saphenous sticks in babies

[invitro]

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Hey guys was wondering if some of the more seasoned anesthesiologists out there could give me some tips for hitting the saphenous vein with a high percentage of success (>80%)

This is what i do (assume it is the pt's left foot)

1. Feel for the medial malleolus.
2. Place a tourniquet just below the knee on the calf.
3. Angle the foot downward with your left thumb and hold the heel in place with your left index finger.
4. Insert your needle 1/2cm lateral from the bump corresponding to the medial malleolus and aim for the back of the knee
5. Start superficial, then slightly deeper. Then fan slowly lateral and medial.
6. Pray that you hit it.

With these principles in place I still only hit it about 50% of the time. It is super frustrating to struggle for 10 min and not hit it only to watch my attending colleague get it in <1min.

Please help me show him up! JK I have to get better though. But seriously his cockiness irks me.

The funniest thing is that I find getting alines and central lines on these small babies way easier! Ultrasound does help though 🙂

 

[michigangirl]

sounds like you have the right technique! 50% is actually pretty good when you're going blind and can't actually feel or see anything. You just have to do tons of them!

 

[imfrankie]

Don't beat yourself up; the very very best struggle at times, and will welcome a free hand to help. I applaud your commitment to improvement. p.s. don't forget the lateral aspect of the foot.

 

[HalO'Thane]

You can also try to salvage the line with a guidewire. Oftentimes if I hit the saphenous but cannot thread the catheter I go through the back wall of the vein with the needle. I then remove the needle but keep the catheter in, pull the catheter back until I get blood return, and use the guidewire from a pediatric a-line kit to try to thread the catheter in.

In addition to starting latereral to the medial malleolus, you can try going both lateral and inferior to it (0.5-1 cm caudal). I've found that this allows me to go in at a more shallow angle, which makes it easier to thread the catheter.

Hope this helps. As mentioned earlier, pediatric IV's can be a very humbling procedure.

On another note...has anyone had experience using ultrasound for saphenous IV's? I did an internet search on this once and found some case reports out of Boston Children's where the saphenous was tracked with ultrasound up to the middle calf region and an IV was placed there (where it is bigger and juicier). Didn't know if anyone else has tried this.

 

[rsgillmd]

You can also try to salvage the line with a guidewire. Oftentimes if I hit the saphenous but cannot thread the catheter I go through the back wall of the vein with the needle. I then remove the needle but keep the catheter in, pull the catheter back until I get blood return, and use the guidewire from a pediatric a-line kit to try to thread the catheter in.

In addition to starting latereral to the medial malleolus, you can try going both lateral and inferior to it (0.5-1 cm caudal). I've found that this allows me to go in at a more shallow angle, which makes it easier to thread the catheter.

Hope this helps. As mentioned earlier, pediatric IV's can be a very humbling procedure.

On another note...has anyone had experience using ultrasound for saphenous IV's? I did an internet search on this once and found some case reports out of Boston Children's where the saphenous was tracked with ultrasound up to the middle calf region and an IV was placed there (where it is bigger and juicier). Didn't know if anyone else has tried this.

That is what I have done -- lateral and inferior. As others have said, it is mainly practice.

I did a blind saphenous on an adult with b/l UE fractures about a year ago. Her existing IV wasn't that great. Didn't feel like subjecting the woman to a central line for a relatively small procedure. I looked like an ace to those in the OR. Of course the next time I tried it a few months later on a guy who was a difficult stick, I wasn't able to get it.

It's a good skill to have.

 

[deleted126335]

Move the catheter slowly and patiently. I can't tell you how many times I have hit the damn thing with a 24g or 22g catheter and only got flash after the tip of the needle had passed through the vessel.

 

[SleeperHold]

Your techique sounds pretty good. I usually go closer to 1 cm lateral, and then only have to fan medial if at all.

 

[invitro]

Thanks guys!

I plan on probably moving a little more caudal and lateral (about 0.5cm caudal and 1 cm lateral from the bump of the medial malleolus).

I'm gonna get there hopefully sooner then later.

 

[imfrankie]

U/S is sweet for IV access. Try a dollop of gel on the skin then peek through the drop (acoustic window) without touching transducer to patient. You see right through the window a vein that is nice, round and patent.