Finding vein anatomically

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cognitus

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Currently doing an ICU rotation and I have a lot of obese or edematamous patients. Any advice on anatomically finding a peripheral vein for blood draws/catheter placement in case getting an ultrasound is too cumbersome? Just looking for a foolproof way to finding veins w/o ultrasound in the most difficult patients. Thanks
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It is more cumbersome to the pt and the ICU nurse to have someone sticking the pt for an absurd amount of time just to place a 22g pea dropper that won't draw back and will infiltrate within the hour. Put on a tourniquet and quickly assess if there's anything decent. If not, grab the ultrasound, get a line that the nurse can actually use for a few days, and don't waste time. If the pt is that difficult and is sick enough to be in the unit, place a central line. Unless there is a contraindication, subclavian is the line of choice.
 
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Ezekiel is correct. If the pt is in the ICU and access is an issue then place a line.

I have attempted the anatomical approach to no avail (?) many times. I suck at AC veins. I will look at my veins and their location and then try to mirror it in the pt and it never works well.

ICU + access issues = central line
 
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cognitus said:
Currently doing an ICU rotation and I have a lot of obese or edematamous patients. Any advice on anatomically finding a peripheral vein for blood draws/catheter placement in case getting an ultrasound is too cumbersome? Just looking for a foolproof way to finding veins w/o ultrasound in the most difficult patients. Thanks
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Agree with others.

If you think rolling the ultrasound to the bedside is "too cumbersome," you are thinking about this the wrong way, i.e., shortsighted.

In ICU fellowship I put in an US-guided PIV maybe once a week, and only in situations where central access was a viable option but not ideal at the moment. Typically this would be a fatty with a bad GI bleed, who needs some good access like NOW so that he/she can then be laid flat for a proper line.

A central line can easily take 30 minutes from the time you decide to do it because usually your "helpers" are worthless with positioning, moving the bed, opening the tray, etc, etc.

I also did a few US-guided art and venous punctures for blood cultures ;)
 
Thanks. Using the US isn't cumbersome. In my unit, sometimes getting one is though. I was wondering if there is a way that I can find vein anatomically. Can someone please answer that?
 
Christmas. You can find the vein by using your sense of sight or sense of touch or both. If you can't see it or feel it, have fun with the hematomas.
 
Ezekiel2517 said:
Christmas. You can find the vein by using your sense of sight or sense of touch or both. If you can't see it or feel it, have fun with the hematomas.
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I wish there was a way to boot you from this conversation. Why post if you can't answer the question?
 
I think what he is trying to say, long story short, is "no". The only vein that I believe can be reasonably approximated based on anatomy alone is the saphenous vein. With little chubby kids it is my go to. But even then, it's not a guarantee by any stretch of the imagination.
 
Oh, and in adults, there is almost always a decent vein on the dorsal aspect of the hand between digits number four and five. Sometimes I'll take a pass or two there before I throw in the towel and grab an ultrasound, even if I can't see or feel a thing.
 
cognitus said:
I wish there was a way to boot you from this conversation. Why post if you can't answer the question?
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Our know-it-all M.B.A. champion of arrogance is back. They still haven't figured you out and booted you from anesthesia residency? You deserve about as much help as a militant CRNA. Because you are about as grateful.
 
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They won't boot DA GAWD
FFP said:
Our know-it-all M.B.A. champion of arrogance is back. They still haven't figured you out and booted you from anesthesia residency? You deserve about as much help as a militant CRNA. Because you are about as grateful.
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ZzzPlz said:
Oh, and in adults, there is almost always a decent vein on the dorsal aspect of the hand between digits number four and five. Sometimes I'll take a pass or two there before I throw in the towel and grab an ultrasound, even if I can't see or feel a thing.
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Thank you
 
man i have the same problem on inpatient im on. patients are all obese or worse, its so difficult to find a vein!! and of course we dont have an ultrasound.
 
Essentially, the point is that sometimes when you're in the ICU, the patient needs some IV medication and there is no US and you are not able to get a consent for a central line. So, I was hoping that I could post in this anesthesiology forum and get some old school advice from the experts in IV placement like ZZZ. So, it really doesn't help to say, "get an ultrasound or central line" when I am specifically looking for advice on placing a peripheral IV if those two options are unavailable. So please, I would prefer anyone to stay silent if you have nothing more to add than, "get a central line or ultrasound."
 
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Everybody working in an ICU should be trained in intraosseous lines, for when there is no PIV and there is no time for a central line.

If there is time, the answer is a central line, in the best position for the operator's experience (if unsupervised). If one is great at IJs, one should put in an IJ, regardless of the local dogma.
 
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Ezekiel2517 said:
It is more cumbersome to the pt and the ICU nurse to have someone sticking the pt for an absurd amount of time just to place a 22g pea dropper that won't draw back and will infiltrate within the hour. Put on a tourniquet and quickly assess if there's anything decent. If not, grab the ultrasound, get a line that the nurse can actually use for a few days, and don't waste time. If the pt is that difficult and is sick enough to be in the unit, place a central line. Unless there is a contraindication, subclavian is the line of choice.
Click to expand...

I would think an IJ would be a preferred line of choice. The risks of subclavian stenosis on possible future dialysis patients is not insignificant. Also, you can have better control of bleeding at the IJ versus the subclavian vein. With an ultrasound, it should be easy. There's also alot lower risk of PTX with that line.
 
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anbuitachi said:
man i have the same problem on inpatient im on. patients are all obese or worse, its so difficult to find a vein!! and of course we dont have an ultrasound.
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Try the feet/ankles. Warm the patients up first.
 
Try the deep dorsal vein of penis, or..... Get an ultrasound, and put in a central line.


All joking aside, there is no answer to your question. In edematous sick old icu patients , there are no reliably good places to place peripheral lines.
 
I was a phlebotomist for several years before med school, and I was pretty useful on an ICU rotation as i was the only one who could place IVs (blood draws/blood cultures) on many of the patients, even after a PIV consult (who had US). Saved lots of patients central lines. I also used the opportunity to perfect my use of US, even though I didnt need it for most.

I think its really just experience. Ive had several years of doing nothing but feeling veins and I just have a really good feel for them. I think the longer you keep trying to really develop the tactile sensitivity of your index fingers the better youll get, without the use of US.
 
Wow, this has become the stupidest thread I've read in a long time. Thanks all.
 
My progression of line placement in a code situation. Quick glance for visible PIVs on arms and legs (like 10 seconds max). Then one attempt at an EJ unless they are fat in which case I/O is my choice.

If you are having to use US in a non emergent situation, Basilic, brachial, and cephalic veins are a great choice. They are usually the last veins to go in very frail people. Just use a longer catheter because of the depth they infiltrate a lot easier. And don't blow the hell out of them with a giant needle if they are renal patients. Nephro gets pissed if you blow a potential graph or fistula sight :)

Its crazy to me that the facilities you did your ICU residencies in needed a physician to place a PIV. Where the nurses not allowed to place lines with US? At any rate I think it is awesome that you where willing to do this for the nurses.

BTW. I was curious how painful a foot IV was so I started one on myself the other day. Ya screw that it was miserable lol. Gotta do what you gotta do I guess.
 
RapidResponseNurse said:
My progression of line placement in a code situation. Quick glance for visible PIVs on arms and legs (like 10 seconds max). Then one attempt at an EJ unless they are fat in which case I/O is my choice.
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Nobody should be putting an EJ in a coding patient. Between chest compression and ventilating the patient there isn't room to be stabbing their neck for a line. That's why femoral lines are what gets put in during codes when peripheral access (or I/O) is unable to be obtained.
 
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take a mama prepstick and wash out the groin generously.. 20 g needle 20cc syringe.. feel for fem artery pulse go medial with your syringe needle.. 20 cc of blood less than 30 secs. Youre welcome.
 
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