Locating Cephalic and Median Vein

[triageyoda]

Hi there. I just started on the IV team at a hospital. My previous background was Infusion in an outpatient setting where all of my IV's were AC's and hand. My new facility likes to place a lot of forearm and inner arm sites for patient convenience or because by the time we get called for a re-start the patient has nowhere left to stick.

I am having a lot of trouble seeing and hitting the Median and Cephalic veins in many of our patients. Either I can see it and it blows, or once I apply traction it disappears on me and I can't touch it again after cleansing. I can hit them all day with my eyes closed if I'm going for the AC or hand, but these particular ones are really giving me a run for my money trying to transition from OP to a hospital setting where I'm now dealing with a patient in a bed, I am now standing up, the patients are often dehydrated and have been stuck all over and have blown sites, etc.

I need to master this last technique before I can be cut loose on the floor. Does anyone have any good advice? I'm really getting stuck on the fact that once I feel it and clean I can't touch it anymore and I don't always know where to go back to and I am consistently under or on top of it and I notice that my traction in these areas is also not the best. I just can't eyeball the angle like I can on the hand and AC's.... help please!

[Anna Flaxis, BSN, RN]

I only started using the AC when I transferred to the ED. Prior to that, the cephalic was my vein of choice. I'll still use it in the ED setting if the patient has fire hoses or if they're not likely to get contrast.

For the disappearing vein trick, try holding traction more gently, pulling downward on the skin instead of pushing into it, if that makes any sense (you can try this on yourself; find a hand vein and watch how if you push into the skin, the vein disappears, but if you use your finger to pull the skin taut, it's still there) and try using your traction finger as a landmark; position it so it's pointing directly where X marks the spot.

Also, you can touch the site after cleansing if you apply CHG to your gloved finger, allow the CHG to dry, and then don't touch anything with that finger. It's your "sterile" finger, and you can use it to palpate for the vein right before you stick.

[iluvivt, BSN, RN]

You are complying with the no touch technique which is the correct way to do it. If you do need to touch the site slide on a sterile glove to your non-dominate hand and then you can touch it. Traction is crucial ..you can pull up and then tuck any loose skin under the tourniquet then always pull down on the skin an not on the sides or you will just flatten the vein. You are advancing your skills and trying to use veins that you cannot see well but can feel and that will take some time to get good at it but keep on trying.

We avoid the ACF and re-site as soon as we can unless needed for CT power injection and if so we place it and take it out if we can. We found a huge correlation between sites placed at the ACF and other areas of flexion with thrombosis. If you can described exactly what is happening when you try to access I can pinpoint for you what it is you can do to improve

[Anna Flaxis, BSN, RN]

You are complying with the no touch technique which is the correct way to do it. If you do need to touch the site slide on a sterile glove to your non-dominate hand and then you can touch it.

Absolutely, this is what the INS says, and the standard that you should follow.

[triageyoda]

Thanks so much for the feedback and encouragement! Yes, we also only use the AC for a CTA or port power injection and also avoid areas of flexion related to thrombosis, inconvenience, and length of patency.

I am left handed and seem to have trouble with patients especially when they are in the bedside chair. If I am restarting a right forearm and applying traction with my right hand from underneath, those faint veins disappear on me. I like the idea of using the thumb as a marker I will definitely try that. I have also started looking for a freckle, etc. Can you still get good traction in these areas by using the two finger spread technique lateral to the site? I've been trying it but find that on the older skin especially I still run into occasional bunching up. I think its really just practice at this point. I like being able to feel where I'm going if I can't see it, so when I go to scrub, and look back and the vein is gone I freak out because now all I see is an arm, a blank canvas where I know I saw a vein a few seconds earlier! I really don't want to just stab blindly so I'll feel and re-clean, but then I'm not sure about the depth at that point...