Placing IV's

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Only put in 2 peripheral IVs in intern year? That sounds...wonderful...

Things are different here in australia - most hospitals have "policy" that RNs don't put in IVs unless they have some extra certification. Which most nurses don't get. Since interns here don't get to do central lines, that means residency is cannula central. The 3AM IV resite call is something that'll be burned into my memory for a while...

I don't pretend to be a great IV person (militarymd is absolutely right - anaesthesia gets paged for difficult peripheral IVs constantly) a few tips

Get pt to co-operate, if possible. If you're going for hand veins, get them to clench/unclench hand and let their arm hang down. You'd be suprised how much difference it makes to finding veins. And this sounds stupid but...look at both hands. I wish i had a dollar for every time I struggled to get a 22g into the first arm i picked, while my pager went crazy...then seeing perfect veins in the other arm :bang:.

Like planktonmd says, have the tourniquet tight. And tether the vein with your non-dominant hand so the vein doesn't roll. Inserting just upstream of a vein junction will also help with stability.
Make sure that you aren't inserting the IV at too much of an acute angle - too easy to go through-and-through.

And finally...practice. *Without* everyone in the ward/OR/PACU/pre-op watching you. Steal some IVs and practice with another resident, or even just a plain length of IV tubing.
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Planktonmd said:
A- Apply the tourniquet as tight as you can
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:eek: get a good arterial clamp on so you don't get venous blood flow (especially not good in kids).


Are you a resident?

If you have not seen a case where a second IV is needed then either you are not a resident or you have not done enough cases.
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First i didn't say you shouldn't place a second iv if needed, second what are you doing livers all day that you need a bunch of ivs?

If someone needs to get better at placing iv's there are enough patients around who need an iv started.
 
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I started using ultrasound whenever I get called to help place IV nowadays on large patients where the nurses have already tried multiple times.

I have noticed that there are many nice veins you can see under US in the arm that you otherwise would not be able to find in these morbidly obese patients.

I am a hospital employee so I don't bill for my own procedures, but I wonder whether placement of PIV's under ultrasound is a billable anesthesiologist procedure, any PP attendings want to chime in?
 
at my program residents rarely place iv's. i've not even come close to 100. the preop nurses do it for the patients. if somebody needs one intraop we place it, but most procedures 1 iv is fine. i did a lot as an intern though.
 
Intrathecal said:
I started using ultrasound whenever I get called to help place IV nowadays on large patients where the nurses have already tried multiple times.

I have noticed that there are many nice veins you can see under US in the arm that you otherwise would not be able to find in these morbidly obese patients.

I am a hospital employee so I don't bill for my own procedures, but I wonder whether placement of PIV's under ultrasound is a billable anesthesiologist procedure, any PP attendings want to chime in?
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You can "bill" ANYTHING you want.......whether you get paid or not is a different story.

This would be insurance company dependent....as for CMS...I don't know.
 
Every single patient going in for a case that will last more than a cuppla hours gets a second PIV in the opposite extremity while under GA. Pt has an extra life-line, I get to tighten up my technique, and it helps my confidence for when I go see the edematous as hell pre-eclamptic pt that the IV team has made a pin-cushion of.
Oh yeah, I forgot about how slick you look when you slide an 18g in above pt while all your spectators in the bleachers go wild.
Bows left, bows right, blows kisses at the audience, and walks out.
 
Hey Greenbean, I second PlanktonMD and AussieGirl. Just keep practicing...every chance you can/if you can.

To other med students wondering about this, I just went to our pre-op holding room a couple of days during my anes elective and practiced my sticking skills. I sucked at first, and I'm still good at making hematomas, but I'm getting better. Start with 20/22g, if they need bigger they can always place another later...at least you got some practice and they can start the case. Act like you know what you're doing, it helps everyone.:D
 
dhb said:
:eek: get a good arterial clamp on so you don't get venous blood flow (especially not good in kids).
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You don't have to listen to anything I say since you are obviously an expert.
I was addressing people who are still learning, you my friend are obviously done learning everything there is to know about this business :)
 
The best opportunity I had as a student to place IVs was during my ER rotation, I asked the charge nurse to get me when they needed an IV (they usually asked the er techs). I think I placed about a dozen or so, not a lot, but wonderful practice.
 
Planktonmd said:
You don't have to listen to anything I say since you are obviously an expert.
I was addressing people who are still learning, you my friend are obviously done learning everything there is to know about this business :)
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Think about how much pressure you need do interupt venous blood flow then come back...
 
dhb said:
Think about how much pressure you need do interupt venous blood flow then come back...
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I am not sure I understand what you are trying to say!
Most of the times when I get called because someone could not start an IV the main reason (in my experience of thousands of IV's) is a tourniquet that is not tight enough.
The pressure you need to interrupt venous flow is not that high but you need to apply significant pressure to compress the deep veins within deep layers of soft tissue, you are not trying to stop arterial circulation but you need a tight tourniquet to get a good view of the veins, very simple, and works almost every time.
So, what is it that you want me to think about and come back?
When someone 10 times more experienced than you is offering their practical experience for free for people who want to learn (obviously not you professor), maybe you might want to consider that there are a few things that you might still not know.
I always felt grateful when people more experienced than me tried to teach me things but an attitude like your's makes me think that I am actually wasting my time trying to do the same.
 
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Planktonmd said:
I am not sure I understand what you are trying to say!
Most of the times when I get called because someone could not start an IV the main reason (in my experience of thousands of IV's) is a tourniquet that is not tight enough.
The pressure you need to interrupt venous flow is not that high but you need to apply significant pressure to compress the deep veins within deep layers of soft tissue, you are not trying to stop arterial circulation but you need a tight tourniquet to get a good view of the veins, very simple, and works almost every time.
So, what is it that you want me to think about and come back?
When someone 10 times more experienced than you is offering their practical experience for free for people who want to learn (obviously not you professor), maybe you might want to consider that there are a few things that you might still not know.
I always felt grateful when people more experience than me tried to teach me things but an attitude like your's makes me think that I am actually wasting my time trying to do the same.
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Hell, I'll even listen to the village idiot. Then I'll treat his advice the same as everyone elses. I'll consider it, look it up/validate/try information or technique, determine if I like it or if its appropriate for my patient and if I do like it, incorporate it into my arsenal. Im with plank on this, you should never stop learning. Theres always someone bigger, badder, faster to learn from
 
Planktonmd said:
I am not sure I understand what you are trying to say!
Most of the times when I get called because someone could not start an IV the main reason (in my experience of thousands of IV's) is a tourniquet that is not tight enough.
The pressure you need to interrupt venous flow is not that high but you need to apply significant pressure to compress the deep veins within deep layers of soft tissue, you are not trying to stop arterial circulation but you need a tight tourniquet to get a good view of the veins, very simple, and works almost every time.
So, what is it that you want me to think about and come back?
When someone 10 times more experienced than you is offering their practical experience for free for people who want to learn (obviously not you professor), maybe you might want to consider that there are a few things that you might still not know.
I always felt grateful when people more experienced than me tried to teach me things but an attitude like your's makes me think that I am actually wasting my time trying to do the same.
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I believe Mr. Pot is trying to teach Mr. Kettle a lesson.
 
dhb said:
I take good advice when i see it but this is stupid
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If the tourniquet is comfortable for the patient then it is not doing it's job.
But this whole advice was not intended for people who already know everything like you, it was aimed at people who still want to learn.
So, yes I agree with you, If you think it's stupid, then ignore it.
 
Planktonmd said:
I am not going to insult you although it has been more than 3 days since the last time I did that and you seem to be starting to itch.
Could you please not attempt to hijack this thread?
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ok, mr. pot.....or wait ...is it mr. kettle????


oh and feel free looking stupid insulting me anytime you like.
 
Plank, I am gonna take your advice :D, it makes sense to me.
 
A quick check to make sure the cuff is not too tight is to check the radial pulse...I put the band on tight and then verify arterial blood is still pumpin. :cool:
 
Man, EVERYONE just RELAX, it's just a damn tourniquet... I'm sure everyone is able to get their IV's in very nicely.... jeeez...
 
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greenbean said:
oh and heres another reason why its tough for me to do place the second iv: after the ETT is in, everyone ELSE(circulators, scrubs, surgeons/etal) is in this big rush to prep,drape and attack, ...well what happens to the pt's arms? either they get tucked, or a nice giant bair hugger with 3 blankies gets ploughed onto them and then they drape. and that's the end of that
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Regular blankets on top of the warming blanket?
 
lvspro said:
Every single patient going in for a case that will last more than a cuppla hours gets a second PIV in the opposite extremity while under GA. Pt has an extra life-line, I get to tighten up my technique, and it helps my confidence for when I go see the edematous as hell pre-eclamptic pt that the IV team has made a pin-cushion of.
Oh yeah, I forgot about how slick you look when you slide an 18g in above pt while all your spectators in the bleachers go wild.
Bows left, bows right, blows kisses at the audience, and walks out.
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Am I the only one that does this?
 
lvspro said:
Am I the only one that does this?
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Even if a case is very long I usually would not place a second IV unless access because of positioning is very limited and/or you expect fluid shifts etc to be an issue. I think that case length alone is not a good reason to place another IV.
 
lvspro said:
Am I the only one that does this?
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My threshold for placing a 2nd line is very low. That said, I follow this edict (applies to a-lines too):

If it looks like it's going to be easy, I wait until I need it. If it looks like it's going to be hard, I do it up front before any positioning.
 
I actually like to wait for the pt to be prepped, draped, an surgery going on. My view is this, if you can do it under those conditions then you should be able to do it anywhere.
 
I think its funny that there is such reservation about starting a second peripheral IV. In my view, If you think about it you should do it. There is absolutely no harm in a second IV. Do I place them for every ASA1 case. no. But I cant remember the last ASA 1-2 case Ive done.
 
I've had several attendings that prefer a second IV if both arms are going to be tucked and you won't have access to them during the case if needed. This makes sense to me unless as previously stated it is an ASA 1 for an inguinal hernia repair or something else small. It is much less traumatic for the pt. to have a second IV placed "just in case" than it is a pain in my ass to try and place a second IV under the drapes with both arms tucked. Would you rather wake up with a second IV in your hand or with an EJ in because I couldn't get to your hands when your first IV stopped flowing half-way through the case?
 
greenbean said:
Hi everyone
I'm a new CA1. This is sorta open to anyone. I have not had a lot of experience placing IVs(maybe did 1 in med school and 2 in internship). I see alot of the attendings placing IVs in our patients when they IV is too small or not fx-al enough for the case we are doing, or the pt just needs another IV. Sometimes, the IV nurses cant get the and then its up to anesthesia to get it.

Well thats where my problem lies. I am not good at putting iv's in; in fact im pretty terrible. I tried to put them in with one of nurses in preop in the AM before my first cases of the day, but im slowing them down and they dont really want me around b'c of that reason. So far i have tried maybe 10 total. I do watch alot of iv;s being placed. I mentioned this to my attending and he said it was unacceptable that I was not placing IVs and I should be doing 4 a day. But when I ask to put IVs in our pt's after we put them to sleep, he usually makes up some excuse so it doesnt happen. Sometimes he puts in the iv's himself, even after knowing i want to do them so badly(and no, they are not the impossible, last ditch scenarios where if the iv doesnt go , the **** hits the fan b'c if that were the case i'd totally understand)


im curious how the upper levels have faced this situation; or does every1 training nowadays just blow off this time traditioned skill and its something that the 'oldies' had to deal with
any help or suggestions?

thanks,
green :(
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Next time your attending is in the room with you, tell him/her to go ahead and take a coffee break. Then reach for that nice 14G, look for the EJ and BAM! stick it in. That's a good way to practice when everything else is covered.

And planktomMD is right. Show no fear at all. As a matter of fact, try to put on a mean face like you are really pissed off.
 
toughlife said:
Next time your attending is in the room with you, tell him/her to go ahead and take a coffee break. Then reach for that nice 14G, look for the EJ and BAM! stick it in. That's a good way to practice when everything else is covered.

And planktomMD is right. Show no fear at all. As a matter of fact, try to put on a mean face like you are really pissed off.
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Easy on that 14g in the EJ, start with peripherals after induction and work your way up. You go dropping 14g in the EJ when your Staff turns around and they may get pissed:eek:+pissed+. Try that 14g in the hand, FA, AC to build confidence.
 
BubbleHead said:
Easy on that 14g in the EJ, start with peripherals after induction and work your way up. You go dropping 14g in the EJ when your Staff turns around and they may get pissed:eek:+pissed+. Try that 14g in the hand, FA, AC to build confidence.
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Agreed. EJ is just a bit too easy, IMHO. I'd rather go for the tougher spots first, then the larger superficial veins like above.
 
lvspro said:
Agreed. EJ is just a bit too easy, IMHO. I'd rather go for the tougher spots first, then the larger superficial veins like above.
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thought about this thread today when my attending left right after induction for my patient for pancreatic pseudocyst drainage and biopsy, complete with a 20 ga in the right wrist. tried and failed on some miserable veins in the only arm i could get to, then said the hell with it, dropped the 16 in the EJ and got on about my day. :laugh:


best one-liner from the case -

attending surgeon - "hey (me), what was her hemoglobin?"

me - "let's see here... 12.5, sir. Do you plan on lowering that for me?" :D


i could sense the surgical resident tense up and wait for the attack, but the attending just laughed.
 
Ben Hur 17 said:
Start with 20/22g, if they need bigger they can always place another later...at least you got some practice and they can start the case. Act like you know what you're doing, it helps everyone.:D
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20, especially 22, is actually harder to place than larger-bore catheters IMO. The needles are too flimsy and will bend if you don't enter the vein fast enough.
 
Interesting topic to lurk. It is unfortunate you've been having such difficulty getting more hands placing your lines. It's interesting to see the views and the way things are taught to students in different areas of medicine.
Other the airway, one of the most important things we've learned...probably out of necessity and lack of help out in the field is our lines. Day or night, in the rain, upside down in the car or in spaces only big enough for a human being we get them.
Dude you have got to find someone who can give you those lines. You won't get them all but you'll build up that confidence and experience. I can only imagine most physicians have gone thru the same thing.
 
I'd rather start a case with a foot IV then plop an EJ in the holding area or on a fully alert patient in the OR. At least in the OR you can throw some Nitrous on the patient while you scrounge around in their neck. It really sucks for the alert preop patient to be placed in reverse t-berg alone. But throw in a joker putting pressure above the clavicle right before they head back to get cut and that's even more misery.

Personally I've found EJ's to be so unreliable. They kink, come loose, goof up, leak, pull in air, fall out, are sloppy, extravasate, are nearly impossible to secure reliably, and they just friggen suck. Like I said, If its an emergency fine.

If they are gonna be inpatient then line em baby. That crap ass IV you snuck in there wont last on the floors anyways. Floors and PACU nurses flip out on EJ's and funky foot IV's also.

But I get it. You gotta do it then fine. Its the last resort. Just put in something worth a damn once you get em induced n' situated. I'll take a stable 20g PIV over a wobbly 14g EJ almost any day.

Back when, if time permitted, I would bring in the U/S and shoot for a cephalic, basilic, or anetecubi rather than go for the EJ. But if time is on the line then, like I said, do what you gotta do.

Anyways amusing thread....
 
Hey all -
I need help! I am still having trouble with those pesky IVs. In a typical week, I have to have my attending take over for 2-3 of my patients (and they aren't all renal patients either). How long did it take you all to feel like you got very comfortable with placing IVs? Also, any suggestions for when you think you may have hit a valve?

Thanks
 
I'm pretty terrible at IV's as well. I can always get the flash but that damn catheter never wants to thread into the vein....
 
semajjsj said:
I'm pretty terrible at IV's as well. I can always get the flash but that damn catheter never wants to thread into the vein....
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if you can't thread the catheter it's because you're not in the vein. 2 possibilities or you went through and through or the tip of the needle is in the vein but the catheter isn't.
When you get a flash you need to advance the needle further so that the catheter enters the vein without going through the other side with the needle of course.
It takes at least 2-3 hundred iv's to get really facile i'd say.
 
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