clincial ? - ivs

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amyl said:
do anyone have any great no fail tips for IV placement in diff sticks? do you use u/s, NTG? thought some peeps here might have some interesting approaches...
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I use routinely US. That's amazingly easy.
 
I use ultrasound all the time-it works great...
 
Trisomy13 said:
i transposed some letters in diff sticks and thought, my god why are placing IV's there?
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:laugh: I'll bet you could get some good reactions telling patients that's where you intend to start one!
 
The main reason why people fail to start IV's is usually because they place the Tourniquet too loose or too far from the IV site.
The other reason is not being able to have good control of the needle while stretching the skin with the other hand.
If you pay attention to these simple things you should not need something exotic like ultrasound to start an IV more than once every five years.
 
Planktonmd said:
The main reason why people fail to start IV's is usually because they place the Tourniquet too loose or too far from the IV site.
The other reason is not being able to have good control of the needle while stretching the skin with the other hand.
If you pay attention to these simple things you should nor need something exotic like ultrasound to start an IV more than once every five years.
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Unfortunately the druggies also know these tips and trash all the good veins, then the not-so-good veins, then the bad veins thus leaving you the ****-for-veins. You mustn't have a very large IVDA population. Ultrasound guided deep peripherals are magic.
 
Planktonmd said:
The main reason why people fail to start IV's is usually because they place the Tourniquet too loose or too far from the IV site.
The other reason is not being able to have good control of the needle while stretching the skin with the other hand.
If you pay attention to these simple things you should not need something exotic like ultrasound to start an IV more than once every five years.
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If the patient has a lot of subcutaneous fat - you can stretch few miles the skin....still you'll not gonna get an IV or maybe you're lucky. I like to go straight to US when I consider that it is necessary.
 
Sevo is pretty helpful 😀

For those of us who aren't very familiar with US for peripheral lines - any hints from those who use it?
 
Start all the time above elbow - the basilic vein is easily to be identified (lateral, easy to compress...). Use a sitting position with the patient arm straight and comfortable. Adjust the US machine to the adequate depth. If you have any doubt if this is an artery - use the doppler with correct angulation of the probe. Use a lot of lube. Use a 22 g arterial line kit. Perform the procedure in a similar way with the a line placement. Oh- numb the skin with buffered lido.
I am looking in my digital library and maybe I can post some pictures.
 
2win said:
Start all the time above elbow - the basilic vein is easily to be identified (lateral, easy to compress...). Use a sitting position with the patient arm straight and comfortable. Adjust the US machine to the adequate depth. If you have any doubt if this is an artery - use the doppler with correct angulation of the probe. Use a lot of lube. Use a 22 g arterial line kit. Perform the procedure in a similar way with the a line placement. Oh- numb the skin with buffered lido.
I am looking in my digital library and maybe I can post some pictures.
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If I'm going to all this trouble, I'll be using the ultrasound to put in a central line instead of a dinky little peripheral 22g, and I guarantee it will take me about the same amount of time or less than futzing around looking for a crummy little peripheral vein with the u/s.
 
Fastrach said:
If I'm going to all this trouble, I'll be using the ultrasound to put in a central line instead of a dinky little peripheral 22g, and I guarantee it will take me about the same amount of time or less than futzing around looking for a crummy little peripheral vein with the u/s.
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Complications associated with the central line placement?
What about the indications for IV lines placement?
We are talking about peripheral IV access.
When a central line is required - a central line it will be placed.
For a banal appendectomy I will choose a peripheral IV instead of a central line. The time required for the placement is the same. Remember that you have to dress in a sterile gown for your central, use whatever kit, use maybe the same US probe and eventually have a CXR for subclavian or jugular....If you go for a femoral maybe a lawsuit later for infection - soap is not getting there....for some of our patients.
Wouldn't you now choose an US technique?
 
2win said:
Complications associated with the central line placement?
What about the indications for IV lines placement?
We are talking about peripheral IV access.
When a central line is required - a central line it will be placed.
For a banal appendectomy I will choose a peripheral IV instead of a central line. The time required for the placement is the same. Remember that you have to dress in a sterile gown for your central, use whatever kit, use maybe the same US probe and eventually have a CXR for subclavian or jugular....If you go for a femoral maybe a lawsuit later for infection - soap is not getting there....for some of our patients.
Wouldn't you now choose an US technique?
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Ok, maybe for a very routine, quick case I might try taking a look with the ultrasound for a peripheral. But if no veins clearly jump out or if it is in any manner taking more than about 1 minute, I'm just going to place a central line and be done with it. My complication rate with them is < 1% these days, and using sterile technique is not a problem either. And I wouldn't put in a femoral line unless someone held a gun to my head or the patient was going to die without one.
 
Aside from the obvious tips of tight secure tourniquet, if it is a truly tough patient, let the arm dangle on the side with the tourniquet on and a warm blanket around it for 3-5 minutes. The basilic vein is a good tip too as above.

If this is a routine case and the patient has fasted properly and has no super aspiration risk (known hiatal hernia, uncontrolled reflux, burps up cheeseburgers, etc.), take them back to the OR and breathe them down with some Sevo and watch the veins pop up or put in your central line. Don't waste time.

If you use ultrasound, make sure you are billing for it.
 
I agree with all the various tips for hard sticks...

However - totally disagree about central lines. Sometimes, it's just not worth the trouble for a peripheral IV. I'm not doing a big laparoscopic case or colon resection on a 300# patient with a 22ga IV that I got in the antecubital with US. Ain't gonna do it. Put in an IJ and be done with it. Do you really have complications with your IJ sticks? I've put in more than I can count, and have never dropped a lung, never put a big cath in big red. Big patients and IV drug abusers reap what they sow unfortunately, and almost every one of them will tell you that many that have come before you have had problems starting IV's as well. When they tell you "the last time they had to start it in my neck", it's a really good clue. 😉
 
will the insurance company even pay you if you put in a centeral line for a case that should have just had a peripheral iv?
 
external jugular. then no need for central line, less likely to carotid puncture (assuming you're not using ultrasound).
If you're in a big hurry, or lose the access you already have at a critical point, can use the feet in a pinch. (though nurses hate it, presumed bigger infection risk, and they need to hep lock it before the patient walks)
 
RussianJoo said:
will the insurance company even pay you if you put in a centeral line for a case that should have just had a peripheral iv?
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in truth, probably. Difficult/impossible access is among the indications for central lines (on the anesthesia boards, anyway.) Insurance companies pay for picc lines in difficult access patients, and some of those require placement in IR, which would be just as pricey.

In the big picture, from a cost control standpoint, the extra hour you spend trying to get access leads to the hospital losing much more money than the cost of a central line kit and placement, as an open OR and unoccupied OR staff (surgeon, scrub tech, circulating nurse) await your patient.
 
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anesthesiadoc said:
in truth, probably. Difficult/impossible access is among the indications for central lines (on the anesthesia boards, anyway.) Insurance companies pay for picc lines in difficult access patients, and some of those require placement in IR, which would be just as pricey.

In the big picuture, from a cost control standpoint, the extra hour you spend trying to get access leads to the hospital losing much more money than the cost of a central line kit and placement, as an open OR and unoccupied OR staff (surgeon, scrub tech, circulating nurse) await your patient.
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thanks for the reply.
 
anesthesiadoc said:
external jugular. then no need for central line, less likely to carotid puncture (assuming you're not using ultrasound).
If you're in a big hurry, or lose the access you already have at a critical point, can use the feet in a pinch. (though nurses hate it, presumed bigger infection risk, and they need to hep lock it before the patient walks)
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External jugular....sadly many an IVDU has already attacked these! On the other hand, when called for difficult access on the ward it's one other doctors often haven't blown (or they think that cause they can't see it with the patient sitting up it's no good:laugh:). Downside - if they bleed (esp warfarin etc) and no one notices you can get a haematoma significant enough to compromise the airway or produce significant hypovolaemia and anaemia. Those complications aren't common - but ext jugular is not my preference for a ward patient who is going to sit in a dark corner of the ward all night.

I do like them for resus (we often don't use central lines in early resus here unless they have already been placed) cause obviously blood flow to the brain is better preserved (and in an arrest you've got increased intra thoracic pressure from CPR) and a little head down is generally not objected to.

But to the med students/non anaesthetists out there...if you are going to place an eternal jugular - put a proper sized line in. Pet peeve - big vein with small IV in it ARGH! Our ED loves 22G in the antecubital fossa - now what am I supposed to do with that?😕 At least put a 20G in so I can wire it if I need to.

Feet are good - just remember the foot-brain circulation time is longer than arm-brain circulation time.... don't get caught out overdosing at induction.
 
anesthesiadoc said:
external jugular. then no need for central line, less likely to carotid puncture (assuming you're not using ultrasound).
If you're in a big hurry, or lose the access you already have at a critical point, can use the feet in a pinch. (though nurses hate it, presumed bigger infection risk, and they need to hep lock it before the patient walks)
Click to expand...

External jugular is not one of my favorites though I use it sometimes.
I don"t like the valve presence and also the possibility of catheter migration out of the vein. Do you know the incidence of valve damage? I dont but is mentioned.
Foot IV-s - nice idea, they hate me on the floor for them...
For really really emergencies - IO access if nothing else is feasible fast.
 
proman said:
Unfortunately the druggies also know these tips and trash all the good veins, then the not-so-good veins, then the bad veins thus leaving you the ****-for-veins. You mustn't have a very large IVDA population. Ultrasound guided deep peripherals are magic.
Click to expand...

truthfully, IVDAs will tell you the best vein, if you ask them
 
ultrasound for PIVs? really?? not for nothing, but numbers are key in this 'riddle'.
 
Remember few years ago - US for nerve blocks???
World is moving fast.
 
my point being by the time it takes one to prepare for an US guided IV insertion, any adequate to above-adequate IV inserter doesn't need an US nor 3-5 minutes to get an IV (and that's with equipment at the ready.) i'm just sayin is all...
 
Only used U/S twice for PIV's but it was needed. The other night had a super-fatty for an appy from the ED. Showed up with a 20ga in her AC (well, kind of in her AC, the catheter was over half out of the skin.) We needed some access but didn't really need central access. Went to sleep with half out IV and then started looking. Hands were so fat that I couldn't feel anything so attending said get U/S and look in AC. Lady was so fat with her arm straight attending had to retract the fat so I could get U/S probe into AC fossa to even look. Found one and stuck it. U/S has it's place for PIV, just not very often.
 
I've heard of a guy who did a whole case using the dorsal vein of the penis. Pt was IVDU, said it would work, and it did.

The question is, who has the job of getting that vein to dilate in the first place? Sounds like a med-student job to me.
 
TrustMe said:
Only used U/S twice for PIV's but it was needed. The other night had a super-fatty for an appy from the ED. Showed up with a 20ga in her AC (well, kind of in her AC, the catheter was over half out of the skin.) We needed some access but didn't really need central access. Went to sleep with half out IV and then started looking. Hands were so fat that I couldn't feel anything so attending said get U/S and look in AC. Lady was so fat with her arm straight attending had to retract the fat so I could get U/S probe into AC fossa to even look. Found one and stuck it. U/S has it's place for PIV, just not very often.
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I would suggest the arm not the antecubital fossa. And this was my point - not routine use - just for difficult IV-s.
Soon you gonna see in anesthesia analgesia....
2win
 
dfk said:
my point being by the time it takes one to prepare for an US guided IV insertion, any adequate to above-adequate IV inserter doesn't need an US nor 3-5 minutes to get an IV (and that's with equipment at the ready.) i'm just sayin is all...
Click to expand...

The patients that I have used U/S on are typically the ones we are called on because the most experienced holding room nurses can't get an IV on them (or don't even try).

There are plenty of patients out there who have EXTREMELY difficult IV access and it takes more than 3-5 minutes.
 
A classic SDN thread. I have some questions about PIV under US. Do you look at the screen or the needle for the flash? do you use a steeper angle with US? US probe in plane or not? I see people use a regular angiocath instead of the safety needles, what is the advantage of former? Thanks.
 
Interesting. I have used the US twice for iv's. First one didn't work. Second one I got an 18g and upgraded it to a ricc. I'm sure that vein will not be used anymore... I should practice some more.
 
Trisomy13 said:
i transposed some letters in diff sticks and thought, my god why are placing IV's there?
Click to expand...

Was in the department to grab the US one day to take for a ward difficult IV access pt (IVDU of course) and one of my consultants did ask "Is it a male? Why don't you try the dorsal vein of..."

I declined.
 
I find that using one of the old Jelco catheters on a 10 cc syringe is best. That way, similar to when doing a central line, you can watch the screen AND feel for that easy "loss of resistance" of blood return when gently aspirating on the syringe. Once you're in, boom, just drop your angle and advance catheter- just like using the catheter over the needle in the central line kit. I was having mixed success with u/s IV's until I did it this way, and I felt that it was because I was trying to watch two things at once- tissue deflection from the angiocath and the little window for blood return as well- doesn't work so well. I do an out of plane approach as well.
 
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