Starting an IV with Lidocaine or Not?

[hayest]

I recently had surgery. My physician actually started the IV without Lidocaine. He knew I wanted the area numbed before the IV was placed. I've heard the reason before from other nurses and now him..... Lidocaine can hide the vein to cause a 2nd stick. I was willing to risk it. I wanted him to use the Lidocaine and I thought he was. He found the vein, said "here's a stick", (i felt nothing -- thinking this is great), then he said "here's a stick" and OMG .. that hurt like hell. I was VERY upset with him. I haven't had the opportunity to ask him why he didn't use Lidocaine. I know he told the preop nurse that if he could not start it, he would have her do it. I knew he was nervous. Keep in mind, he starts IV's all the time, just not in front of a lot of people. I had everyone leave the room and it was just him and me. Not only do I want to know why he did not use Lidocaine, but why didn't he ask me again and why didn't he give me the chance to ell him that I would allow him to try a few times. He did bring up after starting it "now I know where I can start the IV - next time, we will put creme on your hand to numb it". My reply was "a little late in saying that". What is the consensus of using lidocaine to start IV's or not?

[FlyingScot, RN]

I always ask the patient where do you prefer the IV to go.

This alone can make all the difference in a patient's reaction to the stick. If they have some control over the situation they tolerate it much better. If you take that away from them then all their emotions go into overdrive. I've had patients ask for lido. We aren't allowed. I explain that to them and let them choose where the IV goes. I've never had a patient refuse or become upset about it.

[iluvivt, BSN, RN]

Once in awhile I will use Lidocaine. If a patient requests it and if I need to start an IV in an area that has really thick skin. Usally it is beacuse they generally have thick skin or I can't find a vein in another area where the skin is not so thick.

If you have a skilled insertor or a highly skilled insertor a successful IV start can be accomplished fairly painlessly. If you have someone that is not skilled it can be quite painful especially if they miss and keep digging around and especially if they do not know where the major nerves are and hit one! Every day at work I start IVs after someone else has failed and the patient usually tells me that it did not hurt at all compared to the attempts they just endured. The skill of the insertor, the gauge of the catheter, the location and quality of skin and the patient's level of anxiety and other pain they may be experiencing are all factors the may impact just how painful an IV start really is!

You can eliminate the burn of Lidocaine by adding a little bacarb to it

[macawake, MSN]

I've never once used Lidocaine when inserting a peripheral intravenous catheter. I've used Emla cream on children and on one or two adults in non-emergent situations.

If my adult patients are awake (I work PACU and anesthesia), I always ask them if they have a preferred location for the peripheral iv and giving the patient that choice seems to relieve a lot of the anxiety they might feel. Most patients say that they hardly felt the iv go in anyway.

If Lidocaine is used it does seem that alkalinizing it closer to physiological pH is the way to go.

Cochrane Review: Adjusting the pH of lidocaine for reducing pain on injection - ResearchGate

Efficacy of alkalinized lidocaine for reducing pain on intravenous and epidural catheterization - Springer

[OCNRN63, RN]

When I worked in Day Surgery, I used it, and most of the patients preferred being numbed. If you use buffered lido, it doesn't burn. I never had a problem with the vein collapsing; if you make sure to place the wheal to the side of the vein, it generally doesn't collapse IMO.

[Khaan]

Why not do intradermal bacteriostatic saline? We've done that, and it reduces pain when inserting the needle directly through the bleb within three minutes.

[hayest]

A lot of what is done has nothing to do with "medically appropriate" and everything to do with what is most convenient for staff or what someone has decided that every patient wants or provider preference or any number of other reasons.

If using or not using lidocaine were decided on medical appropriateness, then why are some hospitals using it on every patient yet other hospitals are using it on no patients and some hospitals are using it on select patients?

Every patient gets a hefty dose of Versed before surgery. Why? Someone decided that no patient wants to remember anything about the OR. Of course that's not true. Some patients are adamant they want to remember nothing. Some patients don't care one way or another. Some patients are very distressed by the fact they can't remember anything.

When to remove foley catheters is another one. Catheters are always removed at 6am or 8am per policy. Why? If the patient can't void in 4 hours, you don't have to disturb the provider after hours to get an order to cath the patient. It is not more medically appropriate to remove it at 8am than it is at 4pm.

Patients aren't asked their preference because it would slow down the assembly line.

I found your comment "every patient gets a heavy dose of Versed before surgery" interesting. I recently had surgery. Due to faster recovery, it was done with an epidural/spinal. Which is one of the reasons I decided on the surgery. I did not want to be put to sleep or have any sedation. The consent forms for anesthesia actually had me check the type of anesthesia that I wanted, which was epidural/spinal and then there were two boxes -- one with no sedation and the other with sedation. I already told the anesthesiologist what I wanted a week prior, but I still checked "no sedation". I was awake and alert the entire time. Heard everything that was going in the room. My doctor and the anesthesiologist would talk to me, give me comfort, as well as the CRNA. But it was great and I was more relaxed. After the surgery was over, the anesthesiologist, crna, surgeon and my doctor all said I did great. The CRNA was surprised I did so well. I am grateful for that form offering the patients a choice of how they wanted their anesthesia. My husband on the other would want to be knocked out. It should be the patient who decides and not the facility.

[caroladybelle, BSN, RN]

I loath lidocaine stick more than the IV attempts. I used to let students practice on me before my bilateral mastectomies, and it never bothered me

I did let lidocaine be used when I had my breast biopsies, 3 on one side and 1 on the other. But having a several inches long, 9 gauge needle stuck through your breast, left in for a time while your breast is in the mammo vise, while they take specimens at different areas is a bit harsher than an IV stick. And you don't get to be picky about the site.

Most hospitals that I have worked at do not use lidocaine. The risks of it are often seen as outweighing the benefit. As it is a drug, and nurses are usually the ones starting IVs, and cannot order it, logically in many places, it will not be used.

[Julius Seizure]

Does nobody use J-tips in adults? (SQ lidocaine delivered by pressurized gas - no needle)

[Athanasia]

I work in an outpatient EGD/Colonoscopy clinic, if an adult asked me to use lidocaine or any kind of numbing cream I would probably try my best not to roll my eyes...seriously get a grip. We usually do back of the hand too bc of the way they lie down during the procedure. The pain lasts seconds then it's over. I understand that many many people are frightened of needles I just have to act calm and very self confident and inform them they will get an IV or no sedation. For the fainters, I just flatten the bed, give fluids and a nice cold wash cloth behind their neck. I've heard everything from frantic over the top screaming to "wow you are awesome, I didn't even feel that". You get sort of numb toward the "OMG I hate needles!" When you hear it everyday.

[Khaan]

I work in an outpatient EGD/Colonoscopy clinic, if an adult asked me to use lidocaine or any kind of numbing cream I would probably try my best not to roll my eyes...seriously get a grip. We usually do back of the hand too bc of the way they lie down during the procedure. The pain lasts seconds then it's over. I understand that many many people are frightened of needles I just have to act calm and very self confident and inform them they will get an IV or no sedation. For the fainters, I just flatten the bed, give fluids and a nice cold wash cloth behind their neck. I've heard everything from frantic over the top screaming to "wow you are awesome, I didn't even feel that". You get sort of numb toward the "OMG I hate needles!" When you hear it everyday.

That's a pretty unfortunate point of view. I've used bacteriostatic saline and lidocaine to reduce intravenous cannulation pain. Our patients already undergo a lot of psychological pain. Anything we can do to help them within reason is nice. Balancing the need to do painful or invasive stuff and minimizing this reasonably is what we're in our careers for. Press Ganey is one (terrible) thing, but completely disregarding someone is too extreme (for me).

[Athanasia]

It's just an IV, have you ever had one? I have and it hurts for a second...then it's fine. Most adults can handle it just fine. I stick a minimum of 15 people/day. Today 26...everyone was fine, they even thank me afterwards. You know women used to have to have babies without epidurals? People have become big babies, and giving lidocaine is silly for such a minor thing.

[WanderingWilder, ASN]

It's just an IV, have you ever had one? I have and it hurts for a second...then it's fine. Most adults can handle it just fine. I stick a minimum of 15 people/day. Today 26...everyone was fine, they even thank me afterwards. You know women used to have to have babies without epidurals? People have become big babies, and giving lidocaine is silly for such a minor thing.

I had a baby without an epidural to avoid an IV