Tiny vein tips for IVs

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I had a string of female patients with what I call "veins like spider legs.” So tiny and I missed all of them yesterday. I use a 24 G IV , go slow, try to plump the vein up . Any suggestions?

Specializes in RETIRED Cath Lab/Cardiology/Radiology.

On attempts for ppl who are VERY frightened of needles, or on attempts where the vein is in a particularly sensitive area, I would inject a little wheal of 1% lidocaine with a TB needle -- inject right where I needed to go in with the IV needle.  If the patient can't feel my cautious attempt, there is less movement, reduced anxiety, and I had more success.   Check with your facility's policy about this, first.

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Specializes in Adult and Pediatric Vascular Access, Paramedic.

Hi, vascular access RN here....

It saddens me that this day and age so many hospitals still don't have someone trained on Ultrasound guided IVs available at all times, or a vascular access team!   The reason I say this, is that those tiny little veins you are going after in an adult are not going to last even if you do successfully hit them (they are spidery because they are unhealthy and not a good candidate for access), and they will likely get a nasty infiltrate, which in some cases can lead to lawsuits down the road secondary to the damage vesicants can do to the soft tissue. That being said, I totally understand that a hospital having this service is not in the control of a staff RN.  Here are some tips, the previous posters have given you lots of good ones as well. 

1) Wrap the patient's arms up with warm blankets, this is a totally under rated thing to do, but it can really make a world of difference!   

2) Don't just go for the obvious veins in the hands or AC. Scan the patent's arm with your eyes and look for faint blue lines in the forearms, anterior and posterior.   It took me a while to get the hang of this in my early years as a paramedic, it works better after you warm them.  Many inexperienced IV starters don't even bother looking in the forearms. 

3) Sometimes a lack of veins is due to anxiety on the part of the patient, and sometimes they don't even realize it.  Try to talk them off the ledge and let them know the calmer they are the more the veins will behave.   We had a child at my current job that we had to get access on monthly for an infusion, he was off the wall with anxiety and had little to know veins, even with ultrasound they were constricted down.  Unfortunately, we had to go the sedation route because it just wasn't safe for us or him trying to get an IV while he is fighting us and moving.  Now that he gets sedation and is relaxed his veins are like the size of dinner plates!  Anxiety plays a HUGE role in vein size.  

4) On tricky patients with smaller veins and no ultrasound, try the bevel down trick.  Insert bevel up like normal, but when you get your flash rotate the needle and catheter upside down and advance, observe for continued flash.   Unfortunately you cannot do this with IV catheters that have wings.  

5) I do not recommend using the lidocaine for veins this tiny, as you will likely hit and ruin them trying to get a intradermal wheel, additionally lidocaine can also cause veins to spasm and disappear completely.  

6) If you are trying for a smaller vein, slow and steady wins the race, along with a lower angle.  

7) A lot of IV inserters only use the flash chamber on the initial insertion to know they are in the vein, but fail to check it again after they advance. Even with larger veins, use your flash chamber as a guide after you advance slightly prior to pushing the cannula off the needle.   If you notice your flash stop after you advance, you are likely through the back wall of the vein, pull back until you start seeing more blood in the flash chamber and then either advance again or try to thread the cannula at that point. 

As stated in the beginning of my post, ultrasound guided IVs are best practice for this type of patient, but change won't happen if it isn't advocated for.  

 

Annie

 

 

 

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Annie,

Thank you for all your tips. I was curious about the bevel down technique. What does that do ? I work at an outpatient surgery center where we do a lot of cataracts. The IV is only for sedation so it's not in long. 
 

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mariaconcetta said:

Annie,

Thank you for all your tips. I was curious about the bevel down technique. What does that do ? ...
 

The thought is that doing so allows you to lower the catheter hub.  Proponents of this theory believe that this allows you to  advance the needle and catheter at a shallower angle making it less likely that you advance the needle out the opposite side of the vein.  In addition to inserting the needle with the bevel up as @AnnieOaklyRN posted above, some advocate making the initial entry with the bevel down.  Personally, I've not had much success either way, but you might find it helpful.

When I was first started placing IVs, I was taught to hold the catheter like a pencil using my thumb and first 2 fingers and the hun of the catheter laying in the web between my thumb and first finger.  I started holding the catheter somewhat like a pool cue, with the catheter hub below the palm of my hand.

Watch your coworkers as they start an IV.  If the have a good techique, see if there is anything you think might work, try it.  If it doesn't work, scrap it it and go back to what you were doing.

Regardless of the technique used, the secret to success is repetition.  Do not pass an opportunity to start an IV, no matter how difficulty you think the attempt will be.

Best wishes.

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chare said:

When I was first started placing IVs, I was taught to hold the catheter like a pencil using my thumb and first 2 fingers and the hun of the catheter laying in the web between my thumb and first finger. 

Oh, my. Never seen that. How did it work? All I can think is that's a great way to come in at too steep an angle. I prefer quite a shallow angle approach almost always.

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Specializes in Adult and Pediatric Vascular Access, Paramedic.
mariaconcetta said:

Annie,

Thank you for all your tips. I was curious about the bevel down technique. What does that do ? I work at an outpatient surgery center where we do a lot of cataracts. The IV is only for sedation so it's not in long. 
 

The bevel down allows the most pointy part of the needle to be up, rather than down where it can easily penetrate the back wall of the vein when you advance.  Look at a picture of the end of an IV catheter and you will understand better.  

 

Annie

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Specializes in Med-Surg.
AnnieOaklyRN said:

As stated in the beginning of my post, ultrasound guided IVs are best practice for this type of patient, but change won't happen if it isn't advocated for.  

This has been a game changer at my facility.  The problem is our vascular access team will prioritize central lines and get to us when they can and they leave at 3pm.  The Rapid RN does them well is busy with stroke alerts and rapid responses, but they are big help.  A couple of day surgery nurses can do them but they are busy with patients and leave early evening.  Some ER nurses can do them but we have a very busy ER and they rarely come to the floor.   Some ICU nurses are trained but can't leave their critical care patients.  The med surg nurses that were trained have all quit or transferred as med surg nurses frequently do. But with a 6:1 ratio I'm not sure I want to be trained and be pulled all over to start IVs.  

So it's a nice idea but in practice it would be better if every RN had the training.  

 

 

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Quote

5)  I  do  not recommend using the lidocaine for veins this ti ny, as you will likely hit and ruin them trying to get a intradermal wheel, additionally lidocaine can also cause veins to spasm and disappear completely

100%. I will put extra pressure on myself every time and barter with the patient that I'm confident this will be less pain if we just go for it with one poke. 
 

Patients (and even nurses sometimes) think this sounds like you don't care about others' comfort but almost every time I've convinced them to go for it they say it was the least painful ever (which I take to mean they've had experiences with people digging around which is what is truly painful)…I don't think they've had a lot of experiences with the whole thing in and done in literally < 2-3 seconds or so. I have never once had lidocaine make my job easier and my observational opinion is that the theory of lessening the pain psychologically sounds good to the patient,  who only has bad experiences to compare with. 
 

You can have a 2-3 second procedure which includes a poke or you can have two pokes and a lot of monkeying around. 

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Specializes in NICU, PICU, Transport, L&D, Hospice.

Topical lidocaine is better for IV starts.  It requires pre-planning and more time to work.  They used that on my spouse before she got her first port.  

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Hard stick and difficult to draw patients are part of my daily routine.  Some people have spider veins, scarred veins due to drug use, rolling veins, and even excellent veins.  Honestly, I have my fair share of unsuccessful attempts in all of those conditions.  It's an energy and self-confidence eater.  But through the years, II've learned to do it in steps.  You need to conduct recon on both arms and hands first.  After deciding on the best spot, warm compress and hang the arms down.  Please use a 22 gauge IV cath. and larger if you can.  That is 2 birds one stone, for drawing blood and fluid admin.  In Nuc Med and CT, 20 gauge and larger is the ideal but 22 gauge is the last resort.  Focused, confidence, and prayer is the key before attempting. If you  had a rough night and didn't get any sleep, don't be shy to asked for help. 

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All so very true! I always tell patients that get annoyed if you miss , that "it's not as easy as you think it is"!

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Specializes in CEN, Firefighter/Paramedic.

Learn ultrasound, LOL

 

honestly im to the point now where I don't go digging or praying small veins will hold up.  If they look like a hard stick or spider veins, I just grab the ultrasound and drop an 18 into the gorgeous vein nearly everyone has in their anterior forearm.  

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