r/nursing • u/msulliv4 RN - ER 🍕 • Jun 05 '23
Nursing Hacks IV insertion tips/tricks from a (sadly, former) ED nurse
so i am getting multiple DMs after my comment on a recent post about IV insertion and figured i'd just share with the whole gang. training other nurses in IV/USIV technique is one of my favorite things. please bear in mind that not everything described here is "best practice" but in emergencies with no access, you can't make them any deader, and you need access as soon as possible. yes, there are I/O guns, but not everyone is comfortable using them and *gasp* in the chaos of the ED, it often might not have been put back in the right place. or even better, dead batteries!
i approach this whole topic from a "where am i running into problems?" approach, in chronological order
confidence: being nervous WILL decrease your chances of a successful IV placement. if you seem confident, your patient is calmer, which makes everything easier. nervous patients also tend to tense up which makes the vein move, no bueno. also, get yourself into a comfortable position, with the patient's arm in an optimal position for YOUR insertion (Not necessarily too comfy for the patient) with good lighting. my success rate was significantly lower when i didn't have space to optimize our positioning.
finding a vein: first, using a chlorhexidine scrubber (the kind you have to snap to activate) to really wet the skin a) can help you see the vein better as it reflects light and b) using chlorhexidine as a sort of lube while rubbing the skin can get veins to pop up.
having the patient hang the arm off the side of the bed will also help make veins pop up more (thank you reddit friend!). gravity is your friend
so when you're first starting off really trying to get lines in, i recommend going for the low hanging fruit in the AC. these veins are not only (usually) palpable, but they're also sturdy and it's harder to blow these veins. feeling AC's will familiarize you with what good IV veins should feel like. sturdy, good-for-IV veins will feel like a bouncy rope that you can trace up/down the arm (at least for a few cms).
another tip is a bit of creativity. look in places you wouldn't always think to look, such as in the upper arm (many lean patients will have a very juicy one running up the middle of their bicep) or the posterior forearm (careful with these, they tend to be way more fragile than you'd expect and are prone to blowing). in emergencies i have gotten them in ankles, feet, legs, shoulders, breasts. please don't try this until you're very good at normal IVs. i cannot stress enough that these are last resorts in actual emergencies (during or peri-arrest), in the absence of anyone ultrasound-trained or with I/O access.
if you really can't feel anything but see some blue superficial veins, you can use these as a last resort but i recommend a few things here:
- use a smaller gauge (probably a 22 depending on the size)
- have your IV connector line flushed and hooked up to a saline flush
- once you see a flash, pop the tourniquet off, advance the needle and catheter a bit, then remove just the needle with whatever safety mechanism you have. then, very gently, connect the catheter to your flushed connector and gently "float" the IV in by simultaneously advancing and slowly flushing the catheter.
this doesn't always work, but in highly edematous patients, you can sometimes "push" the edema out of the way to help you see/feel the veins hiding beneath all that fluid.
i found the vein but it's rolling: this is where traction becomes super important. what i mean by that is grabbing the pt's arm with your non-dominant hand from BEHIND and gently tugging the skin in that direction. that will make the skin and soft tissue surrounding the vein taut and prevents rolling. for hand IVs, i use my non-dominant hand to “hold their hand” in a position like in the old movies where a monsieur kisses a mademoiselle’s hand lol. i use my thumb to pull all the hand skin down and this provides traction.
DO NOT FORGET ABOUT TRACTION!
also, if your angle is too shallow, you are striking the vein with more surface area on the needle which is the equivalent of cutting a tomato with a dull knife. carefully steepening your approach can be helpful (you obviously just have to be more careful when advancing the needle).
i got a flash but now i can't advance: take a close look at your angiocath (IV pre-insertion), before you even get close to the patient. what you'll notice is that the needle is slightly longer (1-2 mm) than the plastic catheter itself (the difference in length is proportional to the size of the angiocath; 18s have a bigger needle/cath length difference than 20s, 20s more than 22s, etc). when you see flash, that tells you the needle has been introduced into the vein, but it does not necessarily mean you've introduced the catheter into the vein. so when you're trying to advance and meet resistance, that's likely your catheter pushing on the outside of the vein with no secure site of entry.
to fix this, stop advancing as soon as you see a flash. then, without advancing, drop your angle so that it's not so steep. then, move the whole angio cath (plastic and needle together) about 2 mms (or whatever the needle/cath length difference is) to actually introduce your catheter. if you've introduced, you should be able to slide the catheter in and press your safety button to remove the needle.
i advanced the catheter into the vein but now i'm meeting resistance: you might be pushing up against a valve. there's some controversy on this, as damaging a valve can lead to longer-term problems (i've never seen this and am very careful with them using the following technique). try flushing your catheter while advancing, as this can help push the valve flaps out of the way and "let you in." worst case scenario, as long as your IV works, you can just leave it partially inserted and tell the patient/next RN to be super careful with it.
i keep blowing veins: this probably means you went "through and through" with your needle. this is more of an advanced technique but sometimes you can actually salvage these.
first, immediately pop the tourniquet off if you're seeing the vein blow. then, with your flush attached, gently pull the catheter out a little bit while trying to "pull blood." if you're able to pull your angiocath back into the lumen of the vein (but not out the other way, the way you came in), you may start to see blood return in your flush. if that's the case, try gently advancing your catheter now while flushing very gently. this can often get you "past the blow." obviously if you're flushing and the blow is getting bigger, it may be time to abort. again this is a more advanced technique.
the other common vein blowing scenario is when you're infusing or flushing into a delicate vein that just can't handle much pressure. you'll see this a lot in frail elderly patients. when i'm sticking them, i pop the tourniquet off as SOON as i see flash, as this will greatly reduce the pressure burden on the vein near my puncture.
please add any of your own in the comments!! and i cannot stress enough that once you feel confident with regular IVs, advocate for yourself and see what your hospital offers in way of ultrasound IV placement training. now that i do these i actually find them way way easier than the old fashioned way. it is an invaluable skill.
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u/maureeenponderosa CRNA, Propofol Monkey Jun 05 '23
This is so excellent!
Only thing I would add is in patients you know will have teeny tiny little veins (like grandma), I have them hang their arm off the cart/bed while I’m interviewing them to allow for a little engorgement of the vessels. That way by the time I’m ready to stick them they’re a little juicer.
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u/msulliv4 RN - ER 🍕 Jun 05 '23
omg yes i’m so mad i didn’t remember this. gonna add now. thank you!!
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u/maybaycao BSN, RN 🍕 Jun 05 '23
Good tip for fragile veins is to use a BP cuff as a tourniquet. This allows you to control the amount of pressure as too much of it can blow a fragile vein - I usually inflate to 30 mmHg. IV won't last long due to the hematoma. Once your IV is in, release the pressure otherwise the vein will blow.
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u/TheKirkendall RN - ER 🍕 Jun 06 '23
Phillips monitors have a "Venipuncture" mode on them that will inflate to cuff to roughly 30mmHg and hold it for a minute or two. Super useful!
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u/Professional-Belt805 Error 404: Hemoglobin Not Found Jun 06 '23
I’ve done it this way a few times myself. Worked like a charm.
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u/honeyheyhey RN - ICU 🍕 Jun 05 '23
2 things I'll add, you mention using a 22, they should be used more often! Keeping the catheter to vessel ratio of less than 45% is essential to preventing thrombus and phlebitis. Putting a massive catheter into a vessel that won't support will only lead to frustration for you and pain for the patient. In most cases for regular bedside nursing a 22 will be fine. The catheter will say how many mls/min it can handle, it may surprise you how much you can put through them. Additionally, it's a myth that you can only give blood through a 20. Research has shown that hemolysis only occurs at high rates of infusion.
Second, you mention looking at upper arms which I do recommend unless the patient has ESRD. Even if the patient already has a working fistula on the other arm, they fail all the time! You want preserve their vasculature as much as possible.
Great post!!
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u/NKate329 RN - ER 🍕 Jun 06 '23
We have diffusics IVs in addition to angiocaths. They have 3 holes in the end of the catheter, so the 22s can be used as a 20 for CT. I use them all the time for fragile veins.
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u/pushdose MSN, APRN 🍕 Jun 06 '23
A 22 Nexiva/Diffusic is maybe the best IV catheter ever invented. Too bad they’re so expensive.
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u/msulliv4 RN - ER 🍕 Jun 06 '23
omg i haaaate these lol. i feel like i had to throw every trick out the window learning how to use these. i just quit trying and stockpiled every angio cath i could get my hands on. it’s been a year and i still have IVs left lol
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u/bassetbullhuaha Custom Flair Jun 06 '23 edited Jun 06 '23
Garbage, pure flat out garbage. BD Insyte Autoguards for everything.
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u/ecobeast76 RN - ER 🍕 Jun 06 '23
They don’t thread easy! I hate them. I use them for hard sticks for ct contrast. I was at one facility where that’s all they had in each size. No angiocaths. Was so annoying!
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u/NKate329 RN - ER 🍕 Jun 06 '23
I slide the cath off the needle and then put it back as soon as I open the package. Just needs to be loosened up. I still use a 20 angio most of the time but just on the more fragile veins. The other thing is our angios are 1.16 in and the diffusics are only 1 in. Sometimes the vein just isn’t straight enough for that length.
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u/bassetbullhuaha Custom Flair Jun 06 '23
Our hospital switched to these and got 700 complaints within the system and got us back to our BD Insyte Autoguards. Hatetrid is very real for the Nexiva
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u/NKate329 RN - ER 🍕 Jun 06 '23
Haha, we have both. I’ve floated to a few other ERs in our system and none of them have the diffusics at all and I hate it when I have a hard stick. It’s also nice when you have someone who swears they’re a hard stick (whether they are or not) and they say “you have to use a butterfly!” I use to give the hardest eye roll and now I don’t even have to argue with them haha
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u/bassetbullhuaha Custom Flair Jun 06 '23
Ultrasound time! 2.25 in 18 in your bicep for being stupid with your butterfly talk
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u/hesdustydinkleman Jun 07 '23
Oh I absolutely show them and I don’t say it but I allow them to say “oh it is a butterfly”. Then when I get the vein that no one can ever seem to find, I tell them “good job” and when they say thanks I just tell them “oh I was talking to myself”
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u/Nurs3Rob RN - ICU 🍕 Jun 06 '23
The smaller IVs and CVR really need to be stressed. I’m cross trained for our VAT team and 95% of the IVs we place are 22 gauge. Even when the patient has a massive vein we still place 22. Why? Because flow rates on your average 22 are still in excess of 1 liter an hour. Ours are like 1.6L an hour. Even in ICU with 6 drips chained they almost never exceed that. So we use the small one with the smaller CVR that is less likely to cause complications and more likely to last a long time.
For traumas and CTAs we’ll go bigger of course but that’s a pretty small percentage of our patients.
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u/honeyheyhey RN - ICU 🍕 Jun 06 '23
It's such a huge misconception in our field that bigger=better. The amount of times I've been called in to replace an 18 and the entire vessel is thrombosed, it's too many times to count.
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u/Gone247365 RN — Cath Lab 🪠 | IR 🩻 | EP⚡ Jun 06 '23
For real! People don't realize how fast you can blast 1L into a good 22 with a pressure bag. Outside of rapid transfusion I'm happy with a good 22 for pretty much anything.
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u/NurseHugo Jun 05 '23
For the love of GOD if you have time, wrap each arm in a warm blanket for a few minutes before you look for an IV. It makes a huge difference when patients are cold vs warm. I also prefer using a manual blood pressure cuff at 60-80. Hurts the patient less and provides better pressure
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u/porneiastar Jun 06 '23
I was just gonna say, a warm compress will bring up some real beauts that were “flat” or nonexistent before. I use this especially for dehydrated patients.
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u/dsquaredsandie Jun 06 '23
Yes! But then I would have a confused old lady who removes the blanket as soon as I leave the room 😩
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Jun 06 '23
Reviewing a photo with basic anatomy of the larger blood vessels you should try to hit - radial, ulnar, cephalic, brachial, basilic. Helpful for everyone not just ultrasound.
Also I teach people to feel for the place where the primary forearm vein crosses the bone. And feel and “bouncy-ness” are always more important than what you see.
I also show brand new nursing students how to insert an IV into a nasal cannula held down on a clipboard. You can also demonstrate stabilizing a rolling vein with this method.
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u/PB111 RN - ER 🍕 Jun 06 '23
Damn I love the nasal cannula idea. I’ve mostly been trying to show them with my shitty hand drawings, this sounds way better.
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Jun 06 '23
Yeah it is awesome because it’s transparent and you can show them what it looks like to go through the vein, lower the angle, the feeling of “give” when you get through a tough vein, etc.
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u/larbee22 Jun 06 '23
For people with larger arms I usually use two tourniquets laid on top of one another. For some reason that amount of pressure makes deeper veins pop for me. I’m a hand girl, as I work in endo and it’s just easier there positioning wise- I usually have the pt make a fist around my two fingers, my pointer and middle finger. Then I have them keep that position while I put the IV in. Also, don’t forget that you can take the pts armband off. There’s usually a lovely wrist vein hiding under there 🤩
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u/pushdose MSN, APRN 🍕 Jun 06 '23
this is an incredible technique
They use an Esmarch tourniquet here in the video to “reverse” blood flow in the arm. You can also use a 6” wide ACE bandage (readily available) and achieve similarly incredible results. You wrap the arm starting from the bicep, very tightly, down to the mid forearm. Squeezing the blood towards the hand. It makes veins pop up that you never thought were there.
This is for really hard sticks that you just can’t see or feel anything with a regular tourniquet.
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u/LilTeats4u BSN, RN 🍕 Jun 06 '23
Wouldn’t this put immense pressure on the valves in the veins and potentially cause damage?
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u/pushdose MSN, APRN 🍕 Jun 06 '23
It’s only for a minute while you get the IV. These people have shit veins anyway. And it’s not immense pressure. I’d wager your compression stockings get about as tight.
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u/Responsible-Mode-432 BSN, RN. ER 🎪 Jun 07 '23
30yrs as an RN in the ER and this is a first, I default to a maunual BP cuff for hard sticks and it always gets the job done. This I imagine is very similar, thanks for sharing!
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u/Nurse49 RN - ICU 🍕 Jun 06 '23
For my older patients I usually use a looser tourniquet. I find too much back pressure increases their likelihood of the vein blowing.
And for my young especially female patients, I crank that tourniquet down. They’re often the hardest for me to palpate or stick. And they can handle the extra pressure. Usually.
Also, don’t be afraid to ask where they usually get IVs. Especially older folks often know exactly which sites work best for them.
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u/HeyLookATaco RN 🍕 Jun 06 '23
My best learning experiences have been on IV drug users. Yes, their veins are trash. But they give AMAZING advice. They know which veins work and which ones they've overused, what direction they go, what landmarks to use if they're tatted up and you can't see much, and they generally have a pretty easy going attitude about mistakes. One of my first nights on the floor an IV meth user talked me through his veins, laid his arm across my lap and said "just wake me up when you're done." Then he immediately started snoring and I got a stress free educational experience.
Bless you, buddy, wherever you are.
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u/mouse_cookies RN - Telemetry 🍕 Jun 06 '23
When I worked med/surge on a floor heavy with confused and IVDA patients, I honed my IV skills on that population because they didn't mind if you tried more than once or twice.
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u/TurbulentSetting2020 Jun 06 '23
This this this!!
There are sometimes older, frail pts that I don’t even use a tourniquet on! Their veins just can’t handle it!
Alf I almost always ask the pt where they usually have good success with IVs or blood draw! They will NEVER steer you wrong!
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u/Username30145 Jun 06 '23
What's a good way to practice IV skills if you don't have to do them at work? A banana? A specific bought or DIY kit?
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u/msulliv4 RN - ER 🍕 Jun 06 '23
sadly i wish i could give an easier answer. the key is to try and fail dozens upon dozens of times on real patients.
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u/beleafinyoself BSN, RN 🍕 Jun 06 '23
You don't really need a kit but you should at least get used to tying a tourniquet and being able to release with one hand, plus the motion of inserting the needle and advancing the catheter with your index finger (or whatever finger). I think I used a pincushion to practice. Also, placing practice palpitating veins on all your friends. In my opinion it's better to feel for a good vein than look for one. That way, when you do get to try on a live patient, you are already familiar with everything you can be
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u/Keurigthecoffeemaker RN - ER 🍕 Jun 06 '23
I learned to get my technique down with a straw and tape, tape down the straw onto a table and get the technique of whatever way you like to slide the cath in!
It helped me a lot with muscle memory and learning different ways to feed a cath in that I felt comfy with
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u/Michren1298 BSN, RN 🍕 Jun 06 '23
I used to just have them use the clear side of the package the IV came in. I like the straw idea. It isn’t wasteful and seems a little better. Thanks.
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u/Nurse49 RN - ICU 🍕 Jun 06 '23
You can sometimes use a glove taped over IV tubing. It isn’t perfect, but can help give a rough estimation of palpating for a vein and how to anchor then advance both needle then catheter.
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u/ribsforbreakfast RN 🍕 Jun 06 '23
When I was in nursing school they had us practice on an orange at home. Mostly to get the mechanics of sticking/threading.
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u/chick_nerd RN - Med/Surg 🍕 Jun 06 '23 edited Jun 06 '23
Thank you for this! I have yet to successfully insert an IV ( only 3 attempts). Hopefully this will help me get at least one before I graduate.
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u/texaspoontappa93 RN - Vascular Access, Infusion Jun 06 '23
Does nobody else double tourniquet?? Throwing an extra tourniquet on my fluffy patients helps me find veins I couldn’t even feel before. You can also get way more pressure without sheering the skin
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u/bcwarr RN, CEN, CCRN, FP-C Jun 06 '23
Blood pressure cuff inflated to 60 is the best thing I’ve found for big arms as well as fragile elderly arms. No skin trauma and better vein pressure!
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u/ChickenSedanwich BabyLand🍼 Jun 06 '23
Love this thread!! My tip: If you’re having trouble advancing and can’t flush your catheter in but the vein isn’t blown, you might be hitting a valve. Use your flush to pull back to draw blood, pulling the valve open with pressure. While pulling back, try advancing the catheter. If it works, it works!
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u/Michren1298 BSN, RN 🍕 Jun 06 '23
Look for that nice juicy radial vein that runs up the forearm along the radius. It may be hard to see, but you can feel it. It is my favorite go to spot for an IV and they last forever. I put a small chlorahexadine patch on it and then the dressing only needs to be changed once a week like a PICC.
I do float a lot of IVs in but it was hard for me to explain. I demonstrate. I’m saving your post so I can explain to new nurses when I precept. Thanks for writing it all out!
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u/stobors RN - ER 🍕 Jun 06 '23
Look at your veins in the hands/wrists/forearms/AC. Palpate and locate yours. People's anatomy varies slightly but is mostly similar to yours. Follow your guide.
Don't be afraid to explore uncharted territory. I had an iv drug user who told me his best vein was the one above his knee running up his inner thigh. 16g placed. Inside the wrist typically has a nice straight one running between the tendons. Very tender area but workable. Alongside the index finger is a good one. The thumb has good ones.
Ask the patient if possible, especially if they have health problems and need to be stuck often.
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u/VMoney9 RN, BSN, OCN, OMFG SKITTLES! Jun 05 '23
I've been downvoted here for saying "splurge for a veinlite", but I won't place an IV on a granny or a 25YO bodybuilder without one. I'm one of the best sticks in my oncology infusion unit.
You can see veins you can't feel. It holds down rolling veins. You line up the light and you can look away for a moment, knowing that the target is still centered. Even if it doesn't light up the vein and I can just feel it, my targeting remains true.
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u/NurseHugo Jun 05 '23
I have been trying SO hard to get my unit to buy one of these. Nobody in this hospital has used one. They are to DIE for, just for spotting valves even!
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u/VMoney9 RN, BSN, OCN, OMFG SKITTLES! Jun 05 '23
I like the Accuvein to go shopping around the arms and identifying valves, but I always switch to my Veinlite for the placement. I like how it holds the skin and vein in place.
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u/NurseHugo Jun 05 '23
You will have to educate me a little, are the accuvein and veinlite two different devices or modes on the same device? It’s been a while!
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u/VMoney9 RN, BSN, OCN, OMFG SKITTLES! Jun 05 '23
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u/readorignoreit RN 🍕 Jun 06 '23
Didn’t even know this existed… which model did you get?
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u/VMoney9 RN, BSN, OCN, OMFG SKITTLES! Jun 06 '23
I paid $474 for the Veinlite Plus. I just did a brief search on the prices and options. To be honest, based on how it works, the EMS pro could be better for placement. You'll need to take more time searching, but it probably lights up the vein better once you've found your site.
I don't know, I've never used it, but that's my theory I'm making, and I've been drinking.
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u/Michren1298 BSN, RN 🍕 Jun 06 '23
After doing IVs without one for over twenty years, I have a hard time using a vein finder. Some people love them though. I’m strictly a palpate person while I chat up the patient to try to put them at ease. Then I grab my gloves and get ready.
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u/ruca_rox RN, CCM 🍕 Jun 05 '23
I agree with this, if it's a good vein light. It can really make a difference.
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u/texaspoontappa93 RN - Vascular Access, Infusion Jun 06 '23
The vein light only helps with a very particular vein for me. It has to be just deep enough that I can’t palpate it well but shallow enough that the light can see. I’m also afraid of becoming dependent because I don’t wanna be a deer in headlights when it breaks
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u/theshuttledriver Jun 05 '23 edited Jun 06 '23
Great pearls here.
Can someone speak to the notion of “dropping” the IV once you get flash, prior to advancing further? So that you pass the lumens of the vein with the catheter itself and not just the needle tip?
I feel like I was taught this method in school, but in practice I do not do this, and find that most often when learners are working with me, this very motion is what causes them to infiltrate veins.
I teach that the end of your IV is a scalpel, so pivoting the edge around inside the vein is “ILL ADVISED”. The margin for error is millimeters. And it’s blind. So idk. Never made sense to me.
Rather, what I do, and what I teach my interns and learners, is to begin and advance with a steady low angle. If this is wrong, change my mind! Explain like I’m 5.
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Jun 06 '23
I do drop, you’ll have to drop more for a deep vein with a smaller radius so you don’t go through it (easy to visualize with US). You don’t really have to drop too much if you’re hitting a shallow vein since your angle is already closer to parallel to the vein if that makes sense.
I find that most new learners have the most difficulty getting the feel of that tiny distance you need to advance after the flash. Most people advance too much.
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Jun 06 '23 edited Jun 06 '23
Dropping the needle is the wrong mental image. What you actually accomplish with that motion is raising the tip, getting it away from the walls so you can advance the catheter without slicing through again.
The top of the bevel isn't sharp. You can even pick up the needle, raise the vein up off the skin, and begin threading your catheter with the needle if you want. You're trying to get the pointy tip of the needle away from the walls and the tip is on the bottom. Dropping the part outside their body is basically incidental.
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u/theshuttledriver Jun 06 '23
Well it’s a lever, so what you drop on the outside lifts the bevel inside the vein. What I’m saying is, it’s quite a bit of play for a space less than a cm. Im not sure if it achieves anything more than just going in at a constant low angle. In 10 years experience I’ve had no issue with that approach, but they teach it differently in the schools.
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u/beleafinyoself BSN, RN 🍕 Jun 06 '23
I guess it depends on what you consider a low angle? 30 degrees? Less?
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u/einebiene RN - vein whisperer Jun 06 '23
Hard sticks::
Large gloves with hot water to likely sites (acs and hands). Don't be afraid to double tourniquet UNLESS you have mister 'I can see your veins from a mile.away' or mee-maw who you can see veins but is on thinners. Gravity is your friend.
Once you get flash, lower the angle, then LIFT the entire catheter a little, advance. This prevents going through the vein.
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u/Substantial_Sun_8961 RN, BSN, CPEN Jun 06 '23
You literally covered every tip I’ve been taught starting IVs in the ER 😂
Special tips for kiddos, since that’s my specialty
Most babies/toddlers have their best veins in their hands and feet, and putting IVs in the AC of a squirmy toddler just means you’re going to be running back to the pump every 10 minutes when they shift and occlude the catheter. Please please please try hands first, plus if you blow distal, you can always go proximal but the reverse is not always true.
When sticking hands, most hand veins are hella superficial. If you go in at a 45 degree angle on a pediatric hand vein, you’ll go right through it half the time, even if you immediately level after it flashes. For hands, once you’ve gotten through the skin, drop the angle of your catheter to between 5-10 degrees, and you’ll have a lot better luck hitting hand veins.
If you’re starting an IV on a kiddo, and you have ANY doubt about their ability to hold still, go get help holding the arm. Pediatric veins are already smaller, and them jerking their arm every 5-10 seconds makes impossible to start lines. Hold by pushing your thumb into their posterior elbow and wrapping your fingers around their elbow, spanning the joint, which will prevent them from bending their arm very effectively. If they’re still moving the arm, you can add an additional hand to immobilize the shoulder joint at the same time. If all else fails, burrito the toddler. Take a sheet and get them swaddled tightly, leaving whatever arm you want to poke out of the swaddle. The vast majority of toddlers cannot get out of a sheet swaddle, and for a really angry kiddo, it can at least take care of three limbs while a person holds the fourth.
And don’t be afraid of baby feet! The saphenous veins in a baby are often great places for IVs as they’re bigger veins that are fairly sturdy.
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u/kkmockingbird Jun 07 '23
Peds doc but we had to place all IVs at my residency (ugh). Scalp is also a backup option for young babies. (I found art lines/sticks to be easier on babies and toddlers due to the angle and landmarks. Do not miss placing those IVs lol.)
Finally just a shout out of appreciation for the US. I had never seen it so up close as when I had an MRI earlier this year and it was used on me. It was a damn good IV. If I was placing IVs now I’d definitely get trained.
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u/noeustressallowed Jun 06 '23
I'm a newer nurse but I watched/learned from our nurse that's really good at putting IVs.
They taught me to use a tied up glove filled with warm water and place it where you're about to insert. When a vein is rolling you can try inserting parallel to where the vein is and when you're under the skin try to chase the vein, on top of traction and anchoring. Double tourniqet can help sometimes and make sure it's flat to the skin and not all rolled up.
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u/hereigoagain-onmyown RN - NICU 🍕 Jun 06 '23
Now who has the nicu version of this cheat sheet as a lot of this sadly does not pertain to our population! Great tips and refreshers to read though!
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u/atepidreception RN - ER 🍕 Jun 06 '23
I wanna reiterate what earlier commenters were saying about using a bp cuff as a tourniquet, especially for the older folks more prone to blowing veins, and will further offer this advice: look to your monitors for help!!! Several types of monitors have a venipuncture feature (Philips, Nihon kohden are two I've used). On the Philips at least this involves touching the bp measurement on the screen to open up the menu and then scrolling down until you see venipuncture. It's usually somewhere near where you adjust your auto frequency. The benefit is that they should in theory be able to inflate juuuuust enough to occlude, no more. They're usually programmed to only stay inflated for two minutes, so if you've got a long search ahead of you you might have to be positioned close to the monitor or have a coworker nearby to hit the button again.
Another tip, especially for the fluffy: look for scars. A trained eye can spot the small scar sometimes left behind from a previous IV. If you have a patient who's been in the hospital several times and is a hard stick with nothing popping up at you, use them as a guide, a treasure map even! If you can't palpate under it you may just have to go at a deeper angle. I see these a lot in the ACs. If they say they've needed ultrasound-guided in the past, don't be shy about advancing that needle (slowly and carefully!) past the point where you'd expect to be hitting flash. Those US lines go deep. Just be mindful that if you're hitting a vein buried below a lot of tissue with a normal length catheter it may not be appropriate for CT contrast. The pressure of that contrast infusion can be too much and dislodge a catheter that isn't very well-nested inside the vein.
A final thought my husband swears by: women usually have a vein about smack-dab in the middle of the AC on the LEFT side. Not the right, and not sure men have the same, but it's a common anatomy. If you're in a pinch and up the proverbial creek and resorting to blind sticks, it's not a bad place to go.
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u/HeyLookATaco RN 🍕 Jun 06 '23
Holy shit. Left AC, not the right, you're spot on. Just checked myself and everyone at the nurses station. Thank you, you sorceress.
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u/msulliv4 RN - ER 🍕 Jun 06 '23
excellent pearl re: scars. a goldmine often hides beneath. thanks for adding :-)
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u/Solvair Jun 06 '23
This is really good! As an ED tech for too long, I've mentioned many of these things when I'm training others on IVs, ill add a few of my own as well
-If your patient has fragile skin/prone to skin tears (often their skin looks like paper mache), ill often tie the tourniquet on top of their gown
-To add to the "gravity is your friend", so is the edge of the bed. Use the edge as a fulcrum to assist the patient to keep their arm straight. Having them fully flat with their arm hanging off is usually ideal, it's often not comfortable or practical. Having them laying at around 30 degrees, relaxing their arm with their elbow on the side of the stretcher is often best (for me)
-There is an ergonomic element to this....for you. Put the bed up high (or you sit) where the patient is in a position of comfort for you (if you can). Having the patient sit at a near 90 degrees will make doing an IV harder. If you're uncomfortable you'll be prone to rush to stop the discomfort. Also save your back. If your patient isnt keeping their arm straight (altered reasons, not constricted reasons) you can try putting your leg up on the stretcher bottom and put their hand beside your knee and gently press down to straighten their arm. It's easier to show this than explain it! Ideally have someone help hold their arm.
-Be familiar with your needles. Their width is not the only difference. For the ones that I use, the blood will move up the catheter on a 20g and 22g while the needle is still there, but not the 18g. Also, the 18g is longer so you need to account for that length when looking at your vein and choosing the site of insertion. You don't want to have it (ideally) sticking halfway out because you're up against a bifurcation.
-From my personal experience, right arms seem to be better than the left. I don't ask the patient their IV site preference anymore and generally start at the right AC. If I don't go here the provider WILL order a CT angio and ill have to come back in here again and do another IV (they require a minimum of 18g in the AC, but will begrudgingly accept a 20g)
-When actually inserting the IV don't free float your hand. Meaning you should have your IV hand (last 3 fingers) resting on your patient. This will keep your hand stable and will help increase your chances of not getting it pulled out should your patient pull their arm back (especially with kids)
-A perfect site for IV insertion, especially on a patient with rolling veins, is when their veins make an upside down Y. You use the two side veins as "walls" to prevent the roll and you put the IV into the middle. (hopefully that makes sense)
-A tip I found after our ER upgraded our needles and everyone was blowing veins... In the beginning I recommend newer people to manually take the wing and guide it into the vein. The people teaching IVs were often telling people to press down on the hub and push the catheter in. I have found that often when pressing down people move their hand in more too (which moves the needle also) and end up blowing the vein. So once you're ready to push it in, take the wing and guide it in until you're more comfortable in your IV skills and have a more controlled touch.
-Even if you can't get the IV but can get blood (probably only relevant to ER), do it. Sometimes they don't need an IV and the initial blood work is all they really want.
-If your IV flushes but doesn't pull, congratulations! You made what I (we?) call a medic line (it flushes but doesn't pull any blood) keep the IV. Often straight sticking a patient is easier than an IV as you just need a small spot vs a "runway".
-Speaking of runways, make sure you feel above and below the site of insertion. Does it curve? Bifurcate? Are there obvious valves? You need to have a bit of a stretch for the catheter to be there. You can always go a little lower than your site to catch the vein you do feel further up.
-Be mindful of where your insertion site is. If you're going in the AC and put it in directly in the bend or even worse, above slightly, you will make the patient effectively not be able to bend their arm or do so with great pain/discomfort. Avoid this if you can
-A more advanced technique, but if you did go through the vein and it didn't blow up, you can retract the needle, drop the hub and slowly pull it back. When you see the blood flow into the hub, push the catheter back in and see if it can flush/float it into the vein. ***Note, the 'know your equipment' part is important here. This is something that I can do with my needles... It has a valve in the hub to prevent blood flowing everywhere, prior ones did not have these.
-Pet peeve version.... When taping up your tubing to the patient... Please don't tape it onto the tegaderm. If I have to straighten the tubing or whatever, it's difficult to remove the tegaderm/tape combo. Tegaderm also doesn't restick well. Tape it separately on the patient.
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u/HookerofMemoryLane Street Medicine, Homeless Healthcare Jun 06 '23
Saved immediately. If I could cite this, I would.
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Jun 06 '23
Heating pads can help the veins “pop” a bit more too.
Interesting that you say the posterior forearm veins tend to blow…I usually put my IVs there or above the posterior wrist and they last days. Anterior forearms never last. Maybe we just have very different experiences!
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Jun 06 '23
Ok so I have a question for ya. I’m in cicu, which often means a decent bit of edema, often on heavy set patients to begin with. Any advice on blind sticks? I try to avoid it unless it’s absolutely necessary (nothing visible, nothing bouncy with a tourniquet, and nobody US certified available) I check hands, knuckles, UA, AC, shoulder, the meaty part of the FA, but on some of these folks, they’re just so edematous, that there’s nothing visible or feelable(that can’t be a word).
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u/einebiene RN - vein whisperer Jun 06 '23
First add heat to the likely sites (i do large gloves filled with hot water to ac and hand). Give it couple of minutes. Double tourniquet. Palpate.
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u/msulliv4 RN - ER 🍕 Jun 06 '23
i feel you. i’m in CICU now. i almost exclusively place ultrasound lines now. i know this is very unhelpful lol but some patients are just 100% not gonna work going the old fashioned route
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u/images-ofbrokenlight RN - PICU 🍕 Jun 06 '23
Anyone out there have peds/nicu tricks?
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u/survivorbae RN 🍕 Jun 06 '23
For babies: Idk if these are obvious or not but I generally use a 24 short (14mm instead of 19mm) for anything under 6 months. Use a hot pack to warm up the vein. The saphenous vein is often your best bet if there’s nothing obvious in the hands. I angle shallower on babies. Cut the tourniquet in half lengthwise so it’s narrower and isn’t covering half their arm. I also cut the dressing in half for the same reason. Get the parent to give the baby sucrose as you’re inserting. Swaddle the baby tightly, minus the limb you plan to poke. Get the parent or a coworker to help hold the baby. Make sure to use an arm board and tape it up really well!
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u/NeuroticNurse LPN 🍕 Jun 06 '23
In regards to number three: more times than I’d like to admit, I accidentally dislodged a perfectly good Ivy, because I was too paranoid about pinching the patient’s skin while screwing the connector on. It happens every once in a while and I feel so bad every time
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u/bodielisi RN - ER 🍕 Jun 06 '23
All great tips. I found that after becoming proficient in ultrasound IVs that they became easier than regular ones as well. My body placement/angle and room to move are key.
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u/msulliv4 RN - ER 🍕 Jun 06 '23
absolutely. i have a near 100% success rate with the ultrasound. it’s nice because even if you make an error you can visualize exactly how to fix the problem. RNs i have found are scared to do it bc it involves a lot of failure at first but for me it’s exactly like riding a bike. once you get it, you got it.
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u/littlerayofsamshine Jun 06 '23
Try theivguy on Instagram. He has great videos showing some of the techniques this fabulous nurse has mentioned.
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u/msulliv4 RN - ER 🍕 Jun 06 '23
great advice, so much of this is really tough to understand or “get” without a visual
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u/porneiastar Jun 07 '23
I always ask my patients “Do you have any issues with IVs or blood draws? Where do they usually “stick” you?”
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u/Responsible-Mode-432 BSN, RN. ER 🎪 Jun 07 '23
I freaking love hard sticks. A trick I always teach new nurses is to use a manual BP cuff instead of a tourniquet. Pump up to appx 100mmhg and it will bring out beautiful veins you wouldn’t see otherwise.
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u/harveyjarvis69 RN - ER 🍕 Jun 06 '23
So I’m all about using a 22, but sometimes they are too flimsy. This takes practice to tell but sometimes you need the bigger gauge to access.
For giant veins an 18 is honestly best, because the cath of a 20 can get stuck on the vein wall. But small, hardened veins could use the 20 just for access, just go slow after initial insertion.
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u/Tridil2000 Jun 06 '23
Do NOT put an IV in an adult foot or ankle EVER!! You’ll be sued in 4 seconds for ANY ISSUE!!
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u/msulliv4 RN - ER 🍕 Jun 06 '23
again, i’m talking emergent resus. peri arrest.also ive been in situations where the patient has no arms so, legs/ankles we go. risk vs benefit.
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u/LordoftheMonkeyHouse BSN, RN 🍕 Jun 06 '23
Great resource here, I don't do them as much anymore but this is just what I learned in ICU. Saving this to forward to newer nurses.
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u/Michren1298 BSN, RN 🍕 Jun 06 '23
I have used a BP cuff, but usually I like to double up on the tourniquets. I just hold them together and tie them on like normal.
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u/nursebarbie20 Nursing Student 🍕 Jun 06 '23
This should be a pinned post! Lots of excellent advice, thank you!
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u/doxiepowder RN - Neuro IR / ICU Jun 06 '23
If nothing is visible due to dehydration or everything is just deep then I will dangle their arm, put one tourniquet high up on the arm and a second one lower down. You can also inflate the BP cuff and then pop a tourniquet on distal.
Also if they're crunchy veins grab at least a 20ga. 22s are too soft to make it through plaque and sometimes to soft to even make it through leathery old farmer skin.
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u/Character_Roof_3889 RN - NPO, probably Jun 06 '23
Studies show dry heat works better at bringing veins to the surface than wet heat. Warm blankets and heat packs will do better than a wet washcloth.
If worst comes to worst and you need heat, but only have washcloths to work with; (this is NOT best practice) this can be used for more than just IV starts and can be done at home. Get a washcloth wet under the sink, pop it in the microwave for 30-60 seconds, put it in a plastic bag and wrap it in a pillow case for a last resort dry heat pack. Be very careful, wet washcloths don’t heat up evenly in the microwave.
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u/ECU_BSN Barb's Nipple Nut Hospice (perinatal loss and geri) Jun 06 '23
Wonder if this can be a pinned post for a bit? Thank you for the education!
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u/dsquaredsandie Jun 06 '23
How do you deal with somebody with a lot of subq tissue, I.e., chubby?
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u/msulliv4 RN - ER 🍕 Jun 06 '23
hey! so i was often surprised in the ED by how many people with a larger habitus have a nice AC vein. definitely try that first. nowadays i just go straight for the ultrasound.
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u/Vanners8888 RPN 🍕 Jun 06 '23
I’m in nursing school so this is so so so important to me. Thank you so much for sharing!!
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u/ruca_rox RN, CCM 🍕 Jun 05 '23 edited Jun 05 '23
Wow, this is fantastic! It is literally every single trick I have learned in 21 years. Thanks!!
And I hope I'm not the only one... but reading this kind of vein porn really makes me want to go stick an 18g in my partner's HUGE veins.