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.
