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IV start question.

Posted

I am an LPN, and few weeks ago I observed an RN starting an IV, ( we don't get to many where I work -(IV's) the nurse had a hard time finding the vein, then found one - advanced the cath needle, but got no blood return , and said something like "that is weird, it's in but no return..." then pushed some fluid in, and said someting like "well it's in, its going in fine"... and started the IV bag, 20 minutes or so later the arm was swollen and fluid filled, and the IV was stopped and restarted on another arm , by another nurse. . can you start an IV with-out getting a blood return? Thanks for the answers in advance.

Easy answer...no.

If you don't get flash, you aren't in the vein. Many people can "feel" when they enter the vein which is all well and good, but if there is no flash, you are not where you should be.

Midwest4me

Specializes in A myriad of specialties.

I don't know what the heck that nurse was thinking. You always need a blood return to verify you're in!

Reno1978, BSN, RN

Specializes in SRNA. Has 6 years experience.

Let that nurse know IVs need to be placed in a vein, not just in an arm...sheesh!

pharmgirl

Specializes in ER, ICU, Medsurg.

I have to disagree. I have started many a 22g that I didn't get blood return. Flashed when I entered but not return blood. Flushed well and the IV maintained its patency. It was explained to me that sometimes the 22g cannula is too small to bring back blood, idk, but I do know that it is possible

OttawaRPN

Specializes in acute care med/surg, LTC, orthopedics. Has 5 years experience.

And so it went interstitial. D'uh. I guess we saw that coming.

Please tell this nurse she needs to review her venipuncture techniques.

I have to disagree. I have started many a 22g that I didn't get blood return. Flashed when I entered but not return blood. Flushed well and the IV maintained its patency. It was explained to me that sometimes the 22g cannula is too small to bring back blood, idk, but I do know that it is possible

I guess I was thinking flash as opposed to blood return (which is what the OP stated). I've started IVs without blood return (sometimes they just suck to the side of the wall too and you can't get anything back), but never without flash.

BlessedMomRN

Specializes in ICU. Has 2 years experience.

I've seen fellow nurses get a flash, but once cath is introduced and flushed, no blood return. The IV still worked fine. I've been told that the cath could be against the vein wall.

By the way, I'm a three year old ICU nurse and stink at starting IVs. The patients usually come up with an IV in from ER before being admitted to my unit. I try every time, but frequently don't get it. Then one of my fellow nurses start a 20 gauge with their eyes closed.

If the nurse wasn't in the vein, when she flushed it, she should have seen the skin blow up with saline. I've seen it done ONCE where there was no flashback on a #24. Patient had tiny veins. no problems after wards. Even when there is a flashback on a #24, usually don't see blood return after the catheter is properly placed within the vein. just my experience.

klone, MSN, RN

Specializes in Women's Health/OB Leadership. Has 15 years experience.

I have had successful IV starts without a flash or blood return. Definitely not often, but it does happen.

Even if you DO get blood return, it's not a guarantee that you're still in the vein. ALWAYS ALWAYS ALWAYS observe the site as the fluid is running in. If you're not in the vein, the skin around the site will start to puff up almost immediately after you flush the IV.

MassED, BSN, RN

Specializes in ER. Has 15 years experience.

yes you can start with no blood return, sometimes the blood is too slow coming out, but it's still a good line.

Zaphod, BSN, RN

Specializes in ICU-CCRN, CVICU, SRNA. Has 4 years experience.

Frequently, yes. Especially on dehydrated or severely hypotensive patients. I always have a flash, but many times no blood return and IV runs fine.

kessadawn, BSN, RN

Specializes in pediatric critical care. Has 7 years experience.

Working in peds means we rarely have a blood return, but always a flash. You can get a flash, the site flushes beautifully, the fluids are running well, but it can still infiltrate soon after you walk away. The key is frequent assessment of the site.

klone, MSN, RN

Specializes in Women's Health/OB Leadership. Has 15 years experience.

Okay, I'm seeing people use "blood return" and "flash" as two separate things. What is the difference, for those of you who are not using the terms interchangeably?

sunnycalifRN

Has 6 years experience.

Okay, I'm seeing people use "blood return" and "flash" as two separate things. What is the difference, for those of you who are not using the terms interchangeably?

my use of the terms is: "flash" refers to seeing the blood fill the cath or hub (depending on type of IV) when inserting into the vein

"blood return" refers to, after attaching your flush syringe, flushing a couple of cc's, then gently pull back . . . you should see blood freely flow into the syringe.

Of course, with small gauge IV's, the blood return may not be as brisk . . . but with an 18 or 16, the "blood return" should be very brisk.

coolpeach

Specializes in ER/Ortho.

I am great at starting IV's. I am a new nurse Dec 09, but darn it ..its my thing. I did a small stint in the ER, and now I work on the floor. I am the one the other nurses call when they can't get it. Being a new nurse, and feeling I still have so much to learn it makes me happy I can do something right.

Anyway, I would not assume I had a vein if I didn't get a flash EVER. I would continue took until I got a flash. I am not concerned with blood return. I usually get the flash, and flush if there is not pain or swelling then we are good to go.

usalsfyre

Specializes in CCT. Has 8 years experience.

It's entirely possible to establish patent venous access without a flash or being able to draw. In dry/low perfusion state patients there may not be enough pressure in the venous system to cause a flash, especially with a small catheter. In addition it is not at all unusual to be unable to draw off an existing IV cath.

It's hugely important in these cases to establish patency by flushing the line, multiple times if need be.

Emergency RN

Specializes in ED, CTSurg, IVTeam, Oncology. Has 30 years experience.

i've probably put in well over 100,000 iv's.

average 7000 per year x 14 years of iv team, and then not even counting the other 11 years doing ed, ct surg, and onc; so i think i've seen just about anything that one can see with iv's.

from my experience, yes you can successfully cannulate a vein, get flashback but no continued blood return (happened to me on multiple occasions), though it is generally unlikely, especially if the initial flashback was good and strongly positive. i mean, if the blood flashback was fast and quickly filled the flashback chamber; this usually means it's stuck in a fair sized vein with a good amount of pressure and an ample blood supply. if it stopped flowing so suddenly after advancement of the catheter, it could be one of several reasons:

1. the catheter punctured through the vein and is now sitting in the subcutaneous tissue beneath the vein, or during the advance the catheter tip pushed the vein away from the needle tip, and never made it into the lumen in the first place.

2. the catheter tip is stuck up against a valve, effectively sealing the catheter to back flow.

3. the catheter caliber closely approximates or exceeds the vein's lumen, such that no distal blood can flow around the catheter in a proximal direction; since the venous system is unidirectional because of it's valve structures, a finite amount of blood volume exists between each valve segment. if the initial flashback already sucked all the blood out, and no more blood can go into that vein segment because of the catheter size, then no more blood will come out.

an easy way to test to see if the iv solution is indeed in the vein or not, is to pull back the catheter about 2-3 mm (if sitting on a valve blood should flow once pulled back), or to allow the iv to run wide open for a few seconds. if the area swells immediately, then it's quite obvious that the catheter is not in the right spot. but sometimes, with patient's who have very loose subcutaneous tissue, fluid seems to get in but not cause significant or visible swelling right away.

you might try this: have the iv run wide open and visually note the character of the flow; then constantly observe the flow character while simultaneously applying a tourniquet well proximal to the site. if the flow rate slows down, then the iv is good (as venous pressure increased with tourniquet resistance, flow rate will decrease). if the flow continues unchanged, then venous pressure is not affecting flow, which leads one to believe that the catheter is not in the right place.

all said and done, frankly, if there is any doubt, you should always try for another site. on the other hand, subcutaneously injected iv fluid (ie hypodermoclysis aka s.c. infusion) remains a reasonable technology that may sound archaic to some, but still has positive clinical value for gentle rehydration. one can give up to 3 liters of fluids a day using s.c. infusion.

Edited by Emergency RN