Venepuncture tips and tricks? (tricky sticks)

[IMG69]

Currently i'm doing extremely well with my punctures on some extremely difficult patients but it usually takes us 10~ mins to find a vein, i'm talking extremely difficult sticks, a lot of our patients are dying and will die but has anyone got some tips for these very difficult patients? All 80+ year old patients with serious neurological, renal, cardio/resp issues -eg one patient has a BP of 57/33, they all have massive edema etc. I'm talking even the residents can't locate them with us, we're all literally trying to find the veins lol.

Any techniques or methods anyone would care to share? Tourniquet isn't really helping, it's extremely hard to palpate a vein in these patients, we do seem to have the best luck when turning to the hand vasculature.

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[IMGASMD]

Currently i'm doing extremely well with my punctures on some extremely difficult patients but it usually takes us 10~ mins to find a vein, i'm talking extremely difficult sticks, a lot of our patients are dying and will die but has anyone got some tips for these very difficult patients? All 80+ year old patients with serious neurological, renal, cardio/resp issues -eg one patient has a BP of 57/33, they all have massive edema etc. I'm talking even the residents can't locate them with us, we're all literally trying to find the veins lol.

Any techniques or methods anyone would care to share? Tourniquet isn't really helping, it's extremely hard to palpate a vein in these patients, we do seem to have the best luck when turning to the hand vasculature.

If bp is 57/33 I hope you either have a central line or a-line. Just saying.

Try your usual stuff, warm compress. Double tourniquet. if edema, press the hand make it more visible. Use ultrasound.

There are no “tricks”. Just practice, don’t get scared when you do multiple tries, know when to quit.

If the lab will change management/urgent/emergent can always do a arterial draw. But at that point if you don’t have a central line or a-line there is something amiss.

 

[ParaMagic1]

Don't forget to check shoulders/breasts for veins, sometimes find some awesome ones. Those often give minimal flash but if you advance the catheter the blood will fill it slowly. Works great for access.

Also, EJ's are often prominent with the right positioning on people with lower body fat

 

[Gurby]

a lot of our patients are dying and will die but has anyone got some tips for these very difficult patients? All 80+ year old patients with serious neurological, renal, cardio/resp issues -eg one patient has a BP of 57/33, they all have massive edema etc. I'm talking even the residents can't locate them with us, we're all literally trying to find the veins lol.

 

[longhaul3]

Currently i'm doing extremely well with my punctures on some extremely difficult patients but it usually takes us 10~ mins to find a vein, i'm talking extremely difficult sticks, a lot of our patients are dying and will die but has anyone got some tips for these very difficult patients? All 80+ year old patients with serious neurological, renal, cardio/resp issues -eg one patient has a BP of 57/33, they all have massive edema etc. I'm talking even the residents can't locate them with us, we're all literally trying to find the veins lol.

Any techniques or methods anyone would care to share? Tourniquet isn't really helping, it's extremely hard to palpate a vein in these patients, we do seem to have the best luck when turning to the hand vasculature.

If you're trying to stick a vein on a patient with SBP 57, it better be the IJ or subclavian.

Stable patients you should just leave it to the nurses to do the sticks. They're better at them than any of us except the anesthesiologists.

 

[LunaOri]

Use ultrasound. Consider putting in a central line (I know it's frowned on as an infection risk, but it might be kinder than torturing the patients with needles). Call the IV team (many hospitals have IV-specialist nurses).
Of course, if the patients are dying, seriously consider whether any blood tests are really necessary.

 

[IMG69]

Ahh this has gone in the wrong direction, of course we can ultrasound, IO line, A-line, central etc. I was looking for things more like the first two replies; warm compress, shoulders/breasts. Things I can actually do to improve my ability/success.

The consultant/attending makes the calls on the ultrasound, other types of access. He just wants us to practice on difficult patients.

 

[Smurfette]

Ahh this has gone in the wrong direction, of course we can ultrasound, IO line, A-line, central etc. I was looking for things more like the first two replies; warm compress, shoulders/breasts. Things I can actually do to improve my ability/success.

The consultant/attending makes the calls on the ultrasound, other types of access. He just wants us to practice on difficult patients.

One of my mainstays as an intern was looking in the foot for a vein if upper extremities and EJ weren't adequate. I got very good at it.
Use a butterfly needle. Fish with the needle by pulling back and changing angles instead of re-sticking if you miss.
Feel free to draw into a syringe or two off the butterfly and then put everything into the lab tubes instead of using a vacutainer. That way if you don't get a ton of blood, you may still be able to get a little into each blood tube. You don't need a full tube to get routine labs (remember they take much less blood from babies and still can get a result), you just need *enough*. Or use pediatric blood tubes.

 

[LunaOri]

One of my mainstays as an intern was looking in the foot for a vein if upper extremities and EJ weren't adequate. I got very good at it.
Use a butterfly needle. Fish with the needle by pulling back and changing angles instead of re-sticking if you miss.
Feel free to draw into a syringe or two off the butterfly and then put everything into the lab tubes instead of using a vacutainer. That way if you don't get a ton of blood, you may still be able to get a little into each blood tube. You don't need a full tube to get routine labs (remember they take much less blood from babies and still can get a result), you just need *enough*. Or use pediatric blood tubes.

Peds tubes, yes. Underfilling tubes, NOOO!!! This is okay for tubes with no anticoagulant (red tops) but will give INCORRECT LAB RESULTS for tubes with anticoagulant (blue tops, lavendar tops).[/QUOTE]

 

[Matthew9Thirtyfive]

For real. Maybe it’s just the military in me, but my threshold to go IO is not that high. If they need a line now and IV is looking hard, time for the brrrt.

 

[kb1900]

Hands, shoulders, feet are underrated. Yes the hand is more painful but so are multiple failed sticks. If you can palpate it you can hit it. Double tourniquet. Press away edema. Very tight skin on elderly (have them squeeze your non dominant hand or a pill bottle and also retract skin with 1-2 fingers on non dominant hand). Insanely tiny adjustments when you fish with the butterfly. Don’t be afraid to practice (this is the biggest thing). Nobody is actually “good” at anything until they’ve done it at least a thousand times. It’s on you to get those numbers up.

Also don’t shy away from the US if you fail. It speeds things up immensely. Also It really helps learning how to “fish” because even a 1mm adjustment of the angle of your needle is massive. I don’t see how an attending would make that US call unless they’re watching your attempts. Just sign out the US and do it.

but yeah if I’m failing and spending more than 20 mins and the nurses have failed, I’m doing an a-stick.


Lastly don’t believe the people who say nurses are better at it and you should leave it to them. I do pretty much > 50% of the draws and lines on my floor after making it known to all the nurses that I want the practice (going into gas). I literally just asked during one of their huddles and they told me to come in at their turnover time and let the new shift nurses know who you don’t get to. Maybe this is a nyc thing but they love it so it’s a win win. I just show up at 530 and go from room to room with all supplies tubes and labels laid out for me- it’s the only thing I look forward to on medicine and sometimes even gets me pulled off or late to rounds.

 

[Smurfette]

Ah yes, my bad. It's been a while. I remember I always had to fill the blue top first if checking INR/PT, etc. At some point we got a minimum number of cc's from the lab on various tubes. I don't have to draw blood now anyhow, but I do know each lab has different testing limitations based on what equipment they have. My current hospitals (which have better funding) use some different colored tubes than where I trained based on the machines/reagents/whatever available.

 

[IMG69]

Hands, shoulders, feet are underrated. Yes the hand is more painful but so are multiple failed sticks. If you can palpate it you can hit it. Double tourniquet. Press away edema. Very tight skin on elderly (have them squeeze your non dominant hand or a pill bottle and also retract skin with 1-2 fingers on non dominant hand). Insanely tiny adjustments when you fish with the butterfly. Don’t be afraid to practice (this is the biggest thing). Nobody is actually “good” at anything until they’ve done it at least a thousand times. It’s on you to get those numbers up.

Also don’t shy away from the US if you fail. It speeds things up immensely. Also It really helps learning how to “fish” because even a 1mm adjustment of the angle of your needle is massive. I don’t see how an attending would make that US call unless they’re watching your attempts. Just sign out the US and do it.

but yeah if I’m failing and spending more than 20 mins and the nurses have failed, I’m doing an a-stick.


Lastly don’t believe the people who say nurses are better at it and you should leave it to them. I do pretty much > 50% of the draws and lines on my floor after making it known to all the nurses that I want the practice (going into gas). I literally just asked during one of their huddles and they told me to come in at their turnover time and let the new shift nurses know who you don’t get to. Maybe this is a nyc thing but they love it so it’s a win win. I just show up at 530 and go from room to room with all supplies tubes and labels laid out for me- it’s the only thing I look forward to on medicine and sometimes even gets me pulled off or late to rounds.

Exactly my philosophy and my attendings.

 

[OneTwoThreeFour]

View attachment 317103

Exactly my philosophy and my attendings.

The reason you aren't getting better advice is that physicians in the US don't put in many IVs (with the exception of gas). So it is not prioritized in our training. As an EM resident, if I am asked to help with an IV it is ultrasound guided, central line, or EJ. It simply is time consuming, not billable unless you use US, and truly not our job.

 

[operaman]

Yeah the few times I’ve had to do it i always cheated and used ultrasound or did an EJ or some other kind of stick the nurses couldn’t do. Definitely keep practicing because I think it’s a good basic skill to have, but outside of a couple fields you just won’t do it enough to ever be great at it.

I strongly encourage students to get proficient with ultrasound for this kind of thing. Lots of opportunities to practice too. I think anesthesia rotations are the best ones because you can practice getting additional access after induction so the patient is asleep already and there’s no rush while you take your time.