new ER nurse needs advice on IV therapy

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Specializes in ER,Neurology, Endocrinology, Pulmonology.

Hello everyone. First of all, I want to thank all of you for taking care of the most fragile patients in our profession. It takes a special individual to do this and as someone who was in pre-term labor several times, one of the comfort points to me was that there is a NICU and that there were nurses on stand-by who would take care of my kids if there was a need for that. It really means a lot.

Now, I need advice from the experts. I would like to hear any suggestions on IV insertion sites and sizes as well as blood draws on pediatric patients.

My most problem lies with kids under 1 year.

What are the best sites for babies 4 weeks to 6 months? What is the best way to insert the IV? Can bloods be drawn with IV insertion on babies?

I am OK with 2 year-olds, but anything younger I just do not have experience.

I am realy good with the elderly and adults.

Please offer some thoughts.

Nat

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Specializes in Neonatal ICU (Cardiothoracic).

On a child 0-1 yr old, start looking where you would on an adult, like hands and ACs. Then check feet, saphenous and scalp veins. On really fat kids the scalp, saphenous and AC's are about all you'll see. When you insert the IV, use a flatter angle and advance the needle slowly. WHen you see blood return, push it in a smidge further and thread the catheter slowly. Tape those suckers GOOD! Sometimes their veins seem to blow less if you draw up a flush in a 3cc syringe on a microbore extension instead of a prefilled 10cc NS flush. I rarely can get blood from a baby's IV, though occasionally on a bigger kid, or scalp IV I can get enough for labs. Be careful, though. Practice makes perfect! Sometimes on really dehydrated kids you can't get it no matter what. We are often called to the ED after IV team has stuck several times. Maybe your NICU could send someone to stick the baby after you've tried.....just save us some good-looking veins and we'll do our best!

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Specializes in Nurse Scientist-Research.

In our unit if we need more than about 1.5ml's of blood we always do an art. stick. I have on occasion seen a nurse clip the tubing on a butterfly set, do a venous stick and drip the blood into the tiny lab tubes (the ones that take no more than 1ml blood). I have never seen anyone draw labs from an IV site (mostly because they are so hard to get no one would want to risk clotting it off). But brand-newborns clot much easier than kids a few weeks old, they have extremely high hematocrits and their blood is often sludgy (probably like many of your dehydrated kids now that I think of it).

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Specializes in NICU, PICU, educator.

Also, if you can keep them quiet (ie binky and Tootsweet) it will help also.

We rarely draw off our IV's unless it is a gusher, then we just drip into the tubes, we don't draw back, it will collapse the vein many times. Art sticks are the way to go for bld draws like Tiffy said.

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Specializes in NICU.

I always start at the most distal vein possible, and then look further up the extremity. For example, I will attempt to start an IV in a baby's hand before sticking the antecubital vein. That way, if the IV can't be started, you have intact vessels further up the arm, or wherever else you may be sticking.

We use 24g. IV catheters in all our babies, and they usually don't bleed back enough for lab. draws. Swaddle the infant snugly except for the area you are looking at. We use TootSweet also; it seems to help a lot with pain control, decreases stress in the ifant, and helps keep he baby from wiggling too much.

I will somtimes place heel warmers over the vessel I am trying to stick. the warmth will vasodilate the vein, and make locating it easier. Remember, a cold baby, or child, will vasoconstrict.

If you have a transilluminator available, this will also help greatly with locating veins. Have a second person hold it at the site you see, while you start the IV. Dim the light in the room; it will make the vein more visible. Transilluminators are also used by our doctors and NNPs to locate vessels for arterial or PICC lines.

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Specializes in NICU.

Swaddling the baby is helpful, just keep the one extremity you're sticking out and wrap that baby up nice and tight! Pacifiers and sucrose water work wonders, as stated previously. We use #24 gauge catheters for all our neonates. Definitely use a pretty flat angle as the vessels are very superficial usually. Rarely draw off an IV - it'll usually ruin the vein for us. We'll do arterial punctures instead for labs. We make our own flushes - we'll use the skinny 1cc tuberculin syringes, fill them with NS, and use them to flush the catheter if we get blood return. Tegaderm the actual site - babies are active and tape sometimes comes loose at the site. Arm boards are a necessity - make sure to splint the extremity right where the catheter is - many times I've seen IV's go bad because the board wasn't right where the IV was and the catheter would keep bending with the baby's movements.

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Specializes in ICU/ER/TRANSPORT.

I try to match the size of the cath to the approx. size of the vain. I'm not ashamed of putting a 24g in a 1yr old.. Another thing a former nicu nurse told me is on the little kids, is to insert your iv with the bevil down. Her reasoning is you'll see the blood flash sooner when you hit a vain and may prevent you from going all the way through it. I've been using this tech. for a few yrs now and it seems to work well for me.

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On a child 0-1 yr old, start looking where you would on an adult, like hands and ACs. Then check feet, saphenous and scalp veins. On really fat kids the scalp, saphenous and AC's are about all you'll see. When you insert the IV, use a flatter angle and advance the needle slowly. WHen you see blood return, push it in a smidge further and thread the catheter slowly. Tape those suckers GOOD! Sometimes their veins seem to blow less if you draw up a flush in a 3cc syringe on a microbore extension instead of a prefilled 10cc NS flush. I rarely can get blood from a baby's IV, though occasionally on a bigger kid, or scalp IV I can get enough for labs. Be careful, though. Practice makes perfect! Sometimes on really dehydrated kids you can't get it no matter what. We are often called to the ED after IV team has stuck several times. Maybe your NICU could send someone to stick the baby after you've tried.....just save us some good-looking veins and we'll do our best!

Do you really find it helpful to advance the needle after getting flashback?

OP, another place to keep in mind is the area right above the thumb, right along the radius there is what I have heard called "the interns vein," called that because it is usually a big'un and easy to get. This is also a good one to get blood off of. I also dont recommend aspirating the blood. We usually get a microtainer and let the bloo flow back ti fill the tube. If you have to use a syringe, you can take a blunt tip connected to a syringe and place the blunt tip at the end of the catheter and have someone aspirate as the blood flows back.

Other odd places to look at on the forearm below the elbow on the outside part and on the saphenous as far up as the knee. These may be hard to keep if the infant is a mover.

All in all, I think a the scalp (just make sure it isnt an artery!!) is the best place for a kid who is goig to be mving around. It frees the hands and feet so he can play wih no restraint.

HTH and good luck!

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Another thing a former nicu nurse told me is on the little kids, is to insert your iv with the bevil down. Her reasoning is you'll see the blood flash sooner when you hit a vain and may prevent you from going all the way through it. I've been using this tech. for a few yrs now and it seems to work well for me.

OMGosh, that is against everything I've ever known, but I can't wait to try it!!! :lol2:

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I have never had a problem drawing blood from peds/neonate iv, use a 3 ml syringe, not vacutainer... the draw is just too much pressure. I have used 5 or 10 ml syringes, just slowly withdraw with steady light pressure... Hope this helps!

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Specializes in Neonatal ICU (Cardiothoracic).
Do you really find it helpful to advance the needle after getting flashback?

Yes, I do..... with our IV catheters you see flash in the cannula before you see it in the hub. This usually means that the needle has just barely entered the vein. I usually nudge it in a HAIR more so the entire cannula tip is in the vein, and threads easier. Ever think you were in, only to advance and see the catheter curl away from the vein? That's why. Now in a tiny kid, I may not do this, because their veins are so small, but in bigger babies like the OP will see in the ED, this technique usually works for me. It all comes down to luck. I can have 20 successful sticks one day, and 20 misses the next.....

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It all comes down to luck. I can have 20 successful sticks one day, and 20 misses the next.....

Aint that the truth!!

I have seen many people use this technique an go through the vein, thats why I asked. Maybe they are pushing in TOO far. Thanks fopr the explanation as to why, though. I appreciate it.

~LMJ

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