A calm start ~ Ensure the patient is comfortable and sufficiently warm to prevent vasoconstriction, allay his apprehension, have him understand the
necessity of the procedure and how best he may help.
Gravity & Position ~Hang the patient's arm down as low as possible, to employ gravity to assist in the venous filling. Raise the gurney sufficiently high
that you can work in good light without hurting your back. If the intended site is distal, kneel or seat yourself so that you can work closely and steadily. For
lower-extremity IV's, one may need to dangle the limb over the side of the bed to encourage dependent filling of vessels. If the patient is hypovolemic or in
shock, one may need to tilt the bed head-down in Trendelenburg's Position to permit access, or to fill neck-veins for access and minimize air embolism. If the
patient is on the floor or the bed cannot be tilted, or the need is extreme, a helper may raise and hold the patient's legs as high as possible to achieve the
same effect.
Universal Precautions ~If the IV cannot be started with gloves on, ---it cannot and should not be started. The operator must protect himself with
adequate body-substance isolation at all times. Glasses, goggles, or splash shields, should also be worn. While some marginally feasible vessels may need, by
this rule, to be foregone, it is essential for operator safety to observe these precautions at all times. With increased practice, there need be no detriment to
one's "success-rate." Palpation, and IV access, are learned skills, and will grow to meet any occasion. ALL patients must be considered infective at all times.
It is NOT ACCEPTABLE to compromise precautions for any reason [this includes tearing off a finger tip of one's glove to permit palpation].
Shaving?: Never shave the patient to start an IV. It is not necessary and may cause nicks. I haven't shaved a patient for over a decade. If the skin and
hair is vigorously scrubbed widely around the intended venipuncture site and is clean and dry, the adhesive will stick well.
Removing Tape: Removing adhesive and dressings from the site is easy, and need not take any hair with it, if you will rub the tape with alcohol to soften
the adhesive. Pick up an edge dabbing at it at the edge with the alcohol while peeling back slowly at an acute angle in the direction in which the hair lies
down. Almost every hair will be spared, and the slightly greater time to do this allows you time to teach and talk with your patient who will be grateful for the
care that is taken.
Removing the Cannula ~ When removing an IV catheter, loosen the dressing. When it is free, place the adhesive bandage over the site while the needle is
still present. Withdraw the catheter while simultaneously pressing down with gauze to control bleeding. This is swift, bloodless, and discrete. If the patient has
an especially excitable and apprehensive imagination, distract his gaze and attention momentarily, perhaps, even by exclaiming some feigned startle towards
something which will require his gaze to be averted thus permitting you to quickly and smoothly withdraw the cannula unbeknownst to the patient. Steady
pressure for 2-3 minutes by you or the patient will stop any bleeding usually, but longer may be needed if anticoagulated, coagulopathic, larger gauge IVs or
marked hypertension. Acutely flexing the arm over the site may increase the size of the wound in the vessel wall which may increase the leak and should not
be done.
The Best Tourniquet ~Use an air-tight blood pressure cuff as your tourniquet. Invert it so that the tubings now run away from the lower part of the limb.
You will have a wider, softer, more comfortable tourniquet that compresses more evenly and effectively, and can exactly regulate the pressure needed to
achieve the effect.
Make the blood go where you want it to go: Always disinfect the insertion site in the direction of the venous flow so as to improve the filling of
the vein by pushing the blood past the one-way valves. Clean vigorously and widely in case a better vein presents itself nearby and to have the tape and
dressing adhere tightly to clean dry skin.
Nitroglycerin venodilation ~ To dilate a small vein, apply nitroglycerin ointment to the site for one to two minutes as you make last preparations.
Remove the ointment as you make your final disinfection of the site with alcohol. Used briefly, good vasodilatation occurs without significant systemic effect if
fully removed, and without the hassle of using hot moist towels.
Replace volume to improve veins: If the patient is volume-depleted, even a tiny IV can help replete and fill the veins. If not NPO, the patient may
drink or fluids may be instilled by nasogastric tube, to improve vein-filling. If a small distal IV or butterfly can be inserted (though not adequate in itself), filling
of the veins in the extremity can occur and retaining the tourniquet will help increase local engorgement.
Can't see a vein?: Trust your fingers even more than your eyes when trying to find a suitable vein.
What is this I feel? ~ A tendon may seem like the vein for which you are hoping, but palpating it through a range of motion may prove that it is not.
"Hardened" Veins? ~ If the vessel is hard, or scarred, try for another. Occasionally, one can, however, get through a scar to a usable portion of vein.
There is a risk of fraying or kinking the cannula, however.
Patient Reports ~Question, and believe, the patient about his previous IV history as to what is successful. But trust your own instincts and do not be
unduly daunted by the reports. He may never have had someone as good and careful as yourself, or so willing to pursue any reasonable alternative.
Awkward Angle? ~ Sometimes, when attempting a very superficial venule at an awkward angle, gently bending the needle into a slight arc without
collapsing the lumen will allow easier cannulation. Using a syringe as a "handle" may permit easier viewing or working angle, or a chance to stabilize the entire
unit by resting the heel of your needle hand on the limb or bed so that the other hand may more freely advance the catheter.
Difficult Advance? ~ Mild obstructions, tortuosity of the vessel, vessel fragility, and frictional resistance can often be overcome by "twirling" the catheter
hub, imparting a rotatory motion, as it is advanced to help glide over some points of hang-up. This will require a free and gentle hand or a trusted assistant.
Some "safety" cannulae with sheathing devices are more awkward with which to do this than older styles.
Less often used vessels: Consider uncommonly used vessels, even radical locations. Digits, medial wrists, basilic veins on the ulnar aspect of the
forearms, cutaneous veins of the thigh, shoulder, chest , mammaries, or scalp veins in adults.
Bottom's Up: Learn to work "upside-down" to take advantage of basilic veins under the forearm. It is frequently easiest to acutely flex the forearm at the
elbow (enhancing vein filling and minimizing "rolling" also), while facing the patient's feet to work on the now-exposed underside of the arm. An adequate
working angle can be gotten at times by full extension and hyper-pronation (inwardly rolling the arm until the palm is now up again). One may need to sit
lower than the arm to do this. Arthritic joints, contractures, spasticity or paralysis, may preclude this.
The Stroke Side?: Paralyzed limbs will usually be stable for an IV, but neither very forgiving of infiltration, nor, in permanent paralysis, having a
sufficiency of usable veins.
Right or Left? ~When feasible, it is a kindness and convenience to the patient to start the IV in the non-dominant side, but when veins are few there will
be more and larger ones on the side used most due to the greater exercise encouraging better and more collateral circulation. If the forearm is used, an IV
need not be bothersome to patient movement as the site will be more stable whereas those in the hand or antecubital fossa will impede flow as position is
changed and endure more intimal wear and tear to the vein with movement or require onerous splinting.
Out of the Way? ~ If, however, surgery or other major procedure is anticipated, the contra-lateral side is to be preferred for the greater convenience of
the surgeon or operator and of the anesthetist/airway management person.
A Moving Target ~ It is usually best if the patient is persuaded to completely relax the limb for the venipuncture. Some persons will tend to stiffen out of
apprehensionn or in the mistaken belief that this will help you . Worse still, is when the patient keeps trying to raise the arm in the same error so that one is
confronted with a moving floating target. I prefer that the patient recline on the bed rather than be bobbing in a "sitting" position. Drug addicts may do so, or
suggest using greater-than-systolic pressure of the tourniquet coupled with vigorous exercise of the arm or even "push-ups" to force engorgement of their
usually vasculopathic circulation. This method is detrimental to any sought-for laboratory specimens, and is mostly unnecessary.
Moving With the Moving Target ~When dealing with limb motion, or motion from the mobile environment (ambulance, air or watercraft, etc.), lock
the arm in extension and block flexion at the elbow. It may be necessary to tuck the distal part of the limb under one's own humerus or axilla to control
motion. Maintain braced contact positions of one's hands on the patient's limbs, be aware of and "get in the rhythm of the motion" of the vehicle or patient,
and perform venipuncture.
Sharps Safety & Volatile Situations ~ Use safe "needle-less" equipment whenever possible, especially with agitated or convulsing patients.
Retractable sheathing cannulae sets, such as Critikon� (Protectiv-Plus)�, should be used in such instances if at all possible. The patient may need to be
restrained, if need be, by overwhelming manpower or even "chemical restraint", to permit your safety from him while any sharp is exposed.
Continuous Drip or IV Lock: Whenever possible for other than brief infusion therapy, set up the IV as a Saline Lock, then prepare the infusion set,
thus for nursing and patient convenience one can readily change from continuous to intermittent infusion and preserve patient mobility. Be cautious,
however, at discharge that the patient has not already dressed and covered his overlooked IV lock in haste to leave. Verify discontinuation of any
intravenous device before discharge.
Flexible Blood Sampling ~ A "dry" lock set can be connected immediately to the catheter hub as the needle is withdrawn. This prevents leakage and
mess, allows a few moments to secure the IV, and to draw laboratory specimens through it before flushing. The flexible connection prevents wiggling and
tugging of the catheter or needle while changing lab tubes, etc. Labs in any quantity can be drawn from even the smallest cannula in this manner without
hemolysis if there is sufficient blood in the vessel.
Finger Tourniquet or Less ~If the patient is very hypertensive, and the vessels appear to be fragile or tense, one can decrease the chance of "blowing"
the vein or causing ecchymosis by using only finger tamponade to tourniquet the vein momentarily for the puncture, or even no tourniquet at all but merely
fixing the vein from rolling with distal and proximal traction.
"Tourniquet Sign" ~If a "positive tourniquet sign" of fresh petechiae under or distal to the tourniquet, be sure to check Platelets, Coagulation studies, and
Complete Blood Count, in addition to other studies planned. While dyscrasias may be found this way, remember also that tourniquet time may have been too
prolonged (which can also cause hemolysis in the specimen) or too forceful.
Think Small ~ Be willing to use even the smallest cannulae. Conventional thinking regarding desired size of cannula, unless immediate massive resuscitation
is needed, may often be discarded as delivery can be ensured through infusion pumps, pressure bags, syringe and stopcock, etc. One liter/hour via pump
equals 24 liters/day ~ more than most patients will require.
What Size Cannula? ~ Choose the cannula size with which you are most confident of inserting. If labs are essential, it may be necessary to downsize
your choice by one size to provide enough caliber of lumen that blood can easily flow around the cannula to allow it to be drawn. Too tight a fit can make it
impossible to draw labs at that site.
Think Small ~ Plan Ahead ~ "Vasculopathic" patients such as diabetics, patients with chronic steroid use or chemotherapy history, long history of IV
drug abuse, fragile vessels, extensive medical-surgical history with "used-up" veins, should have smaller cannulae used whenever feasible to preserve the
available vessel. If long term or frequent use is foreseen, plan prospectively and refer for PICC insertion, tunneled vascular access device, or other long-term
indwelling access. This should be done before the patient's veins are "used-up" so that useable vessels remain for emergency or for when vascular access
devices are infected or fail. IV drug abusers should be encouraged "to save a vein for the hospital !" It's worth trying; some will actually see the wisdom of
this.
Rapier or Broadsword? ~ Smaller needles are more flexible and whippy and may be deflected by a tough vein wall. Larger needles are stiffer and may
have the requisite ability to fix and penetrate the vessel.
Bigger=Thicker ~ Thinner needles and cannulae penetrate more easily. Larger sizes have a greater cross-section and exponentially increase the friction
resistance of penetrating skin and vessel. If distal traction is insufficient, or the resistance under-appreciated and the insertion is hesitant, one may have gained
the lumen and flash-back with the bevel of the needle and lose the IV by pushing the vein right off the needle with the additional bluntness and friction of the
catheter.
Local Anesthesia for Large Lines ~When preparing to insert a large needle, one can minimize the force and pain by first making a "pilot hole" with
a small needle. Local anesthetic may be deposited along the intended track. Insert to nearly the intended depth quickly, and raise a wheal of anesthetic such
as buffered lidocaine or bupivacaine, diphenhydramine, or even of normal saline, on the withdrawal of the needle. "Backing-out" the anesthetic in this way is
the least uncomfortable.
Transcutaneous Local Anesthesia ~EMLA� Cream [lidocaine and prilocaine] can be used in advance (45 minutes) as a local anesthetic through
intact skin at the intended puncture site.
Confusing the Nerves ~ Firmly rubbing the skin during the preparatory disinfection in itself diminishes the amount of perception of the needle.
When does it hurt?: Generally, there are only two significant moments of discomfort from the needle. The actual skin puncture, which should therefore
be with a quick and decisive thrust to shorten the moment of discomfort, and to a lesser extent, the "pop" into the vein itself. One may often explore or
manipulate freely in the subcutaneous area without any offensive discomfort. Most discomfort occurs with unintended deflection or probing into muscle,
tendon, or other non-vascular structures. This may be the clue that your needle has been deflected by hard or "rolling" veins and has missed the target. If
uncertain of safely entering the vessel on a single thrust, one may then "two-step" the insertion by separate punctures of skin and vein to allow greater care to
be taken.
Loose Skin? ~ Prior to insertion, loose skin and connective tissue may need to be fixed with stretching by the fingers both distally and proximally to
straighten and hold the vein in place. Very loose and thin skin may need to be drawn downwards from underneath by the hand in C-clamp fashion to fix its
position.
Sticking it in ~ Sticking it down to stay ~Extra steps to prevent loss of the difficult IV, might include using Compound Tincture of Benzoin, or
even Flexible Collodion, as a skin-protectant and "tackifier" so that tape sticks better and longer. Steri-Strips� ( will enhance the strength of the taping and
are already in convenient lengths. Stoma-Hesive� ( or Skin Blanket� ( can protect very fragile papyraceous skin, and stabilize very loose skin from
movement.
Securing it against loss ~ Protection of the IV by wrapping or splinting should be avoided whenever possible when planning your access. However,
to do so may be essential, with that "last available" vein, awkward locations (e.g. in digits, or protrusion of the hub beyond the knuckles), children below the
age of understanding and cooperation, delirium, etc. When it must be done, custom-design your protection for the problem at hand to meet any foreseeable
problem. Plastic domes may shield the site from tampering and still allow some visualization of the site.
"High Security" ~ Very agitated, delirious, and combative patients can have their IVs protected widely, above and below the insertion site, with 4" wide
Elastoplast� ( tape to resist removal by the patient. If need be, encase the circumference of the extremity with two hemi-cercumferential strips of the
Elastoplast �( under loose tension as the elasticity will allow for movement or swelling and prevent a tourniquet effect. If a T-set is used, access to the
injection port can be provided with a small slit in the tape.
"Now, That's A Splint!" ~Use splints rarely. Plan your IV to avoid their necessity. If splints are necessary to protect the IV or to prevent "positional"
alterations in flow, and the patient too easily bends the common foam and cardboard splint (even if doubled), maximal protection can be provided by using
plaster-of-paris splint roll materials, with warm water [to speed setting time] so that the extremity is rigidly fixed. Bias-cut Stockinet is used for the bandage
in Figure of Eight fashion [this will secure well, yet allow for any swelling]. Malleable Aluminum/Foam splints may be used as excellent "outrigger" struts to
protect against "bumping" the end of the line, or to preserve the curve of the digit necessary to allow flow.
Weighty Matters ~ Weak but restless patients, such as infants and the feeble elderly, may have the extremity with the IV immobilized by weighting it
down on the bed by a 20 lb. sandbag on the tip of the splint, or two 10 lb. sandbags slung together straddling the limb.
Restrain Before Starting? ~ Infants and small children may need to have their limb splinted or restrained before starting the IV. {Remember to
include the tourniquet before securing the splint so as not to have to fish it through to begin the venipuncture, and to be able to remove it. It is best to have all
materials, alternatives and spares, within reach. Often, an assistant will be needed to secure the IV, advance the catheter, flush and test, etc.
Light Work ~In infants, veins can be located by transilluminating the skin or limb with a bright light such as a flashlight or an otoscope.
Hand Tools ~ Sometimes, the best tourniquet will be a human one, squeezing the limb above, while assisting in holding the patient.
Did It Leak? ~
The most sensitive indicator of extravasated fluid or "infiltration" is to transilluminate the skin with a small penlight and look for the
enhanced halo of light diffusion in the fluid filled area. Checking flow of infusion does not tell you where the fluid is going. Checking a "backflow" or aspirate
only tells you that the catheter tip communicates with blood, not whether the fluid infused leaks at some point.
How does it infuse? ~ If a small leak occurs at the point and moment of insertion, the vein may still be usable if the catheter tip can be fully advanced
proximal to the leakage. Observe carefully a test infusion of non-irritating fluid for any extravasation before other use.
Natural Motion ~ Taping down the tubing should always be done with regard to the natural movements of the body thus running all tubing laterally on the
limb in the direction of motion. You can prevent many future tubing tangles by "going with the flow."
Connectors=Disconnectors ~ Do not place tape directly over any connector. It may be necessary to "break into" the line to change tubing urgently,
rescue from any clot, bubble, or drug given in error, or to tighten a leaking connector. One or two stress tapings to prevent a direct yank upon an IV site if
the tubing is snagged should be sufficient. Do not tape down excessive loops or coils which shorten the working length of tubing. Except for stress taping IVs
of the hand or foot and ankle, one should not tape on the proximal side of a flexing joint. The IV will have positional variability of flow and may clot off
entirely. Do not wrap the tubing around a digit when taping [it makes it easier for the patient to clench and pull out or alter the flow. Merely double-back the
tubing with a short loop and secure well. It is appropriate to tape central line connectors to prevent exsanguination or air embolism if the line separates.
Spare Access/Other Purposes ~ Plan ahead. If the patient with hemorrhage is hemodynamically stable so that the customary second IV access is
not actively needed for transfusion or resuscitation, "lock" the access so that it might be used to obtain serial lab studies without repeated venipuncture of the
patient.
Drawing from the Line ~An IV or lock may be used to obtain lab specimens. Stop the flow for one or two minutes if an infusion has been running. If
there is poor flow in the vein, or to clear a drug or solution that might alter the lab results, elevate and "drain" the limb. Apply a tourniquet. Draw a "waste"
with a spare Vacutainer ( to discard, or, if the patient needs all the cells or fluid he can get, do so with a syringe, obtain the specimens, and "return" his cells
to him if it can be done promptly ( Hypertonic & Irritating Drugs ~ When planning the infusion or administration of any irritating drugs e.g. 50% Dextrose, Phenytoin, or Potassium, try
to use a smaller catheter in a large-bore vein so that flow-around dilution will occur and less intimal damage or pain.
Numbing Potassium ~ "Phlebodynia" or "vein-pain" from Potassium can be diminished by adding 10 mg. (1ml. of 1% Lidocaine to each 10mEq aliquot
of Potassium, and prompt relief by an IV push of 10 mg Lidocaine. Total dose should not exceed 50 mgs/hour.
Phenytoin Infusions ~ If the patient can tolerate the fluid, irritation by Phenytoin can be prevented by putting the usual one gram loading dose in a 250 ml
bag of NS (well-mixed); higher doses can go in a 500 ml bag or maintain a ratio of 50mg/50ml. This also minimizes the hypotensating effects of the infusion.
Patients who have been convulsing sufficiently to require intravenous loading also are somewhat volume contracted which will be eased by the additional
fluid. This irritating effect from the propylene glycol carrier of the phenytoin is entirely obiated by the newer and more expensive "pro-drug" Fosphenytoin
which is in a non-irritating aqueous solution. Additionally, although the same side effects can occur as with Phenytoin, they appear less frequently and more
rapid "loading" can be accomplished, up to 150 milligrams Phenytoin Equivalent per minute with care.
Hypertonic "pushes" ~ Other hypertonic drugs, such as 50% Dextrose or Sodium Bicarbonate given as a "push" should be administered slowly under
constant observation to spot extravasation and with frequent aspirations to check patency.
Slow Infusion via Lock: When administering drugs slowly through a lock but with minimal volumes of fluid, use the "two-syringe" method. Insert the
drug syringe to the port at the cannula hub. Insert the flush syringe at the next distal port of the T-set or extension tubing. Give the drug slowly and
incrementally while carrying it into the circulation with fluid from the flush syringe. This allows great control of the infusion rate.
"Locking" the Lock ~ Clamp off the extension during positive pressure on the fluid to best maintain patency of the lumen; this helps prevent a
mini-aspirate of blood at the tip (when pressure is slack) which might become a clot...
The info on this page comes from Emergency Nursing World visit them @http://enw.org/TOC.htm
