IV success Help

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blachatch

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Alright my confidence is really starting to drop at clinicals when it comes to patient's with crappy veins. I was 0-3 the other day at even finding a vein! I have pretty good success when I can see them and feel a good vein. It's the 'dehydrated diarrhea for a week" patients that I can't get an IV for the life of me. The staff at the hospital doesn't really do a good job of helping either that's why I get stuck.

So any tips on what to do if a good vein isn't jumping out at me?
 
Get an anatomy atlas from the library. Look at where the major veins are and consult the book for common variations.

Particularly in the proximal upper extremity, there is not much deviation between the basilic and cephalic veins because of fetal development patterns.

Even if you cannot see them the veins are usually reliably there.

There are 3 major variations of the distal upper extremity. Knowing these helps a lot too.

IVs like many psychomotor skills require confidence. There is a reason it seems like surgeons have an attitude of know all can do all. it really helps.

Next time you do a clinical, get some easy ones first. That will help restore confidence.

All in all, nobody is really bad at IVs until they have done several hundred and still cannot reliably get them.
 
^^ Thanks.. yeah I really need to learn my anatomy and I think that will help.. I just don't have much confidence sticking if I can't see the vein.
 
Practice feeling for them.

Practice on everyone. Yourself, girlfriend, boyfriend, patients.

Even when you see big easy veins on patients, feel them. Follow their course. See if you can trace them from where you can see to where you cannot.
 
Notice the musculature as well. The large forearm vein always runs along the group of muscles that are flexed when you bend your wrist all the way back.

That leads back to the cephalic vein and then you can track back out of the crook of their arm and avoid a positional AC IV, but still get in something a little bit big.
 
Radial vein. Sorry. The large forearm vein I am talking about is the radial vein.
 
In addition to the other advice you've been given:

- Start a little distal to where you palpate the vein. You'll meet up with it as it becomes more prominent.

- Try an insertion angle (between the limb and the angiocath) much less than the 30 or 45 degrees you've been taught.

- If there's a bifurcation, aim right between the branches.

- For a superficial, "can't-miss" vein, try inserting the needle to either side, rather than right over the top. Intersect with the vein subcutaneously.

- Don't get caught up in "go big or go home" nonsense. An 18- or 20-gauge cath works fine in most cases, even for fluid.

- Don't obsess over location. In most cases, one attempt in an a/c is better than two in a hand.

- Cut yourself some slack, psychologically. You're new at this; you'll get better at it.
 
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mgr22 said:
- Don't get caught up in "go big or go home" nonsense. An 18- or 20-gauge cath works fine in most cases, even for fluid.
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I am of the mind that the larger needles have their own technique which must be learned seperately from the smaller ones.
 
Veneficus said:
I am of the mind that the larger needles have their own technique which must be learned seperately from the smaller ones.
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Yes. And I rarely go bigger than a 16. I miss a 14 every time. I don't actually mind because people so rarely actually need a 14.
 
abckidsmom said:
Yes. And I rarely go bigger than a 16. I miss a 14 every time. I don't actually mind because people so rarely actually need a 14.
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As much as I am not fond of admitting it, I have never started nor attempted a 14...

Biggest i've gone is 16...

Usually go with 18 if patient requires otherwise everyone gets a 20...
 
NYMedic828 said:
As much as I am not fond of admitting it, I have never started nor attempted a 14...

Biggest i've gone is 16...

Usually go with 18 if patient requires otherwise everyone gets a 20...
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I've gotten 14s, but only on young males in the summer.

I don't think it has to do with your cojones, it's just not necessary.

Bilateral 14s, full spinal immobilization and a non rebreather. ALS care in 1997.
 
abckidsmom said:
I've gotten 14s, but only on young males in the summer.

I don't think it has to do with your cojones, it's just not necessary.

Bilateral 14s, full spinal immobilization and a non rebreather. ALS care in 1997.
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That is why I don't even bother attempting it...

The difference in flow rate between the 16/14 seems minimal in the pre-hospital setting and I can squeeze the bag if need be.

I've never bothered with the bilateral IVs either. Our ambulances are set up with the stretcher off to one side so its a pain to comfortably/safely access the right arm sometimes.

The other thing i've noted when watching someone fail a 14, it does the exact opposite of fluid resuscitation... Those things bleed like sieve if you don't keep pressure on it for a few.
 
I do make sure to have two means of access in critical patients, sometimes in the same arm if needed. We have access to both sides of the patient in our huge medic units.
 
A trick I was taught for hitting those little veins lots of older folks seem to have is flipping the catheter so the bevel is facing downwards. As soon as you enter the vein you'll get a flash and don't run as high a chance of over penetrating and going right through the other side. Seems to work, but I always forget about it until I've already blown one or two attempts.
 
Thanks everyone I think it will take some time.. It's a simple skill but will take lots of time to become proficient at.. I didn't get to attempt any sticks today ( think the hospital staff gave me a break lol:rolleyes:)
 
Half of it is mental. If you pick a vein, stick with it and don't second guess yourself. The longer you doubt yourself the more you will psych yourself and stress the patient out too. When your going for the actual stick, make it a fluid process. Don't say "quick poke" and pause another 10 seconds. Have confidence and relax. Holding strong tension has also helped me in getting rolling veins of the older folks and tricky veins in general.
 
The thing I always tell my students is don't count down. "alright sir/ma'am, big poke in 3...2...1...*pt flinches*...miss. Just do "alright sir/ma'am/*insert name here*, big poke" Boom goes the dynamite.

Don't look, feel.

Just like any other skill it takes repetitions, they don't take as long to get good at as you'd think though.

A firm scrub with a prep can do wonders to help engorge a vein.

Bevel up. I hear all this stuff about bevel down on old people, tried it and it doesn't work for me but everyone has things that do and don't work for them.

Once you get a flash, drop your angle and advance a touch more, just cause the needle is in doesn't mean the cath is too, you need to go a bit further to make sure you aren't trying to tear through the side of the vein with a blunt plastic tube. Hold the flash chamber with the hand you started it with and use your thumb and index finger to advance the cath. Maybe it's just me but whenever I try to do the "one handed flick" I blow the line.

If you meet resistance don't force it, back up a touch and try to float it past the valve or pull the cath back and try to advance the needle through the valve.

Be quick about it, the quicker and more decisive you are with the stick the less likely the vein is to roll away from you, is less painful for the pt and, for me, has a higher first stick success rate.

Traction, traction, traction!

NYMedic828 said:
I've never bothered with the bilateral IVs either. Our ambulances are set up with the stretcher off to one side so its a pain to comfortably/safely access the right arm sometimes.
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I've gotten torn a new one by the Trauma Team for not having two lines on sick traumas. I mean, if you can't get it you can't get it but if you don't even try it's not pretty. We have access to both sides of the stretcher though.

For us large bore lines are 18g or larger. Generally use 16s over 14s though. My go to cath is an 18g. Our ERs prefer them over 20s because they can draw off of them, 20s usually draw unless you get lucky. Yes, I know about hemolysis but that's not what this thread is about.
 
It would seem type and quantity of IVs also varies by region as to how hospitals prefer things. Most traumas here I bring in with an 18 in one arm.

Almost every hospital in NYC immediately establishes their own IV upon arrival of a legitimate patient. Many prefer to start their own because it is felt the ambulance is not as much of a "clean" environment... As if these hospitals are cleaner :rofl:



Anyway, for the sake of actually staying on topic. If you need hell remembering the anatomy of the veins, take a look at your own arm. If you are like me your arms look like the Alaskan pipeline with a textbook picture of an anatomy book.
 
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NYMedic828 said:
Anyway, for the sake of actually staying on topic. If you need hell remembering the anatomy of the veins, take a look at your own arm. If you are like me your arms look like the Alaskan pipeline with a textbook picture of an anatomy book.
Click to expand...

It's a great thing I never got into drugs :lol: +1000 for helping with the anatomy!
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