Thought you all might have some good advice for me. I'm a med-surg nurse, and I used to be good at starting IVs, but I'm just not anymore. I very seldom have any trouble finding and hitting a vein on the first try, but I feel like my IVs NEVER thread anymore after I get the flash. Since I never used to have that problem I'm inclined to blame it at least in part on the brand of catheters my hospital uses, but of course there are plenty of nurses in the hospital who are threading their IVs every day. (Still, it is a very common thing to hear on my unit: "She has good veins, but I couldn't get it to thread.")

I talked with an infusion nurse here about it, and she said sometimes she rotates the catheter and then it goes in. I had high hopes, but have had no success with this method.

Any other tips to try?

On my unit we commonly use 22s and 20s... 18s only if we have to because someone's getting a CT. I was trained (and repeatedly had good success) with 16s and 18s. Sometimes I wonder if I ought to go back to that... has anyone noticed more or less difficulty threading with either larger or smaller bore IVs?

Getting a flash (usually small amount) and then being unable to thread the catheter in my experience is usually due to one of two reasons- you are either getting just partially in with the needle tip only, or you have gone through the vein.

If you know that your angle of insertion is not too steep ( average 15 degrees or less); it could be the latter. When you do a slow careful insertion and you are not in that deep- and obtain a small flash back; here is a method to try: try immediately lower your angle level with the skin, and advance the entire device (needle and cath) a very small amount 1/16th to 1/8th of an inch; pause a moment to ensure the blood return has not stopped short; then advance the catheter. Using this technique of leveling out and advancing the entire tip a bit helps to ensure that the tip of the catheter (not just the tip of the needle) has entered the vein lumen.

The other common reason for a flash back of blood- but unable to cannulate the vein- is too steep of an angle combined with a fast insertion can cause you to go right through the vein back wall before you note the flash back of blood. If you think this is the case, try lowering your angle and when you initially think you feel that you're in the vein- pause for a brief moment to give time to note the flash back, and if it happens try lowering the device to level with the skin prior to advancement.

A change in catheters may definitely cause a need to change insertion technique. You can also try looking up the manufacturer's instructions for use of their product. You can ask the sales rep- but if you know the name and manufacturer of the device, you can often find the info online. Also, when you have not put in IVs for awhile- it takes a little getting used to again. It's one of those use it or lose it skills. But after awhile of doing them, it allll comes back to you- so no worries. Keep at it!

Hope this helps,

Alice

Thanks, that's exactly how I was taught to use IVs, but I'm going to look at my technique and make sure I'm actually DOING it! I may have gotten complacent at some point, which turned into pessimism after I stopped getting my IVs--right now I generally approach them with a negative attitude of "I'm not going to get it anyway". I think I may also be trying to cannulate too fast, feeling like I'll "lose" the vein if I don't get it in there quickly enough--sounds like this is really not a problem.

Please tell me what brand you are using and I can give you some tips....I have some good suggestions of the most common mistakes I see when I hear this complaint form nurses. Are you using a Braun product (introcan) b/c there are a few things you ned to do differently with this catheter.You never want to rotate this catheter before venipunture..you need to make certain that the locking bevel indicator is seated in the slot....so do not rotate the Introcan prior to insertion

We use BD Insytes.

One thing that I've noticed since getting the suggestions above: I was taught to keep inserting the needle a tiny amount after getting the flash, but when I try to do this, the catheter seems to be hanging up a little bit--I'm trying to advance the catheter+needle slightly, but the needle isn't going in any further. I can see it through the catheter and the catheter has advanced, but not the needle. Does that make sense?

You need to drop your angle flush to the skin once you see the flash...then thread that additional 1/8th of an inch or so. You are lucky to have the insyte b/c on the 20 gauge and smallers you will see the blood flash in your catheter on its way to the flashback chamber..that is a big bonus. The most common mistakes that I see are

1. performing the venipunture at to steep of an angle. Even when I am accessing a deep brachial or basilic vein with US for a PICC insertion I rarely have to go much steeper than a 45 degree angle (unless there is obesity)..SO for a PIV you rarely would need to go greater than a 15 degree angle to the skin. Always feel the vein prior to venipuncture and find a section that is fairly straight..estimate where the tip will be so as not to end up where it bifurcates or takes a sharp turn. So perform your venipunture at a 15 degree angle or less while holding good traction with your non-dominant hand...once you are through the skin if you are still to steep you can drop your angle even more if needed. I am always more successful if I can get on top of the vein..line it up and get into from the top...once you get your flashback drop your angle flush with the skin and advance approx 1/8th of an inch or less for shorter catheters. You should still be getting a flashback..although if the flashback chamber is full it can be difficult for some to tell this. Then pull your needle back just a bit and advance into the vein. It should slide easily into the vein and you should not have to force it. All of this prevents a through and through puncture..which will give you a great blood return for awhile

2 Next I see nurses NOT advancing the catheter more once they get the flashback...you often just have the needle in the tip of the vein and not the catheter..so if you do not advance it..all you have done is enter the vein with the tip of the needle and then pull the needle back...you are out of the vein and never will be able to advance the catheter...you will get a good flashback with this too Actually look at a catheter and you will see what I mean....look at a 16 gauge its easier to see on the larger ones although it is all relative

3 take the time do perform a good assessment if you can..feel the veins...apply a warm pack to potentials.....do the little things that can increase your success..like putting the bed up..propping the arm.. I would much rather do those things than miss and then have to start again. Then after all that hard work..secure your site really well... Try these and get back to us and let us know if it has helped

Thanks so much! I think my problems must be that I am only getting the tip in, and that I'm going at too steep of an angle. I'm always afraid that if I drop the catheter flush with the skin before advancing that the tip will pop up out of the vein. It doesn't sound like that is a concern from what you're saying?

I know I am lucky that I have so much success with finding veins and getting flashes, which is where a lot of nurses get hung up... but I feel even stupider for not being able to thread. I miss being in the ER where I got to start lots of IVs.

Thanks so much! I think my problems must be that I am only getting the tip in, and that I'm going at too steep of an angle. I'm always afraid that if I drop the catheter flush with the skin before advancing that the tip will pop up out of the vein. It doesn't sound like that is a concern from what you're saying?

I know I am lucky that I have so much success with finding veins and getting flashes, which is where a lot of nurses get hung up... but I feel even stupider for not being able to thread. I miss being in the ER where I got to start lots of IVs.

:)Yes, yes. YW! Angle of insertion is often the problem- watch & wait carefully for that initial flash back; next leveling out your angle on the skin before you advance the whole device a tiny fraction just helps to get the tip of the cath into the vein lumen, and can avoid puncturing through the vein back wall. Next, I teach (and practice) advance the catheter enough to cover the needle tip prior to advancing the catheter the rest of the way into the vein = just my technique vs. pulling back the needle. I don't have a problem with pulling back the needle as part of the procedure; I just find nurses new to IV insertion sometimes pull the catheter out of position and get frustrated.

Just wanted to let you folks know that I have been doing MUCH better with IVs since reading and applying your advice here--especially using a very slight angle when inserting. Thank you!

.. You are welcome.....just stay focused for each start and once you see that blood return....drop the angle if you are not already flush to the skin..advance a bit farther..pull the needle back...thread..then hit your button... Keep us posted if you need any more help