Accessing Delicate Veins

[atticrat]

Any ancient chineese secrets for sticks into delicate veins?

Here are mine,

Go as High as possible, -forearm instead of hand, ac instead of forearm....

Go as big as possible, vein not cath.

Bevel Down with cath.

Flush very slowly.

 

[socalmedic]

if you can try not to use a tourniquet that little bit extra can save the vein from blowing.

 

[medicRob]

Any ancient chineese secrets for sticks into delicate veins?

Here are mine,

Go as High as possible, -forearm instead of hand, ac instead of forearm....

Go as big as possible, vein not cath.

Bevel Down with cath.

Flush very slowly.

+1 for Bevel Down.

 

[MylesC]

Any ancient chineese secrets for sticks into delicate veins?

Here are mine,

Go as High as possible, -forearm instead of hand, ac instead of forearm....

Go as big as possible, vein not cath.

Bevel Down with cath.

Flush very slowly.

Heat packs if you got them. Of course they usually take forever to heat up... but why bevel down? Shouldnt it be up?

 

[LucidResq]

I've heard of bevel down for peds but was not given a reason.

 

[MylesC]

I hit send by mistake. I was always taught bevel up in my CPT class. is there a hidden trick of the trade that im missing? (oh do tell)

Maybe the bevel down makes sure you dont go right through a weak vein?

 

[socalmedic]

i do bevel down on any 22 or 24, the thought behind that is the length of the bevel is the same as the diameter of the catheter. it is hard for me to explain but with the bevel down you can advance further in with out going through the vein. also if you hit the bottom of the vein with bevel down it will do less damage and hopefully just slide along the inside of the vein instead of piercing it.

 

[MylesC]

Right on that makes perfect sence... thanks SOCAL ill try that on the next PT that comes through needing a draw B)

 

[atticrat]

Heat packs if you got them. Of course they usually take forever to heat up... but why bevel down? Shouldnt it be up?

Yes on typical pt's it is always bevel up. But with elderly, peds, tiny, and easy to blow veins I've had succees with the bevel down. Pretty much what socal said, it decreases the chance of advancing the cath through the other side of the vein blowing it out.

It's not a text book method as far as I know. I was shown the technique by a phenominal old school medic, and it's been in my tool bag since.

 

[mgr22]

i do bevel down on any 22 or 24, the thought behind that is the length of the bevel is the same as the diameter of the catheter. it is hard for me to explain but with the bevel down you can advance further in with out going through the vein. also if you hit the bottom of the vein with bevel down it will do less damage and hopefully just slide along the inside of the vein instead of piercing it.

The OP asked about delicate veins, not small veins. I haven't tried it, but I'm wondering if bevel-down might be more likely to tear, rather than pierce a delicate vein.

 

[atticrat]

The OP asked about delicate veins, not small veins. I haven't tried it, but I'm wondering if bevel-down might be more likely to tear, rather than pierce a delicate vein.

You adjust the angle of approach a bit so you penetrate with the bevel, think steeper angle. Then as soon as you are in drop the angle to advance.

Easier to show someone than type out instructions.

I've used it multiple times and it does work.

 

[medicRob]

The OP asked about delicate veins, not small veins. I haven't tried it, but I'm wondering if bevel-down might be more likely to tear, rather than pierce a delicate vein.

An online friend of mine, Kelly Grayson, Critical Care Paramedic and column writer for ems1.com wrote an interesting article on using the bevel-down technique. He explains the way the angles can change with bevel down and what that means for us with regard to IV therapy.

http://www.ems1.com/ems-training/articles/804343-The-bevel-down-technique/

 

[mgr22]

Atticrat, that actually does make sense. Thanks.

MedicRob, thanks for the article. I'll try it.

 

[medicRob]

Also, check out his article on the estimation of CVP based on assessment of jugular venous distention. Most medical textbooks show the angle of Louis to be 5 cmH20, However he is starting above the clavicles at 10 cmH20 (A bit on the high side of normal). This article particularly reminded me of the way to locate the angle of louis using 2 Q tips.

Anyways, here it is:

http://www.ems1.com/ems-products/me...ty-Fair-Evaluating-jugular-venous-distension/

 

[alphatrauma]

For those of you who are advocating and/or practicing this bevel down technique, I would give you this as food for thought:

You are using an invasive device in a way that it was not designed to be used. There are SCIENTIFIC clinical studies, published in medical journals, which show that bevel up is SUPERIOR to bevel down. If there are devices designed and approved by the manufacturer for both techniques, that is an entirely different situation.

If there is an adverse outcome as a result of an IV start, what will you tell your Chief.... or worse yet, the jury? You decided to go bevel down? Based on what clinical education or instruction? You read about it on EMT Life?

 

[medicRob]

For those of you who are advocating and/or practicing this bevel down technique, I would give you this as food for thought:

You are using an invasive device in a way that it was not designed to be used. There are SCIENTIFIC clinical studies, published in medical journals, which show that bevel up is SUPERIOR to bevel down. If there are devices designed and approved by the manufacturer for both techniques, that is an entirely different situation.

If there is an adverse outcome as a result of an IV start, what will you tell your Chief.... or worse yet, the jury? You decided to go bevel down? Based on what clinical education or instruction? You read about it on EMT Life?

Tell ya what. I will message Kelly, the writer of the article and ask him if he would like to come here and weigh in on the advantages and disadvantages of using bevel down.

Also, I am quite sure that wrappers weren't meant to be used as occlusive dressings either, but they work great. This is one of those old school tricks and tons of nurses
and Paramedics know this. As far as I know, the Pediatric IV Insertion bevel up vs down study by Black, et al was the only study of bevel up vs down and one shouldn't
dismiss something over 1 study. If I am not mistaken it was 33% bevel up success vs 30% bevel down. I would like to hear what Veneficus' opinion is on this matter.

 

[rhan101277]

if you can try not to use a tourniquet that little bit extra can save the vein from blowing.

I do this for old folks.

 

[alphatrauma]

Tell ya what. I will message Kelly, the writer of the article and ask him if he would like to come here and weigh in on the advantages and disadvantages of using bevel down.

I read Kelly's blog, and have nothing but the utmost respect for his experience in the profession... but it stops there, when it comes to off label use of invasive devices.

Also, I am quite sure that wrappers weren't meant to be used as occlusive dressings either, but they work great.

Not even close to being in the same realm or comparable to intravenous therapy.

As far as I know, the Pediatric IV Insertion bevel up vs down study by Black, et al was the only study of bevel up vs down and one shouldn't
dismiss something over 1 study. If I am not mistaken it was 33% bevel up success vs 30% bevel down. I would like to hear what Veneficus' opinion is on this matter.

I would argue, if bevel down is so effective (which it currently isn't), why are we not learning it in nursing school, paramedic school, etc...

Here is the same study - 75% vs 60% and 58% vs 42%, 1st and 2nd attempts respectively. The 33% and 30% you reference were related to infants weighing less than 5kg

Pediatric Emergency Care: Pediatric Intravenous Insertion

Veneficus' opinion would be just that, an opinion... which would not lend any credibility or validity to sanctioning the bevel down technique as accepted formal practice.

 

[medicRob]

I read Kelly's blog, and have nothing but the utmost respect for his experience in the profession... but it stops there, when it comes to off label use of invasive devices.



Not even close to being in the same realm or comparable to intravenous therapy.



I would argue, if bevel down is so effective (which it currently isn't), why are we not learning it in nursing school, paramedic school, etc...

Here is the same study - 75% vs 60% and 58% vs 42%, 1st and 2nd attempts respectively. The 33% and 30% you reference were related to infants weighing less than 5kg

Pediatric Emergency Care: Pediatric Intravenous Insertion

Veneficus' opinion would be just that, an opinion... which would not lend any credibility or validity to sanctioning the bevel down technique as accepted formal practice.

I was taught bevel down in nursing school for pediatrics. It was never covered in Paramedic school, however.. but neither is patellar percussion, tactile vocal fremitus, and other useful skills. Just because it is not commonly taught in EMS or Nursing programs doesn't mean it isn't effective.

 

[Shishkabob]

Taken from the same study you posted, in the conclusion:

The bevel-down technique might be useful in small infants.

Might / might not.