IV starts

[PoorInvestment]

So I'm a categorical PGY-1 (they call us CA-0 up here in the MKE) and I'm doing an actual month in the OR. I have no trouble at all putting in the big lines, art lines, and intubation but when they send me to preop to put in a simple IV line I get stumped. I am like 0 for the century putting in stupid IVs. In light of Jets post about procedural skills, I'm reaching out for some help here. The sooner I can get proficient at these things the better off I will be come next year when I'm in the OR full time. Anyone have any rock solid tips to get me out of my slump? Skol Vikings!

~PoorInvestment~

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[aredoubleyou]

Like anything you gotta do a bunch before you start to get proficient. Most important couple things I see new people make mistakes with are

1) Pick a good vein, straighter the better, bigger the better- - when you get more skilled you can put in the ivs into the curvey little veins. Think about where the tip of your iv will end up - you dont want it to end at a branch point or near an acute angle - - so if you have to go a a couple cm thru subQ before entering the vein, its ok.

2) Enter the vein almost parallel- dont hit it at an angle like an IJ or a-line.

3) Once you get flash, you still might not be in far enough - advance it further in the vein before sliding the catheter off the needle (so make sure your vein is straight before you do that with either anatomy or traction). In general it seems that the bigger the IV the more metal you need to have inside the vein before you slip off the catheter.

4) Dont worry about the pain your causing the patient - I see people looking at the pts face and not the hand. Also the more lidocaine you put in, the harder it can become to see the vein. Also - it sounds stupid I see everyone doing this (including myself when I started) - inject your local where youre needle is gunna enter the skin, not right over the vein, which can be an inch downstream.

Hope that helps.

 

[huktonfonix]

In general it seems that the bigger the IV the more metal you need to have inside the vein before you slip off the catheter.

All you gotta do to figure this one out is to take a look at different sized IV catheters. the tip of the needle may only be a coupla millimeters past the catheter in a 22, but may be 4 mm or more past the catheter in a 14.

 

[dhb]

skip the local

 

[CambieMD]

skip the local

IVs are very important. If you are good @ them your patients develop trust in you and assume that you know what you are doing.

Do not skip the local. Most people make the mistake of injecting the local too close to the vein and obscuring their view. Local makes a big difference. If you are really hurting a patient your chances of getting an IV are greatly reduced.

I also use a generous amount of alcohol swabs. I was told by someone who can place an IV in a rock that alcohol swabs cause vasodilation and helps veins to become more prominent.

I think that the biggest key in getting IVs is taking your time to look and and reassuring the patient.

I put an IV in a 14 month old today. A few days ago an IV was attempted in radiology. They stopped trying and gave up. I spent a few minutes looking and got a 24 gague on the side of the foot.Again patience is the most important attribute to possessre if you want to get good @ IVs.

Cambie

 

[drccw]

repititive motion too...

every asleep patient should get a second IV... for you to practice.... get good at IVs... you will become the go to guy in the hospital... but all it takes is time to get over that learning curve and then you can slam them into anyone..

 

[dhb]

If you are good @ them

... you can skip the local:


are you telling me that the stick for the local is that much less painfull than from a 20G? (don't tell me your doing a local with a 30G)

How many people in pp use local for piv?

I use local for iv's bigger than 18G (very infrequent on an awake patient)

 

[CambieMD]

... you can skip the local:


are you telling me that the stick for the local is that much less painfull than from a 20G? (don't tell me your doing a local with a 30G)

How many people in pp use local for piv?

I use local for iv's bigger than 18G (very infrequent on an awake patient)

I use local for even 22G IVs. It is good pr especially in amulatory surgery where the pts are generally healthy.There are few reasons for not using local.

Yes, I use a 30G with my local.

Cambie

 

[huktonfonix]

I use local for even 22G IVs. It is good pr especially in amulatory surgery where the pts are generally healthy.There are few reasons for not using local.

Yes, I use a 30G with my local.

Cambie

Its the local itself causing the sting. I dont bother with it for 20g or less unless they look to be a "difficult stick"

 

[pgg]

Its the local itself causing the sting. I dont bother with it for 20g or less unless they look to be a "difficult stick"

If you inject slowly and add some bicarb to the lidocaine, the local doesn't really hurt. Rub the skin a bit or distract them for the local and they usually won't feel the local needle either. Patients remember the IV, but usually nothing else we do. I think it's worthwhile to make their IV experience a painless one.

Our techs make huge batches of lido+bicarb 1 cc syringes with 30-ish gauge needles every morning so there's no delay or extra work involved.

 

[RussianJoo]

you guys use local with your iv's? I totally think the local would be 100 times more painful than the iv stick.. I have never seen anyone use local at the two hospitals i rotated at, i think if i asked for local they'd laugh at me. Also when i was getting surgery done at a very nice upscale surgery center no one used local for my IVs... Do most of you guys use local? Is that becoming the standard of care?

 

[RussianJoo]

So I'm a categorical PGY-1 (they call us CA-0 up here in the MKE) and I'm doing an actual month in the OR. I have no trouble at all putting in the big lines, art lines, and intubation but when they send me to preop to put in a simple IV line I get stumped. I am like 0 for the century putting in stupid IVs. In light of Jets post about procedural skills, I'm reaching out for some help here. The sooner I can get proficient at these things the better off I will be come next year when I'm in the OR full time. Anyone have any rock solid tips to get me out of my slump? Skol Vikings!

~PoorInvestment~

what worked for me was keeping the needle parallel to the skin and keeping constant traction distally on the area where you stick them, this straightens out the vein and prevents it from bunching up when you slide the catheter down.

 

[OB1🤙]

If you inject the local slow, they often won't feel anything at all. If you power blast it in and dissect the wheal real quick, it hurts.

I use local for all awake IVs, and the thanks from patients for painless IVs has reinforced to me that it's a good idea.

First impressions are valuable in this biz IMO.

 

[lvspro]

Agree w above on starting a new IV on asleep pt's for practice. It's been discussed b4 on this forum.
Pt sceduled for surgery =/> 3 hr, then I always pop a new one in, and the bigger the better. Get good w/18's, then start moving to 16 n 14's. Choose the 30 mm over the 45 mm cath, if possible. After 2 months of starting 2-3 lg bore IV's on sleepers, try 18's on awake peeps. with or sans local is your call. If it looks tough, I just explain to pt that the IV poke is equal to the local, and if they're not pain mgmt pt's, then they will typically tell me to just go for it.
The most important peice of advice I ever got was "take the time to find a winner b4 you even put a tourniquet on." Agree w/above tips.
Finally, try to do it the same way every time until comfy, the try tricks.

 

[bigdan]

...so I was first shown IVs by a peds anesthesiologist, who (very successfully) encouraged me to find the vein bifurcation, just like you see in the veins slightly proximal to the MCPs in the hands, and then aim for the "crotch" - boom - straight in. Works like a charm for me in kiddos.

But I look like a jackass trying that in adults. Where are you aiming in specific in the hand and forearm veins? Seems like some folks swoop in from the top, but I fear blowing thru the back part of the vessel that way. Do y'all go along side the vein and in?

dc

 

[dfk]

sorry cambie, using local is a waste of time IMO. two pinches are not better than one.

 

[FutureDocDO]

Med student here. Former phlebotomist. I've never used local w/ IV's... of course I can't prescribed so that could be why. lol.

I agree with using a couple of alcohol swabs though. Rub it along the length of the vein firmly will usually make it pop up even more. I also rub plenty of alcohol on my gloved index finger. It makes it easier to feel for smaller veins.

 

[Arch Guillotti]

Agree w/most comments here. I used to think that local was for wusses but I have really changed my thinking over time so that I will use it for nearly everyone now especially the ones that are difficult and require a stick in the back of the wrist which seems very uncomfortable, esp if u are digging around. The local has the potential to distort anatomy so you have to be careful w/it but I think that if you are judicious then it can be used easily w/out problem.

 

[ncdoc1974]

As far as 1% lido local-the main advantage: local lidocaine properly placed will help vasodilate the vein. This is well documented in the literature. I do not use it all the time, but more times than not. I think there have been some good tips here...I find that it is helpful to place the tourniquet before I get anything else ready...give the veins time to fill up...then I look for as long as I need to to find the best vein, and rub with lots of alcohol pads as I look...You might want to get someone to help you at first...start by cannulating the vein with the needle and have your assistant slide the angiocath off. (I still use this 2 person technique occasionally in difficult neonates) Do some like this initially, and then work up to sliding the angiocath off yourself...you will get it with time...In the future you will actually look forward to starting IV's in patients when everyone else has failed...