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I.V. Starts . . .
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--improving
your odds! |
| by
Tom
Trimble, RN CEN |
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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. |
| Enter
Confidently: Do not say
"I'm here to try and start your IV." Boldly
state "I'm here to start your IV." The patient will be encouraged by
your confidence, and you might believe it better yourself! "Are you good at it?"
"I'll do the best that anyone reasonably can!" (You have just promised an
earnest effort and set a limit to false hopes.) |
|
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. |
Stabilize
Your Position & Approach: Sit
whenever possible. Hold and stabilize the body part with your non-dominant
arm. Try to set up a "Three-Point Touchdown Landing":
1) Rest the heel of your dominant hand on the body part.
2) Lower your flexed thumb and index finger grasping the cannula controls to just touch.
3) Lower the flat-underside of the point gently, then firmly, against the skin; "I'm
just going to touch you right there so that you know where it is . . . (allow a
few moments as you are doing this to fatigue the nociceptors in the skin) . . . then, One,
Two, Three-e-e" (gently and quickly pop through the skin).
You will have the most stable and delicate approach, full control of the extremity, and
will have set up in the patient mental and physical conditions that make it least likely
for him to "jump." |
|
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]. |
| Failed? Give
A Reasonable Explanation: Explain
in frank and friendly manner, why it didn't work, as best as you can tell. Most patients
with "bad veins" know they do, and have been through it before. Even a plausible
explanation that you're not sure of may still be sufficient. It can be useful to say,
"These things sometimes happen. It's not your fault. It's not my fault. It
can just be the way it is this time. |
| 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 two decades. 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. Be sure that your proposed unusual
location is approved by local policies and is truly needed due to exigent
circumstances. Consider, also, using a "second-best
possibility", of which you are confident, to save the better vein for another day or
for someone who may need to find a suitable vein for this patient more than
you do presently, or as a fall-back plan. c.f.:
Peripheral Catheters Placed in Atypical Locations by Lynn Hadaway,
M.Ed. RNC CRNI |
| 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,
cardiac catheterization, 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. Don't forget to add extension tubing, and
possibly stopcocks. |
| 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 apprehension 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
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.
Avoid sticking an exposed sharp into the mattress. This is an unsafe
and unsanitary practice. The needle will be accidentally
knocked, covered, or overlooked, thus remaining dangerous to all who are near, and to the
patient. Puncturing the mattress cover converts the mattress pad into a "culture
medium" which can no longer be disinfected, and is the beginning of rips and
tears.
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| 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. |
| A Matter of
Gravity -Go With The Flow ! : It is
common to use a saline lock primarily, especially if the patient should be
fluid-restricted, as in renal failure or heart failure. However, if the patient is
unstable, being resuscitated, or is to undergo rapid sequence intubation, always
connect running infusion fluid. You must not waste time doing repeated flushes. Drugs that
drop blood pressure or cause a "rush" can be given slowly more easily via
a running line. The visible continuous drip monitors the quality of the flow so that the
patient does not receive the medication if the tubing is kinked or pinched only to rush in
rapidly when flow resumes and so that incompatible meds do not mix in the tubing instead
of flowing into the patient. |
| Watch The
Drip As You Secure The Line: Frequently in
rushed situations, a cannula can be taped with a little too much pull on the (elastic)
skin, so that it is drawn proximally and against a lumen wall, valve, or flexion point
which may slow or stop flow. This is especially true if the lock is flushed then taped.
Using running fluid will allow you to observe for best flow as you adjust final position
and tape. The time and aggravation saved during critical work will repay this effort.
If the tape job has pulled the cannula into a position where it
does not flow well, and there is no time to re-do the tape job, a temporary fix is to
place tape over the cannula hub and dressing and use traction to draw it distally and tape
against the skin.
|
| It's All
Downhill From Here:
If the patient needs
rapid volume replacement by gravity, remember to raise the pole as high as possible; if
still more flow is needed, remember to lower the bed further. (The higher the water tank
on the hill, the greater pressure and flow at the faucet in the valley.) This simple step
will buy time to set up a rapid infuser or pressure bag (Remember to evacuate air from the
bag if using positive pressure, and check the squeeze-ball pump on transfusion tubing, to
make sure you do not transmit a large venous air embolism to the patient. An available
tall helper may squeeze the bag, also. Use an extension tubing to ensure adequate length,
easy change-over, and safer transport. |
| 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. |
| Is This A
Hose?: Rapid flows are more easily achieved
with cannulae with larger diameter and shorter length. Flow increases by the square of the
diameter. Flow decreases with longer cannulae due to additional resistance. |
| How Many
Lines?: Stable patients will probably need
only one peripheral access, if well-chosen and secure. Additional lines (minimum=2) are
necessary for patients with major trauma, severe hemorrhage, hemodynamically unstable
medical patients, when rapid sequence intubation or resuscitation is likely, or multiple
incompatible drug infusions must occur. Peripheral access may be needed when a vascular
access device (e.g., Porta-Cath®, Broviac®, or Peripherally Inserted Central
Catheter) is deemed infected or otherwise compromised. |
|
Plan Ahead
For Diagnostic Studies: An increasingly
important consideration in planning cannula size and placement is the likely diagnostic
imaging strategy that the patient will need. If computed tomography (CT scan) with
intravenous contrast will be needed, e.g., spiral thoracic CT to rule out
pulmonary embolism, etc., then it is usually necessary to have a 20 gauge or 18
gauge or larger short cannula peripheral IV in place using an upper extremity. This is so
because the scan involves "power injection" of 75 milliliters of contrast at a
rate of 10-20 milliliters/second with pressures up to 300 p.s.i. The scan travel is timed
and calibrated to this injection rate as it seeks the pathology. This may be in
contradistinction to the perhaps lesser cannula requirements of the patient's clinical
condition. Central lines, peripherally inserted
central lines (PICC), and other vascular access devices (VAD), are usually excluded to
avoid rupture of the catheter. When such lines must be used, "hand"
injection is required and imposes some technical difficulty; planning for use of such
lines must be done at the physician level.
Whenever there is conflict between the feasibility of
available access and the technical requirements of proposed imaging studies, closely
involve the responsible physicians with the radiologists in planning and providing the
needed access.
|
| 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. Propose a policy that EMLA® can be placed by the Triage Nurse or first nurse to begin care
in cases such as children, oncology patients, etc., whose need for it can be
foreseen. A warm moist washcloth or "heel warmer" pack can enhance the onset and
effectiveness (which are also useful, with care to avoid scalding, when
nitroglycerin is not appropriate). |
| Confusing the
Nerves: Firmly rubbing the skin
during the preparatory disinfection in itself diminishes the amount of perception of the
needle. Simply pressing against the skin firmly with the underside of the needle for
several seconds before venipuncture fatigues the nerves before the skin puncture occurs. |
| 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, are hypoallergenic, and in convenient lengths. Stoma-Hesive®
(or Skin Blanket®) can protect very fragile papyraceous skin, and stabilize very loose
skin from movement. If the patient's skin
is so diaphoretic, oily, friable, or sensitive to adhesives that nothing will stick,
wrap the IV in place with a loose weave or knit bandage, or consider having it sutured in.
|
| 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-circumferential 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, or OrthoGlass® fiberglass splinting
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
afterwards.} 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. |
| "Do You
Have To Restrain Him Like That?": For some children or patients in whom their agitation and potential
combativeness cannot yet be safely relieved, it can be wise to restrain or use a
"Papoose" or "Mummy" wrap, but this can be unsettling to the feelings
of the family. Explain as you set up and proceed that you want very much
to make the best possible chance for success on the first effort. "Imagine that
you are a Diamond Cutter or someone going to do some very precise work that could only be
done once, you would set up an assembly jig so that it couldn't move at the wrong
moment, wouldn't you?" |
| Light Work: In infants and small children, veins can be located
by transilluminating the skin or limb with a bright light such as a halogen diagnostic
light, otoscope, or Intubation Lighted Stylet. Be wary of burning skin and limit
duration of contact. |
| 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." Function follows form. |
| 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 with a small syringe
equal to twice the dead space volume; then obtain the
specimens. Remove the tourniquet. Resume infusion or flush briskly to ensure patency.
Advise the patient that there are many technical and medical reasons why
this may not be feasible or permissible every time or in every setting. |
| 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 (very
slow and gentle; you're also moving the potassium! Let it "dwell" for 30
seconds before resuming flow.) of 10 mg Lidocaine. Total dose should not exceed 50
mgs/hour. Be sure that this complies with Policy & Procedures, has an order covering
it, and the drug administration is documented. This may not be permitted in
institutions that have eliminated concentrated electrolyte solutions from
care areas (and substituted pre-mixed piggy-bags without injection ports) in
concert with JCHAO's Patient Safety Initiatives. |
| 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 obviated
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. |
| "Slamming"
Adenosine: Adenosine must be
given as quickly as possible {as it may otherwise degrade before reaching central
circulation due to its short half-life}. Use the two-syringe T-set method with a large
volume flush syringe (30 ml) or a running IV line from which one can
"draw-down" the syringe of large volume flush (and clamp above so the fluid
doesn't back-flow up into the bag) for the rapid "slam" of the drug. Push the
drug and hold the syringe plunger firmly as the force and volume of the upper flush
downwards will push the Adenosine plunger backwards possibly "dead-spacing" the
drug or blowing out the plunger. |
Know When To
Quit: Not being a
"quitter" is admirable when persistence is necessary to achieve a reasonable
goal. However, it is the right thing to do:
- If the requested access is not possible.
- If you are becoming frustrated and aggravated or are
feeling "unlucky" in your efforts.
- If the patient-nurse relationship is being damaged.
- If the patient is undergoing an unreasonable number of
attempts, or doesn't tolerate further effort.
- If vascular access has quite reasonably become a matter
for the physician requiring special skills or permitted locations.
- If the purpose or intent of the line does not justify the
efforts involved. Another plan should be tried.
|
| Know Who Your
"Pinch-Hitter" Is: Be
aware of whose skills match or exceed your own, or who might be "lucky" on a day
that you are not. "Frequent Flyer" patients may know who among your staff has a
successful track record with them, or with whom they have a "rapport" even if
things don't go well. Specialized staff such as Intensive Care Nursery, Anesthesia,
Interventional Radiology, Vascular Surgeons, may be needed for some patients. It is wisdom
to call those who may have the best chance before all "veins are used up." |
| Advocate For
Proactive Planning: When
patients are encountered early in the course of serious progressive illness, and it is
obvious that ongoing vascular access will be a recurring problem, speak appropriately to
the medical team and the patient regarding the early insertion of a Vascular Access Device
(e.g., Porta-Cath®, Peripherally Inserted Central Catheter or Midline Catheter,
Broviac®, Groshong®, etc., before
all peripheral veins are lost (that might
need to be used when the line is infected
or non-functional, peripheral blood cultures are needed, or other emergency occurs). |
|
For Novices to Starting IVs:
We recommend the article: |
|
On the road to successful I.V. starts
Lynn C. Hadaway, RN,C, CRNI, MEd
Doris A. Millam, RN, MS
A supplement to Nursing2005
May 2005
Volume 35 Supplement 1
On the road to successful I.V. starts
Pages 1 - 14
|
|
|
Additional Information on Managing Peripheral IVs for Novices:
We recommend the article (and its excellent website):
Notes on ICU Nursing
http://www.icufaqs.org/ |
Peripheral IV's for Beginners
Mark Hammerschmidt, RN
&
Chief Review Editor:
Jayne Mulholland, RN CEN CCRN
|
|
|
Attention is called to ENW's Disclaimer.
Before instituting any practice change, check all applicable standards and policies.
It is particularly cautioned that Emergency practice described is for
needful circumstances and may vary from conventional practice.
Verify local requirements first. |
|
"I.V. Starts --- Improving Your Odds!"
[http://ENW.org/IVStarts.htm]
is a webarticle presented by:
Emergency Nursing World ! [http://ENW.org/]
©1997-2006 Tom Trimble, RN [Tom@ENW.org] |
|
