Tricks for IV access

[EMsandwhich]

Sometimes I get so frustrated with trying to get IV access that a video like this makes my day a whole lot better...

http://www.youtube.com/watch?v=MQIBiJsk4Xo

On hard to get access patients I find my self going to the deep brachial more often than not... if that doesn't work I guess I'm just stuck with the central line...if unstable then IO...

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[Doctor4Life1769]

Lame.

Was hoping for something constructive (or at least funny). Thanks anyway.

 

[coldweatherblue]

Thought it was pretty funny. Good music selection and video editing, first couple shots while BB King was playing were well put-together. 👍

 

[WerdSalid]

Ej

 

[FDNewbie]

Sometimes I get so frustrated with trying to get IV access that a video like this makes my day a whole lot better...

http://www.youtube.com/watch?v=MQIBiJsk4Xo

On hard to get access patients I find my self going to the deep brachial more often than not... if that doesn't work I guess I'm just stuck with the central line...if unstable then IO...

Just my $0.02:

Ultrasound-guided IV access is your friend. I routinely place IVs that way after the nursing staff as well was the IV team fails. Def. useful esp. when you only need a blood draw (don't necessarily need to place an IV) or you just need access, but not a central line.

IOs are great. But I'd encourage ya to get very comfortable with placing central lines in unstable patients. I look at that as our specialty. A subclavian or femoral should take ya 5-10 min tops, from start to finish. And if they're truly unstable (coding, etc), a dirty femoral will take 15-30 SECONDS, and you can use it immediately (no need to wait for placement confirmation), providing 3 access ports for immediate use (assuming you place a triple lumen). And these patients typically get all their ED lines removed & replaced with clean ones anyway when they get up to the unit.

 

[deleted77919]

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[FDNewbie]

I've played around with U/S guided peripherals but don't find them all that useful. If I only need blood they're getting a fem stick. If I need access I'll go EJ or start a line. EJ is faster than carting the U/S over and if I'm going to use an U/S to look around at vessels I'm gonna place a central line I can bill for.

That's def. a valid viewpoint. I'm a softie; I think fem sticks hurt ppl a good bit, so I do the U/S-guided blood draw instead.

On that note, have you found that on pretty dry patients, even EJs can be hard to find, even with the patient in T-bird?

 

[deleted109597]

I've learned that working somewhere the nurses don't suck helps. Since, you know, they can actually get the IVs without needing help.

 

[AmoryBlaine]

I've played around with U/S guided peripherals but don't find them all that useful. If I only need blood they're getting a fem stick. If I need access I'll go EJ or start a line. EJ is faster than carting the U/S over and if I'm going to use an U/S to look around at vessels I'm gonna place a central line I can bill for.

Agree, I think u/s guided peripherals (esp deep peripherals) tend to be very tenuous. You often end up needing these long catheters that can be mostly in the SQ tissue.

I go to the central line pretty quickly. You know that isn't going to fall out. Any patient who is a tough stick is someone who usually has a good chance of being on the sicker side anyway.

Agree with the statement about lines in unstable patients. If you can't get a SC central line in in about 2-4 minutes you need to practice more.

 

[xaelia]

I think we've pretty well established by this discussion that there is a role for central at multiple sites vs. IO vs. deep brachial u/s vs. EJ depending on the specific clinical situation, level of experience, and resources available.

If you gave me one option to be my fallback panic temporary access, it would be bilateral IOs given their nearly zero complication rate and extreme speed with the drill.

Landmark methods for central access work great until you lose your landmarks and ability to palpate pulses in 300+ lb. fatness that's nearly standard where I work.

 

[AmoryBlaine]

I think we've pretty well established by this discussion that there is a role for central at multiple sites vs. IO vs. deep brachial u/s vs. EJ depending on the specific clinical situation, level of experience, and resources available.

If you gave me one option to be my fallback panic temporary access, it would be bilateral IOs given their nearly zero complication rate and extreme speed with the drill.

Landmark methods for central access work great until you lose your landmarks and ability to palpate pulses in 300+ lb. fatness that's nearly standard where I work.

Agree. Impossible to argue. IOs are hugely underutilized. You can put anything through them (not true of a peripheral IV).

 

[FDNewbie]

If you gave me one option to be my fallback panic temporary access, it would be bilateral IOs given their nearly zero complication rate and extreme speed with the drill.

Landmark methods for central access work great until you lose your landmarks and ability to palpate pulses in 300+ lb. fatness that's nearly standard where I work.

I think landmarks as simple as the tibeal plateau for an I/O can be challenging in very large patients. But sternums always work too (unless they've had a sternotomy prior). And I still think you can get decent enough landmarks for a central line on a really large person, regardless of the site you choose. Just my experience.

Lastly, I wouldn't say I/Os have a nearly zero complication rate. We've had a fracture or two with it's use. Wasn't me, so I can't tell ya if the patient had underlying skeletal dz, etc, but just keep in mind that NOTHING has a zero complication rate. That just means you haven't done enough of 'em yet ;-)

 

[AmoryBlaine]

I think landmarks as simple as the tibeal plateau for an I/O can be challenging in very large patients. But sternums always work too (unless they've had a sternotomy prior). And I still think you can get decent enough landmarks for a central line on a really large person, regardless of the site you choose. Just my experience.

Lastly, I wouldn't say I/Os have a nearly zero complication rate. We've had a fracture or two with it's use. Wasn't me, so I can't tell ya if the patient had underlying skeletal dz, etc, but just keep in mind that NOTHING has a zero complication rate. That just means you haven't done enough of 'em yet ;-)

In an adult? No way.

Can you tell us about these patients? Fracture is really not described as a complication of IO. You're making an 18ga puncture into a thick part of a long bone, that should not fracture a healthy tibia or even an unhealthy tibia for that matter.

 

[Arch Guillotti]

Agree. Impossible to argue. IOs are hugely underutilized. You can put anything through them (not true of a peripheral IV).

Forgive my ignorance but what can you put through an IO that can't go IV?

 

[Arch Guillotti]

And I still think you can get decent enough landmarks for a central line on a really large person, regardless of the site you choose. Just my experience.

Your experience is very different from mine. Neck landmarks and positioning in super obese is a pain in the rear.

 

[AmoryBlaine]

Forgive my ignorance but what can you put through an IO that can't go IV?

Vasopressors.

Norepi, epi, and dopa are really not mean to be infused peripherally. Alot of people do it and get away with it but that doesn't mean it's a good idea.

 

[FDNewbie]

In an adult? No way.

Can you tell us about these patients? Fracture is really not described as a complication of IO. You're making an 18ga puncture into a thick part of a long bone, that should not fracture a healthy tibia or even an unhealthy tibia for that matter.

Not trying to be an *****, but if you brush up on I/O literature, you'll see it's a well-described (albeit rare) documented complication. For example: Katz DS, Wojtowycz AR. Tibial fracture: a complication of intraosseous infusion. Am J Emerg Med. Mar 1994;12(2):258-9. eMedicine (one of my fav. quick references) lists it as a known complication as well: "Other possible complications include local hematoma, pain, fracture and growth plate injuries (with incorrect placement), and fat microemboli (not clinically significant) and compartment syndrome if extravasation is not recognized upon insertion."

Your experience is very different from mine. Neck landmarks and positioning in super obese is a pain in the rear.

I'm not going to even play like it isn't a pain. But I can pretty much ALWAYS find a clavicle in an obese patient. How medial or lateral you are can be hard to assess, but I can at least get an idea of the general area to make my attempt.

IJs...I only do by ultrasound. Partly because I've never been taught to do it blind (except once or twice a LOOONG time ago) and partly because I honestly believe it to be the standard of care - a PTX or dilated carotid is a completely unacceptable complication IMO when you're able to do IJs under real-time visualization. Granted, in really large & extremely dehydrated patients, my approach as varied between a true IJ and a supraclavicular subclavian approach (both via U/S guidance), the point remains the same. It's nearly fool-proof I find.

Femorals...same spot in almost everyone. Even if you can't find a pulse. In fact, I harp on the lower classmen that when a cardiac arrest comes in and we need a line, they NEED to be able to place & secure a femoral without being able to locate a pulse (ie the femoral artery). The anatomy is fairly reliable across the vast majority of patients. Having said that, you do often need someone to retract the pannus in a larger patient lol.

 

[AmoryBlaine]

Not trying to be an *****, but if you brush up on I/O literature, you'll see it's a well-described (albeit rare) documented complication. For example: Katz DS, Wojtowycz AR. Tibial fracture: a complication of intraosseous infusion. Am J Emerg Med. Mar 1994;12(2):258-9. eMedicine (one of my fav. quick references) lists it as a known complication as well: "Other possible complications include local hematoma, pain, fracture and growth plate injuries (with incorrect placement), and fat microemboli (not clinically significant) and compartment syndrome if extravasation is not recognized upon insertion."

You're not being a ******, it's an academic discussion.

That said, I disagree with you if you are saying that we should be considering tibial fracture as part of our decision making when thinking about placing an IO.

I can't pull up this paper, do you have the pdf?

There's a difference between a described, reported complication and a something that we need to consider in everyday practice. If you look at the case reports on central line placement you can find just about any complication but when we are placing central lines what do you think about: infection, arterial puncture, PTX.

The only adverse effects that should enter our cognitive clinical practice when we place an IO is insertion pain and the possibility of local inflammation.

 

[FDNewbie]

You're not being a ******, it's an academic discussion.

Good. I know it's hard to read tone online.

That said, I disagree with you if you are saying that we should be considering tibial fracture as part of our decision making when thinking about placing an IO.

Oh I'm not saying that it's a common complication you have to keep in the back of your mind as a real issue you're likely to deal with; I'm just sharing that it is indeed a known (albeit quite rare) complication. I believe a lot of it depends on 1) pre-existing conditions in the patient (osteoperosis, etc) and 2) incorrect placement technique.

I can't pull up this paper, do you have the pdf?

I can email our librarian to email me the PDF 😀

There's a difference between a described, reported complication and a something that we need to consider in everyday practice. If you look at the case reports on central line placement you can find just about any complication but when we are placing central lines what do you think about: infection, arterial puncture, PTX.

The only adverse effects that should enter our cognitive clinical practice when we place an IO is insertion pain and the possibility of local inflammation.

I wouldn't argue that 🙂

 

[Arch Guillotti]

Vasopressors.

Norepi, epi, and dopa are really not mean to be infused peripherally. Alot of people do it and get away with it but that doesn't mean it's a good idea.

uh, ok. I thought it might be something else I wasn't aware of.

 

[FDNewbie]

Agree with above. I've seen Dopa eat through peripherals like crazy... And I'm pretty sure most ICUs limit how high you can run DopaGtt through a peripheral. Typically 5 or 10 tops. Anything higher, you need a CVL.

 

[WilcoWorld]

Agree with above. I've seen Dopa eat through peripherals like crazy... And I'm pretty sure most ICUs limit how high you can run DopaGtt through a peripheral. Typically 5 or 10 tops. Anything higher, you need a CVL.

Yep - essentially the dopamine infusion rate through a peripheral IV is limited to ineffective doses, so you get all of the risk with almost none of the benefit.

 

[xaelia]

Yep - essentially the dopamine infusion rate through a peripheral IV is limited to ineffective doses, so you get all of the risk with almost none of the benefit.

You seem to suggest there's an effective dose to dopamine.... 😀

I'm stuck using it because of the norepi shortage and it makes me sad.

 

[deleted77919]

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[FDNewbie]

They can be. If I can see anything at all I'll lidocaine the pt, makes them a lot more cooperative bearing down while I am poking them. If I don't see something I can hi tit's off to a central line.

Gotcha. Yea I was wonderin cuz at my hospital few if any docs start IVs, and nurses can't do EJs, so I'm flyin solo on that one. Wasn't sure what others' experiences were like. If it's there, it's there. But sometimes it's really hard to find esp. if they're contracting their neck muscles too.

I like subclavians, low complication rates, no need to muck around with ultrasound. Usually it's a very quick line.

Ditto in loving subclavians, but cuz there's minimal setup time, and it isn't in the groin haha. Although every now and then (1 outta every 10 or 20) there's one that I simply can't find...at which point I'll switch to my fail-proof U/S-guided IJ.

I don't really agree re: the low complication rates statement though, primarily cuz at least from what I've seen, a LOT of ppl are a wee bit too gung-ho as to how they're pokin the needle under the subclavian, and cause wayy too many PTXs. Ie, ppl have no idea how deep they're pokin, and just dive in. I use the "walk the needle down the clavicle, and once you're under, stay flat/parallel" method, so you always know you're very superficial. Sure, that means you may miss the vein (very very rarely) if it's a bit deeper, but I rather miss it and do an IJ than give a sick patient a PTX as well as a central line.

I'd also def. say IJs have a lower complication rate in terms of not dilating on an artery & not causing a PTX given you do the entire procedure under direct visualization. But where's the skill in that? 😛

 

[bartleby]

Agree, I think u/s guided peripherals (esp deep peripherals) tend to be very tenuous. You often end up needing these long catheters that can be mostly in the SQ tissue.

Unless you're doing a superficial vessel in the forearm, the 1 3/4" "long" catheters (as opposed to the standard 1 1/4") should be considered mandatory, otherwise there just isn't enough catheter in the vessel.

The main benefit of an ultrasound guided peripheral IV vs an EJ is the ability to power injection of contrast for a CTA through the peripheral. An EJ which infiltrates under power injection is not pretty.

The other main benefit of u/s guided peripheral IVs vs either central lines, or IOs is in patients in whom access is difficult but admission is not a forgone conclusion.

 

[AmoryBlaine]

Unless you're doing a superficial vessel in the forearm, the 1 3/4" "long" catheters (as opposed to the standard 1 1/4") should be considered mandatory, otherwise there just isn't enough catheter in the vessel.

The main benefit of an ultrasound guided peripheral IV vs an EJ is the ability to power injection of contrast for a CTA through the peripheral. An EJ which infiltrates under power injection is not pretty.

The other main benefit of u/s guided peripheral IVs vs either central lines, or IOs is in patients in whom access is difficult but admission is not a forgone conclusion.

Even with the long catheters on the fatties you might not have much in, then they bend their arm or jerk their IV tubing and...

Your last point is valid, but I think we can all agree that rare is the pt who you are having to do creative access on who is going to go home...

 

[Hamhock]

Unless you're doing a superficial vessel in the forearm, the 1 3/4" "long" catheters (as opposed to the standard 1 1/4") should be considered mandatory, otherwise there just isn't enough catheter in the vessel.

The main benefit of an ultrasound guided peripheral IV vs an EJ is the ability to power injection of contrast for a CTA through the peripheral. An EJ which infiltrates under power injection is not pretty.

The other main benefit of u/s guided peripheral IVs vs either central lines, or IOs is in patients in whom access is difficult but admission is not a forgone conclusion.

Or, even better yet, using one of the Arrow radial/femoral arterial lines - plenty long..

Or a single lumen, pressure-approved "central" line placed in the deep brachial.

HH

 

[fiznat]

Vasopressors.

Norepi, epi, and dopa are really not mean to be infused peripherally. Alot of people do it and get away with it but that doesn't mean it's a good idea.

Never heard of this. Granted I'm just a paramedic and MS-0 so that probably explains it, but what's the problem with peripheral lines for these drugs? We do it in the field and I see it in the hospital all the time... Someone else mentioned the drugs "eating through" the catheters? ???

 

[docB]

Not trying to be an *****, but if you brush up on I/O literature, you'll see it's a well-described (albeit rare) documented complication. For example: Katz DS, Wojtowycz AR. Tibial fracture: a complication of intraosseous infusion. Am J Emerg Med. Mar 1994;12(2):258-9. eMedicine (one of my fav. quick references) lists it as a known complication as well: "Other possible complications include local hematoma, pain, fracture and growth plate injuries (with incorrect placement), and fat microemboli (not clinically significant) and compartment syndrome if extravasation is not recognized upon insertion."

I don't know why but I couldn't find this article. Did they use the old style manual IOs for this or the newer EZIO or the BIG? That might have made a difference too.

 

[The right Path]

Never heard of this. Granted I'm just a paramedic and MS-0 so that probably explains it, but what's the problem with peripheral lines for these drugs? We do it in the field and I see it in the hospital all the time... Someone else mentioned the drugs "eating through" the catheters? ???

The drugs don't "eat" through the catheters. Drugs through peripheral IVs are more likely to infiltrate into the tissues- short catheter, relatively easily dislodged, and/or the integrity of the vein can break down. Concentrated vasoconstrictors in the tissues work on the blood supply to those tissues and now you have a ischemia. You can google some pics to see what happens.

 

[AmoryBlaine]

Never heard of this. Granted I'm just a paramedic and MS-0 so that probably explains it, but what's the problem with peripheral lines for these drugs? We do it in the field and I see it in the hospital all the time... Someone else mentioned the drugs "eating through" the catheters? ???

There is a risk of something terrible happening (extrav as mentioned above).

Now keep in mind that this is not deripheral dopa = dopamine extravasation syndrome. Obviously the IV infiltrates. Theoretically you could max someone on 4 pressors through PIVs and not have a bad outcome.

I just don't think it's worth the risk, esp when then evidence probably suggests that pressors are not the most important thing in surviving sepsis.

 

[bartleby]

Your last point is valid, but I think we can all agree that rare is the pt who you are having to do creative access on who is going to go home...

I wish it was. Between the HIV ex-IVDA crowd, dialysis types, bariatrics, and various chronic rheum and onc cases, it is not as rare locally as you'd think

 

[FDNewbie]

I don't know why but I couldn't find this article. Did they use the old style manual IOs for this or the newer EZIO or the BIG? That might have made a difference too.

Sorry it's not exactly the most scholarly written article lol, but give 'em a break. It's from almost 2 decades ago haha. Article attached.