Joined: Feb '07; Posts: 1,022; Likes: 1,028
    RN-Emergency Services; from CA
    Specialty: ED, Cardiac-step down, tele, med surg


  3. by   brownbook
    One trick an IVDU taught me (by the way, ask the IVDU where any available vein is, they know waaay better than you), but what one taught me was if you get in, but just a little flash of blood that stops, gently tap a finger on the skin on top of where the catheter tip is. Take your time, when, if, you start to get a better return of blood gently advance the catheter.
  4. by   Euro_Sepsis
    - 2 tourniquets (one up in the axilla, one at the wrist), creates more venous engorgement and pressure so you might feel veins you previously couldn't but also helps prevent going all the way through veins that are overly compressible.

    - vigorous scrubbing. Using a chg stick over a "meh" site to prep the skin (like before a blood cx) and really scrubbing for 30-60 seconds can inflame a superficial vein and make it easier to see

    - alternative sites. Palpate or run your fingers over the back of forearms and the ant-lateral bicep. Also the saphenous vein just in front of the medial malleolus and tracking toward the back of the knee. We tend to forget about the "out-of-sight" spots above the sleeves or on the posterior of the arm. That's another reason why I like a high tourniquet.
  5. by   Euro_Sepsis

    EJs. Inquire if your facility lets RNs put them in and see if you can get checked off. There are often times lots of EJs where there aren't any other veins.

    Basillic vein is skinny people. Put the tourniquet up in the armpit, lay them flat-ish and turn their arm out/palm up and see if you can see or feel the vessel that runs from the medial AC to the arm pit. Sometimes even the most fiendish junky doesn't know it's there. This is usually the preferred vein for a PICC or future fistula, so if it's a renal patient or someone with nothing else but who might need 6 weeks of antibiotics after they leave your care, choose wisely.

    A rare trick I've used with success more than once. Start a 24g in a tiny pointless distal vein, leave the tourniquet on and run fluids. You'll engorge a vein in the forearm or possibly AC that you couldn't previously see or feel. Watch carefully when you start a new IV in there because your flash will be mostly saline.
    Last edit by Euro_Sepsis on Jan 31, '17
  6. by   Nalon1 RN/EMT-P
    A warm pack and gravity on the back of the hand.

    I have used the 24g in the hand (thumb actually) and then run fluid with tourniquet on to get an AC to show up, just don't forger to shut the flow off when you're drawing the labs (don't ask how I know, you will only do it once).
  7. by   Euro_Sepsis
    ^lol hgb of 4 and na of 156?
  8. by   NurseHeart&Soul

    Great tips already given. Another completely different angle to consider are vein finders. (I have no partnerships with these companies). I personally found that using vein finders began to increase my understanding of the anatomical locations of veins, patterns among people etc. and helped with my confidence when I thought I felt or saw a vein but just wasn't sure. Food for thought. Good luck! It's a great skill to master.
  9. by   offlabel
    Quote from Euro_Sepsis
    - 2 tourniquets (one up in the axilla, one at the wrist), creates more venous engorgement and pressure so you might feel veins you previously couldn't but also helps prevent going all the way through veins that are overly compressible.
    This tip has been around for 30 or more years and it has to be done correctly to work.

    The distal tourniquet has to be both venous and arterial, stopping all flow distal to it. Put it on first.

    The proximal tourniquet is just a venous tourniquet, allowing arterial flow to continue.

    This reduces the venous capacity that is filled by the arterial flow up the arm by eliminating hand veins for filling. More blood, less space, better veins. If you don't occlude occlude arterial flow, the hand veins will fill with blood, reducing what comes back to the arm.
  10. by   foggnm
    It sounds like you're already on the right path to being an IV expert. Practice, learning from other experts, trying different techniques, learning ultrasound, etc. There is no magic, just practice.
  11. by   R5RN
    Some of these other posters have already mentioned some of these things, but these are all things that I mention to people starting out or looking to improve. For the cases that you mention specifically (frail, tiny, delicate veins), these tips should help a lot. Those veins require patience and POSITIONING.

    - Ask your patients about their veins. I've seen how easily forgotten this step can be. Is there one side that's better? Do they usually get the hand or the AC? Is it just where ever they can find one? Heed their warning if they say that their veins roll, blow, hide, etc. and be prepared for that.

    - Make it easier on yourself by utilizing gravity/positioning and a warm pack. I always get a kick out of people who leave the patient lying in bed and they lift up their arm to look for access. Raise the bed and have them drop their arm off of it. It can be a HUGE difference just with positioning. In regards to warm packs, I will take a large sized glove and fill it with warm water to create a makeshift warm pack. Very effective.

    - I'm a firm believer that if someone misses a rolling vein, it is the IV starters fault, NOT the vein itself. I hate hearing the excuse "the vein rolled away so I couldn't get it". It rolled away because it was not anchored properly. The phrase shouldn't be "the vein rolled", it should be "I didn't anchor the vein well". To combat that, if someone tells you their veins roll or if you can tell just by evaluating the veins yourself, take the extra time to position the vein exactly where it needs to be so that it doesn't roll. I will tell my patients to expect to feel me pull their skin multiple directions before I stick them because I am trying to make sure I am able to hit the vein without it rolling away. Get that vein in a steady position before you start.

    - This sorta goes along with my last tip, but when you're anchoring the vein, if it does move away or if you are having trouble entering it, do NOT release the traction you are holding with your opposite hand. Do that as a last resort. If you have a vein get away from you and you release the traction you were holding, you will have a much tougher time trying to line everything up again. This is especially important with the elderly who have loose skin. My tip is try to move slow and don't fish around. Pull traction tighter, find which direction the vein went, reposition your sharp, and try to enter the vein from the side if needed. Don't be afraid to get a second set of hands if the patient has very loose skin, but be careful to not pull traction so tightly that it collapses.

    - With IVDU, if they still have veins but you are having a difficult time (or anticipate having a difficult time) cannulating the vein, go for a larger IV. Sometimes you may miss with a 20g or 22g trying to sneak around the scar tissue when really what you need is an 18g to be able to push through the scar tissue. (This is not true for every IVDU, but something to consider).

    - Another trick for IVDU or people with difficult to find veins is using the basilic vein in the forearm (that wraps around the underside of the arm that is difficult to access). This vein is more difficult to IVDU to access themselves, and if the patient has veins that are used/damaged from multiple IVs and medical procedures, this vein probably hasn't been used much because of it's awkward position. To position this patient, have them rest the arm across their stomach, then stand on the opposite side of them.

    - Flicking is your friend. Everyone has their own methods for getting veins to appear. For me, my tried and true is flicking. I never every slap veins. By flicking, I mean the motion you make with your thumb and index finger where you flick your index finger forward so that you would hit the vein with the flat part of the nail of your index finger. It doesn't have to be super aggressive, and be careful with very thin skin or those who are prone to bruising. This works best in hands and wrists, and can work ok in forearms. I almost never flick ACs.

    - If you're feeling for a vein you can't see, especially deep ACs, don't look! Seriously, look away from the site. If it's an AC you're not seeing anyway, don't distract yourself by trying to look for something that isn't there. Go entirely be feel. Once you think you feel something, THEN look.

    - If you're feeling for a deep AC and you can't tell if it's a vein next to a tendon, if it is actually a tendon, or if it is just the skin (like a stretcher mark), have the patient bend their arm slightly while you feel where you think you feel a vein. If it's a tendon, you'll know immediately, if it's next to a tendon, you might be able to tell exactly where it is, and if it's a stretcher mark, this may help you determine that it is just that.

    - If you see an indentation up the medial part of the AC where the basilic vein would be, there very well may be a vein in there. It's happened to me a few times on (usually) obese patients that have difficult to feel veins where I have found this indentation even without being able to feel a vein there, and sure enough it was there.

    - If you're dealing with a superficial vein, always try to position yourself so that the needle doesn't have to pass over your fingers. So for example, don't pull traction straight down with your thumb and then have to come directly over your thumb so you can't be as parallel to the skin.

    - Veins that genuinely blow are, for me, the trickiest. Sometimes it is extremely unexpected that a very elastic and fairly decent sized vein cannot handle IV placement. I'm not talking about the ones that I accidentally manage to blow through either with the needle or aggressive cannulation, but those ones that you hit (seemingly) perfectly and smoothly and they just straight up pop. If that happens and you're going to attempt again, I suggest going with a smaller catheter size, really try to get the next vein to puff up as best you can, and go slow!

    The biggest takeaway from my post and my recommendations is positioning is (almost) everything!! Be aware of what you are doing to the vein and have your plan laid out. Get your vein exactly how and where you want it before you break the skin. Good luck!!
  12. by   francoml
    Ultrasound.... Should be the gold standard. I don't know how it is in other hospitals but in my unit (large level one ICU) the majority of our nurses know how to use ultrasound to place difficult IVs. I am a pretty darn good at IVs and if I think a PIV is going to be hard I just grab the ultrasound.

    That being said, I work in a very well funded and nurse friendly environment that fosters clinical expertise and training on advanced techniques. I have never worked in a rural hospital or a facility with poor funding or many restrictions on nurse scope of practice.

    If your facility allows it learn how to use ultrasound. I truly believe that it will be the gold standard in the next 5-10 years.

    Also remember that practice makes perfect and don't be afraid to try just because they are difficult.
  13. by   beccap
    Also something that I learned and that actually works, if when you insert the IV catheter and you see it is starting to blow, release the tourniquet......if you have removed some of the catheter to get your blood, you can advance it while also flushing it. I have saved many IV's that were about to blow (or difficult to advance due to a valve) by using this method. I always check to make sure it is well placed by drawing back on the flush to get blood return.
  14. by   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.

    $300 Vein Finder vs. $20 LED Flashlight - YouTube

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