As I've started IVs here in Dallas for the better part of twelve years and probably over 1000 IVs, here's what I know.
1. If the baby's asleep and wakes when you flush the IV...it's probably bad.
2. If the left arm has an IV infusing and it's twice the size of the right arm (assuming no preexisting conditions)...it's probably bad. But check the TAPE JOB. Too tight on the tape will send an IV south very quickly.
3. If you're having trouble with an IV, break it down - take the tape off CAREFULLY and try to find out if the catheter is still in the vein - or in the skin for that matter. Sometimes over time the catheter can kink, especially with active children. Reflush, retape.
4. Flush your IVs frequently when establishing them. Both right when you hook up your tubing, and during the taping/securing process. You have no idea how strong little arms and hands can be and they can wiggle that catheter out of that vein like nobody's business.
5. During an attempt at an IV on a little one, the most important person in the room are the patients (*for obvious reasons) and the person HOLDING the baby still. An effective helper is the one who does ALL THE WORK and gets no credit. An ineffective helper is the one who doesn't hold on tight enough. You have to pretty well immobilize little ones - and that can be difficult. Swaddle the baby and leave out only the extremity you're working on, if possible.
6. CHECK YOUR IVs FREQUENTLY!! "It looked fine this morning but I didn't flush it..." Duh...and you graduated from nursing school??
7. Try your best not to "overtape" your site. It is a royal PITA to tear down all that tape 20 minutes / 2 days after you started it. Less is more...as long as it's secure.
8. Use a padded board to immobizilize the extremity. Tape securely but not tight enough to occlude circulation - it's easy to do (taping too tightly, that is).
9. Double side your tape for patients with sensitive skin (babies) / patients with tons of hair. In this instance, use your tape mostly on the skin directly around the insertion site, if you need it at all. We use a Tegaderm and silk tape for a chevron, if necessary.
10. Discretion is necessary when establishing an IV. Don't put a 24 gauge in a kid who's 10 years old, has great veins, and is gonna get gentamycin for a week. Use common sense. If he can tolerate a 22, or even a 20, give it to him.
11. Use whatever pre IV anesthetics your institution allows. We have cold spray and EMLA cream. Both work well, but be advised EMLA has a tendency to make veins disappear -and it gives the skin a "waxy" feel, which can make palpating a vein you found 1 hour earlier a very tricky ordeal.
12. IF THE SITE IS COLD, YOU'RE GONNA BE HARD PRESSED TO FIND AN IV. Warm the area up with a warm pack first if necessary. Cold extremities = no veins.
13. Start distally. Look for IVs in the patients hands before moving up the arm. Try to avoid the AC if at all possible, unless it's critical and you need fast access, or if the child just doesn't have anything else...it happens more often than you know.
14. Don't put an IV in a 16 year old girl's right hand IF SHE'S RIGHT HANDED unless you just can't find anything anywhere else. This goes for ALL children/ adults who are at the age where the dominant hand does most of the work. Also true of infants who suck "that thumb". Again, unless you have no other options.
15. DON'T EVER walk in and introduce yourself as the IV EXPERT. Kharma has a way of biting your ass. Let someone else build you up - that way your performance speaks for itself.
16. Be aware that some infusions, like Potassium, sting when infusing, especially to small veins. Antibiotics like gentamycin are caustic to veins as well. Keep this in mind when assessing your patient's response to therapy.
17. Look everywhere for the best access. A large vein in the saph is better than a small vein in the hand, at least for the purposes of the attempt. It's far easier to his a large target with a small needle than to push a catheter thru a tiny vein.
18. If your patient may require fast acting meds (Adenosine), establish an IV as close to the heart as possible. With infants and adults this can be a big deal, since there's maybe 12 inches the med has to travel, but with adults and older teens it becomes very important. When you've got a med with a half life of 12 seconds...it matters bigtime.
19. If you're going to be the one starting the IVs and you don't have much experience...practice on your coworkers before you come in and stick my child. Also, if you have the option - start small...work with the healthier kids before moving on to attempts on the truly sick ones. That way I don't have to worry about you blowing 2 veins I could have used for access.
20. Last but not least, know your limits!!! I can't stress this enough! If you stick twice and aren't successful - FIND SOMEONE ELSE. Preferably someone with more experience/ or someone you trust.
Don't let your pride get in the way. REMEMBER - YOU'RE THERE FOR THE PATIENT - what would you do if it were YOUR child?
Have a great day.