Surefire Tips to Starting the Toughest IVs

Serenity Mirabito MSN RN OCN, MSN

I could feel the pricks of hot sweat begin to freckle my forehead. My armpits dampened as stress quickened my heart. I made one last prayer to the IV Gods as my shaky hand, armed with the spike of a 22g needle, aimed at what I prayed was a vein. "Is the bevel up, is the needle at the correct angle, did I clean her skin correctly, is that a tendon I'm feeling? I should not be doing this!!" I thought, in near panic. Then I began to re-evaluate this whole clinical nursing thing, trying to remember what nursing careers don't involve jabbing people with sharp objects – case management, that's it, I'm going to be a case manager instead! Then, like a knife going through warm butter, the needle slid easily into her vessel, and as I watched the flashback make its way to the end of the IV cannula, confidence made its way through my bloodstream. "Nevermind," I muttered under my breath; who wants to be a case manager when you can work on the trauma unit!". This description is an honest account from last week, and I've been a nurse for 25 years ?.

IV Injections

Seriously though, whether you are a seasoned nurse or in your first semester of nursing school, you will experience the terror and exhilaration of starting a challenging IV. Although this article will not review the technicalities of performing this procedure, it will share tricks of the trade guaranteed to result in successful cannulation every time. In addition, each tip is represented by an equally helpful song title for better memorization. Note: These methods may not be applicable in an emergency; use your critical thinking skills when choosing the appropriateness of implementing these suggestions.

1. "If You Don't Know Me by Now" (Martina McBride)

Not knowing how your equipment works can be the first step towards an IV failure, so it's vital to familiarize yourself with the required supplies. If you are a nursing student or a new nurse, I recommend that you take the IV catheter out of the package and get acquainted with its components before entering the patient's room. I was once a home infusion nurse and was asked by a patient to use an IV device I had never seen before. After two painful attempts, I gave up, then used the brand I was familiar with, and was successful after one try. Later that evening, I watched a 'how to' video on the new catheter and was shocked at how counterintuitive the piece of equipment was. I would have never attempted the procedure had I known its complexity. Having a decent understanding of how the supplies function takes the guesswork out of this potentially nerve-wracking procedure.

2. "You're so Vain" (Carly Simon)

Rarely do nurses get to be selfish while performing their duties, but when it comes to starting an IV, it's all about your comfort. Countless times I have been called to start a 'difficult' IV and walked into a room with the nurse bending over the patient in an awkward position, or the lights are low so as not to be disruptive, or they've used a particular vein because that's where the patient wanted it placed. It's best to be armed with the essential tools to perform this procedure – including your comfort. Raise the bed to at least your waist or sit at the chairside level with the patient. Put the lights on so you can appropriately assess both arms and place the IV safely. Turn the temperature down in the room if you are sweating. Choose the vein that you are most confident in obtaining. If your patient is anxious, ask the CNA or family member to support them. And lastly, barring an emergency, take your time. Having enough minutes dedicated to this procedure takes the pressure off the situation leading to a relaxed atmosphere. It's great to have compassion for your patient during this procedure, but you can't be successful if you aren't also at ease.

3. "Hot in Here" (Nelly)

Unless the patient has veins that stand up and salute the flag, I suggest using heat before sticking them. Ensuring the patient is warm but also using moist heat to warm up the site is important. This technique causes vasodilation making the vein/s fuller and easier to feel. My favorite trick is placing moist heat (warm washcloth) directly on the desired site then wrapping an additional dry, warm blanket around the arm. This gives the veins time to become plump while you set up your supplies and mentally prepare for success. I currently work at an outpatient infusion clinic with no linens available but placing a heel warmer on the chosen site wrapped with a heating pad works beautifully.

4. "Under Pressure" (Queen)

For patients experiencing hypotension or those with fragile veins, you may find using a manual blood pressure cuff instead of a tourniquet more useful. Being able to control the amount of pressure inside the veins can prevent rolling and blowing of the vessels. Using a blood pressure cuff also minimizes painful pinching for folks with friable, loose skin. Be mindful of how long you leave the cuff filled, allowing for a refill break after one minute of inflation. Once a vein is identified, take an alcohol pad and rub it distally, you should see an enlargement of the vessel as it refills. Perfect for poking.

5. "I Got Friends in Low Places" (Garth Brooks)

Letting gravity do the work can be quite helpful for flat, small veins. For example, if your patient is lying in the bed, their arms are likely near the level of their heart; the same could be true if they are sitting in a chair and have their arms elevated on a fluffy pillow. Dropping those appendages below the heart can fill vessels quickly, leading to a successful IV start. Keep in mind that you should always attempt IVs distally before moving proximally.

6. "Hurt So Good" (John Mellencamp)

To use or not to use topical/intradermal lidocaine, that is the question. Initially, I thought this to be an old nursing wives tale, but upon investigation, UpToDate confirms that intradermal lidocaine use for IV cannulation may result in vasoconstriction. This could make IV insertion more difficult. But fear of needles can cause anxiety and hyperventilation, which also leads to vasoconstriction. Since pain management is the 5th vital sign, my recommendation would be to use topical analgesics for this procedure until there have been multiple failures (two), in which case abandoning the numbing agent may be necessary. Implementing integrative measures such as box breathing, visual imagery, acupressure, and aromatherapy can also be used to relieve pain during an IV start.

7. "I Still Haven't Found What I'm Looking For" (U2)

Although I highly urge nurses to feel their way to venous access through palpation, there are times when the use of a vein finder is needed. The vein pathway may be more visible with the ultrasound or transilluminator, but the vessel's depth and quality (bouncy vs hard) cannot be determined. You must also be careful not to burn the skin, so limiting the contact time of the vein finder is crucial.

8. "Stop in the Name of Love" (The Supremes)

It can be appealing to keep attempting an IV insertion, especially if the patient tells you it's OK to do so. However, you should keep in mind that every vein you use depletes the next clinician's choices. There is nothing more frustrating than being asked to start an IV on a patient who has been poked multiple times by only one other nurse. Therefore, unless you are the only available clinician (like I am at my outpatient infusion clinic), you should hand over the needle after two attempts, leaving the greatest opportunity for success in the next set of hands (pun intended).

There you have it, twenty-five years of IV tricks and tips rolled into a 1400-word article. I should also add that I am not above praying to the "IV Gods" before walking into a patient's room, after lathering my armpits in deodorant and giving myself a pep talk in the bathroom mirror. Some days the moon is just right, and you get every IV start on the first try; other days, you go home wanting to be nothing more than a Walmart greeter. From parents passing out in the procedure room to grown men crying at the sight of a needle, to watching a child with cancer not even flinch at her "owie," I've seen it all, and you know what, it's pretty amazing!