rninator

lol, just saw that you do switch to long axis.... awesome.

Hey there, usgpiv's and midlines are my jam, I am hoping to work towards a position where that is just what I do.. I do help train others as well A few things.... #1 and most important in my book, is your set-up. Mine consists of- Mayo stand with towels on it- patients arm extended and rotated to give access to ac,basilic, possibly cephalic or brachial veins. Lift the patient's bed to the mayo stand height. You want the patient's arm to be in a relaxed position that requires no muscle tension. They shouldn't have to be working while you are threading. #2- use lidocaine, I use 1% or 2%,I don't do a "wheel" unless the vein is super shallow, I infiltrate slowly, retracting my needle till i see a wheel form and then retracting.. (remember to infiltrate/wheel just under 1cm behind your intended insertion site, don't use the same needle track) and i find it immensely valuable. If a patient shifts positions, or tenses, it can shift anatomy. Reduce pain. I understand that this is not part of your capacity, I would push that it be part of a standing USGPIV orderset. Consider warming the solution, or buffering. I personally work in a critical access hospital where the next step after me is calling anesthesia in... #3-Know what you are going for, in my strategy, cephalic is optimal (but seems to be widely variable), basilic is most reliable, and brachial is for critical pt only(know how to identify nerve bundles). Examine and know the pt's anatomy before you begin, draw a map in your head of the bifurcations and downhill vs uphill nature of their vasculature. Have a 4-6 inch map in your head and know exactly what you are attempting to do. #4- this is not what is best for everyone, but it is what has been the biggest change in my practice leading to a near 100% success rate. Using short axis view, track your needle down to the vessel wall, puncture the wall, get flashback, and STOP! This has allowed you to enter the vessel at its midline, where there will be the most space from one side of the lumen to the other. At this point, take a deep breath, continue to hold the same forward/downward tension on the needle and shift your view to long axis. Butt the probe up close to the catheter insertion site and find it in long axis, find and visualize how far into the vein the needle is protruding, and push until you see (not feel) it getting close to backwall. At this point, lower your angle as best you can and watch the catheter advance, sometimes is has a little trouble "making the turn" and if you have confirmation that the catheter is no longer on the needle but is pushing against the backwall, retract the needle and push forward/upward at the same time. This is just my 2 cents and what is working for me. I am using 2.5 inch 18g angio's for this.. for more shallow iv's like ac's i would suggest going with your gut with all the other ac's you've done and not switching to long axis...

Great job calling 911, and I would consider having called before driving over, unless you have the means for definitive care for a pediatric patient in respiratory distress, I think calling in people who do as early as possible is prudent. Like others have said, much easier to explain prudence rather than negligence.

one technique i use on elderly patients with lots of loose skin/rolling veins, (works best for me on upper arm cephalic or forearm) is to wrap my left hand around the underside of the arm, palm up, so that my thumb and middle finger meet directly over the target vein, (imagine the grip for pumping a shotgun). following this, I pull enough tension on the skin with my middle finger and thumb to keep the skin taught, while pressing my fingers gently down on either side of the vein, i find this stabilizes the vein and provides good visualization, when i do this, i use a very shallow approach and sometimes without a tourniquet, it's not always the right way to go, but it's great for the folks whose veins are all over the place.

I don't know if it's true in this case, but sometimes when I insert an iv that is the same size as a venous lumen, I won't get any blood return, but it will flush quite easily. My understanding is that the iv itself or in your case possibly the Midline, is blocking bloodflow past iteslf, and any suction pulls against proximal valves, hence no blood return. I've flushed an iv 3-4 times just to convince myself it was fine after not getting any return.

I'm just graduating with an ADN, and am really not into the bsn. I am also looking at ADN to MSN programs, I'll be curious if there is any advice on this thread. Thanks for asking.