What is your approach to difficult IV access?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
P

propofabulous

Full Member
Verified Member
5+ Year Member
Joined
Aug 9, 2018
Messages
71
Reaction score
52
How do you guys manage difficult IV access intraop (say for your super morbid obese vasculopaths)? Any cool methods or tips/tricks that I am missing?

1) Peripheral IV in any extremity
-Blind saphenous if peds
-IO if emergency
2) US for obvious superficial targets in the extremities
3) US guided IV into deep vessel (basilic or brachial)
4) EJ
5) Central line
Members don't see this ad.
 
You should be able to get an IV in literally anyone with an US, and it should almost never take more than 5 minutes (max). If you can’t do this, you need to get better with US.

For deep vessels, no law against using a longer catheter (10cm arrow cath meant for fem art lines works nicely as a poor mans mid line).

You should never need to put in an IO. Period.
 
Members don't see this ad :)
US to deep brachial, or other big veins in the region. I like long 18G as the best overall to see on US and easy to cannulate. Sometimes the distal forearm veins are great US targets, I like the “intern vein” about halfway up the forearm where it’s too deep to get blind but big enough and straight enough to make it an easy target.
 
First thing I do, when I get the “we can’t get an iv, call”, is tell the nurses to cover the pt in multiple warm blankets. Amazing how that simple act sometimes makes things appear.

Look at upper arm/shoulder area on these folks, even at the upper portion of their chest/breast area. I often find an obvious superficial vein there that the nurses would never look for...

On slender folks who look like they’re gonna go nuts if they get stuck any more, I’ve talked with them about some po versed and take them back to the OR, breathe them down on gas (sometimes that will make things pop up) and if nothing shows, place an LMA, pop in a central line, and then switch to an ett to do the case (again, this is for folks with a manageable airway, not morbidly obese).
 
Last edited:
Dude you’re overthinking this. Put the probe on the arm and scan between the wrist and shoulder, usually you’ll find a vein or two. If you have multiple options selection of an IV site is generally case-and patient- specific (need big IV? Arm going to be bent? Dialysis patient with fistula? Etc).

You’re a CA-3, right? If you aren’t learning US guided IVs in residency, better start now. Find someone good who can teach you and practice practice practice. Learning meticulous technique for following your needle tip isn’t hard, just takes repetition. Practicing on the easy ones will give you the skills you need for the harder ones (deep, small, tortuous target).
 
Quick scan of the antecubital area for an antecubital vein or brachial, and then straight to basilic vein in the upper arm if antecub doesn't look good. Long 18g if pt is reasonable sized. If not then 12 cm arrow kit catheter.

1599711300644.png


1599711307887.png


1599711314814.png

academic.oup.com

Mid-arm approach to basilic and cephalic vein cannulation using ultrasound guidance†

Abstract. Central venous lines are often used when there is difficulty obtaining peripheral venous access. The basilic and cephalic veins in the mid-arm re
academic.oup.com academic.oup.com
*


*I use a linear probe. There is no need for a curvilinear probe, even in fatties.
 
propofabulous said:
How do you guys manage difficult IV access intraop (say for your super morbid obese vasculopaths)? Any cool methods or tips/tricks that I am missing?
Click to expand...

Not trying to be a smartass, but I think the more important question is why are you trying to get IV access on a pt who is a difficult stick intraop? Get it done preop homie.


Edit: to be more helpful though, I think the best tip is to get damn good with your US skills. So far (knock on wood), I haven’t run into a situation where I can’t: a) find some sort of superficial or deep vein in the upper extremity; b) place an EJ or c) place a 22g in one of those wispy and friable super duper superficial veins on a finger, inner wrist, and one time the breast (male patient). My final backup would of course be a central line and, depending on the patient, could give PO versed if required, otherwise I guess you could do an inhalational induction and then get access if you reeeeally couldn’t do it awake and the airway looks good.
 
Last edited:
Don't waste your time on ultrasounding the forearm. Place that sucker on the neck and stick the IJ with a long angio.

Your partners are hogging the ultrasound for their blocks? No problem, just bend the hand over and poke a 22 in between the 3rd and 4th finger. Everyone has a vein there. Once you get flash, just thread the catheter.

1599713203421.png


If you want to be a real baller, pick a finger and put a 22 (or 24) on the dorsum of the proximal phalange. There's a vein there and you can support it with a taped tongue blade. Use that to go to sleep and once they're vasodilated you can place a bigger iv in the vein of your choice.

Don't have the force? Then get an esmark and do a reverse bier block to push all the blood into the hand and you will be able to place a 16g in the worst morbidly obese 80 yo vasculopath.
 
propofabulous said:
How do you guys manage difficult IV access intraop (say for your super morbid obese vasculopaths)? Any cool methods or tips/tricks that I am missing?

1) Peripheral IV in any extremity
-Blind saphenous if peds
-IO if emergency
2) US for obvious superficial targets in the extremities
3) US guided IV into deep vessel (basilic or brachial)
4) EJ
5) Central line
Click to expand...

Let's not let the pendulum swing too hard against CVCs.

Ultrasound guided PIV is an invaluable tool to be sure. But, they might be small diameter catheters or somewhat precarious related to deep depth, etc.

If you've spent more than 5-10 minutes with ultrasound and don't have the IV access you want, just put a neck line in, which should take you not more than 10-15 minutes with an assistant. Don't be the CRNA or MD who has been struggling for 20-30 minutes with US PIV and could have already been done with a CVC, which is a better line by really any measure anyway.

If the surgeon is pissy, tell them to leave or remain seated.
 
Last edited:
GassYous said:
Don't waste your time on ultrasounding the forearm. Place that sucker on the neck and stick the IJ with a long angio.

Your partners are hogging the ultrasound for their blocks? No problem, just bend the hand over and poke a 22 in between the 3rd and 4th finger. Everyone has a vein there. Once you get flash, just thread the catheter.

View attachment 318003

If you want to be a real baller, pick a finger and put a 22 (or 24) on the dorsum of the proximal phalange. There's a vein there and you can support it with a taped tongue blade. Use that to go to sleep and once they're vasodilated you can place a bigger iv in the vein of your choice.

Don't have the force? Then get an esmark and do a reverse bier block to push all the blood into the hand and you will be able to place a 16g in the worst morbidly obese 80 yo vasculopath.
Click to expand...

US forearm IVs are successful like the vast vast majority of the time. How is it a waste of time?

Love your Esmarch trick though.
 
dipriMAN said:
US to deep brachial, or other big veins in the region. I like long 18G as the best overall to see on US and easy to cannulate. Sometimes the distal forearm veins are great US targets, I like the “intern vein” about halfway up the forearm where it’s too deep to get blind but big enough and straight enough to make it an easy target.
Click to expand...

I like the long 18g into basilic because of reliable anatomy, but will look for the intern vein in the forearm next time!
 
Members don't see this ad :)
DirtDocMD said:
First thing I do, when I get the “we can’t get an iv, call”, is tell the nurses to cover the pt in multiple warm blankets. Amazing how that simple act sometimes makes things appear.

Look at upper arm/shoulder area on these folks, even at the upper portion of their chest/breast area. I often find an obvious superficial vein there that the nurses would never look for...

On slender folks who look like they’re gonna go nuts if they get stuck any more, I’ve talked with them about some po versed and take them back to the OR, breathe them down on gas (sometimes that will make things pop up) and if nothing shows, place an LMA, pop in a central line, and then switch to an ett to do the case (again, this is for folks with a manageable airway, not morbidly obese).
Click to expand...

Chest/breast IV I have seen rarely, will keep these in mind! Interesting approach to the anxious patient too, thank you
 
GassYous said:
Don't waste your time on ultrasounding the forearm. Place that sucker on the neck and stick the IJ with a long angio.

Your partners are hogging the ultrasound for their blocks? No problem, just bend the hand over and poke a 22 in between the 3rd and 4th finger. Everyone has a vein there. Once you get flash, just thread the catheter.

View attachment 318003

If you want to be a real baller, pick a finger and put a 22 (or 24) on the dorsum of the proximal phalange. There's a vein there and you can support it with a taped tongue blade. Use that to go to sleep and once they're vasodilated you can place a bigger iv in the vein of your choice.

Don't have the force? Then get an esmark and do a reverse bier block to push all the blood into the hand and you will be able to place a 16g in the worst morbidly obese 80 yo vasculopath.
Click to expand...

These are awesome. Have never seen an angiocath into the IJ. Only central line catheters
 
vector2 said:
Quick scan of the antecubital area for an antecubital vein or brachial, and then straight to basilic vein in the upper arm if antecub doesn't look good. Long 18g if pt is reasonable sized. If not then 12 cm arrow kit catheter.

View attachment 318000

View attachment 318001

View attachment 318002
academic.oup.com

Mid-arm approach to basilic and cephalic vein cannulation using ultrasound guidance†

Abstract. Central venous lines are often used when there is difficulty obtaining peripheral venous access. The basilic and cephalic veins in the mid-arm re
academic.oup.com academic.oup.com
*


*I use a linear probe. There is no need for a curvilinear probe, even in fatties.
Click to expand...

Thanks! I forego AC and go straight basilic but your way makes more sense. Appreciate the pictures
 
usually can find something with or without an ultrasound. feet IVs. lower leg ivs. boob ivs. EJ. I feel like we see the worst too... ivda, esrd, morbidly obese. If all else fails i put a central line in awake... i think ive only had to do that once or twice. I feel like if i am having trouble the floors and icu are going to have major trouble and the central line will be beneficial for more than just my case
 
I have yet to try the esmark bandage, majority of the time we are getting an IV in a place where that bandage is nowhere around. Would an ace bandage be easier to obtain/use? Another alternative if they are easy to obtain where you are is a micropuncture kit. Same **** basically that the picc team uses and I have never had them fail to put in a picc.
 
I often use the 5Fr 10 cm in the basilic or brachial vein. Ultrasound guided I have never not obtained IV access. Sometimes I can find those arrow 12 cm wired angiocath kits.
 
MirrorTodd said:
I have yet to try the esmark bandage, majority of the time we are getting an IV in a place where that bandage is nowhere around. Would an ace bandage be easier to obtain/use? Another alternative if they are easy to obtain where you are is a micropuncture kit. Same **** basically that the picc team uses and I have never had them fail to put in a picc.
Click to expand...

Dangle their arm over the rail so blood will pool in their hand. Put the blood pressure cuff on the forearm and inflate it.
 
I like to work as distal as possible to start.
Even though there is collateral flow, if you booger up a proximal vein, that can complicate things.

T-burg then EJ is a good one as well if you can keep the skin tight upon placement.

US is a great tool to use. In residency I’ve had many a unit nurse call saying they need central access. US with long angiocath (or femoral a-line Cath) tightly secured for the win.

CVC has risks that can be avoided if possible.
 
Hork Bajir said:
You should be able to get an IV in literally anyone with an US, and it should almost never take more than 5 minutes (max). If you can’t do this, you need to get better with US.

For deep vessels, no law against using a longer catheter (10cm arrow cath meant for fem art lines works nicely as a poor mans mid line).

You should never need to put in an IO. Period.
Click to expand...

I had a patient a few weeks ago I was called to help get an IV on, she has a long history of being a horrific stick, coming in for port placement by IR. Obese and anxious through the wazoo, is on benzos at home (with no effect). Literally, no veins, anywhere... I ultrasounded her and tried basilic with micropuncture kit on both sides, and those were so damn tiny i couldn't get it wouldn't thread even with blood return when I put the needle in and it was front and center in the vein. She absolutely adamantly refused central line, had a VP shunt on the left neck and right neck was IR territory for the port needed, was going to run away when I mentioned femoral access. Demanded to get nitrous as she heard that helps (not booked as an OR case, I was just helping pre-op get the pt to go to IR). This is the one and only patient I had to tap out literally because of no options and pt being unreasonable about options.
 
If no CI to mask induction, go for it. Gets case started, veins dilate, usually visually obvious but bring an US for the ride. If you have time to waste in pre op, wrap an upper limb in a warm blanket for a few minutes, let it hang in a dependent position, use the cuff in STAT mode, or use an esmarch in a reverse bier block as others have suggested. The basilic vein in the forearm is awkward, but usually superficial, and can be reached in a dependent position with you lying on the floor. For US: Most people have a cephalic vein and antebrachial vein of forearm just the same way they have one nose and two ears, they are usually in roughly the same area of everybody’s forearm. You should be able to assess their viability within seconds with a scan. Certainly, the basilic vein is large in the upper arm, but tends to be RIGHT next to the brachial artery and median nerve. Best know what you are doing here. A better choice is the saphenous vein, usually present in most people who haven’t had a CABG. Place probe by medial malleolus, scan proximally and side to side. There is a visually pleasing compressible hypoechoic circle there, asking for a long 18.

CVC and IO are last resort choices. If a person doesn’t have a central line, they can’t develop central line complications. A good way to start and end the day is without complications. A humeral IO will pop out when arms are abducted for arm board positioning. Also, patients coming in for elective procedures LOVE these procedures and will write long effusive letters about what a great doctor you are. After a while, you and those around you will get tired of these mountains of praise. Be judicious.
 
I had a case where I needed bigger volume access fast and pressor but had so many other things to do in the OR and very little time. I put patient in tberg and placed a 16g EJ, ran fluids and pressor through that. I figured it was basically central access with the size EJ she had. I think the ICU later ended up agreeing because she kept that EJ for the next 3 or 4 days with pressor going and no CVC :-D
 
Hork Bajir said:
You should be able to get an IV in literally anyone with an US, and it should almost never take more than 5 minutes (max). If you can’t do this, you need to get better with US.

For deep vessels, no law against using a longer catheter (10cm arrow cath meant for fem art lines works nicely as a poor mans mid line).

You should never need to put in an IO. Period.
Click to expand...

Myself and my experienced partners have all had the occasional difficult PIV placements despite US, wires, all the tricks..

I find that when I am at the point of taking out the ultrasound, meaning the patient has had 3+ pokes, I am going right to the long angiocath IJ as someone else mentioned, so reliable and straight forward, i suture it in around the hub - hard to beat that. If its a routine case, thats my only access. If its a bigger case I can change it over to a true TLC if I need to once we are asleep if needed
 
If I suspect difficult IV, I have US in the room. If obese and futile efforts to even consider blind I just use US with 20g longer IV catheter under nitrous
My practice is peds but kids keep getting bigger and bigger.
Saphenous and foot IV always available if not contraindicated for surgery. At least if would help start the case.
 
2Fast2Des said:
I had a patient a few weeks ago I was called to help get an IV on, she has a long history of being a horrific stick, coming in for port placement by IR. Obese and anxious through the wazoo, is on benzos at home (with no effect). Literally, no veins, anywhere... I ultrasounded her and tried basilic with micropuncture kit on both sides, and those were so damn tiny i couldn't get it wouldn't thread even with blood return when I put the needle in and it was front and center in the vein. She absolutely adamantly refused central line, had a VP shunt on the left neck and right neck was IR territory for the port needed, was going to run away when I mentioned femoral access. Demanded to get nitrous as she heard that helps (not booked as an OR case, I was just helping pre-op get the pt to go to IR). This is the one and only patient I had to tap out literally because of no options and pt being unreasonable about options.
Click to expand...

For these kind of people I tourniquet right in the armpit and go for the axillary vein, being mindful not to spear any nerves on the way in.
 
It’s painful but there is usually something in the ventral side of the wrist you can put a 22 in.
 
propofabulous said:
How do you guys manage difficult IV access intraop (say for your super morbid obese vasculopaths)? Any cool methods or tips/tricks that I am missing?

1) Peripheral IV in any extremity
-Blind saphenous if peds
-IO if emergency
2) US for obvious superficial targets in the extremities
3) US guided IV into deep vessel (basilic or brachial)
4) EJ
5) Central line
Click to expand...

1)Normal approach (many surprisingly have good hand veins)
2)Ultrasound guided - Antecubital
3) Ultrasound guided - IJ

Edit: Don't drink the residency kool-aid of "every case needs an 18g IV". Drugs can flow through a 22 the same way they can a 14 (sure slower) and when they're asleep then you can stick them wherever you want for a bigger IV. It's anesthesia......get them to sleep

2nd Edit: 4) Sometimes you can even inhalation induce then and let them breath sevo while you stick for an IV. Probably the riskiest way but still and option
 
If I have run out of options, my go to is the dorsal aspect of the thumb - you’ll always find something there (I’m serious...)
 
Also know where the vascular access kits that the vascular surgeons use are located. these are lifesavers when even dealing with difficult ACs or you can even use them to place a catheter in an axillary vein
 
always more challenging when patient is freaking out and can't hold still

1. do the usual tricks (e.g., tourniquet, warm blankets, slapping the **** out of the veins, dependency, etc)
2. quick look at lower extremities
3. most cases can be done with ultrasound guided IV of UE
4. quick look at neck for EJ
5. central line

Not a big fan of gassing patient down with sevo, unless they have a pristine airway and there is a possible target already in my mind
The last time I gassed the patient was an old thin woman who had crap veins even on ultrasound, but had small visible wrist veins -- didn't want lidocaine, kept moving her arms about, agreeable to gas down and IV placement there
 
With y'alls ultrasound IVs - how good are your linear probes at visualizing needle tips in soft tissue prior to venous cannulation? I've found that depending on the manufacturer (i.e. mind ray over GE), the probes do not visualize the tips as well and just show you displacement. Is this enough for you all or are you walking in the tip in the soft tissue?
 
I just use the ultrasound to find the vein and then to an iv like normal. I've tried through and through with a wire and my success rate is horrible unless the vein is big and straight.

About masking a patient down, last time I tried was on a healthy young lady with a good airway where we tried 3 times but couldn't get an iv. As soon as she starts going under, a ton of liquid comes gushing out of her mouth. Literally hits the mask like a geyser. Turned the gas right off, suctioned like crazy and woke her up. She adamantly denies any po intake but we canceled case. She was fine but it shook me and haven't tried since.
 
Twiggidy said:
Edit: Don't drink the residency kool-aid of "every case needs an 18g IV". Drugs can flow through a 22 the same way they can a 14 (sure slower) and when they're asleep then you can stick them wherever you want for a bigger IV. It's anesthesia......get them to sleep

2nd Edit: 4) Sometimes you can even inhalation induce then and let them breath sevo while you stick for an IV. Probably the riskiest way but still and option
Click to expand...

Definitely had attendings who would refuse to place some cardiac patients alseep without a introducer in place. Even if the patient was in florid right heart failure and they already had a PICC line.
 
Norepi said:
With y'alls ultrasound IVs - how good are your linear probes at visualizing needle tips in soft tissue prior to venous cannulation? I've found that depending on the manufacturer (i.e. mind ray over GE), the probes do not visualize the tips as well and just show you displacement. Is this enough for you all or are you walking in the tip in the soft tissue?
Click to expand...

Go in-plane and you can see the whole needle.
 
Norepi said:
With y'alls ultrasound IVs - how good are your linear probes at visualizing needle tips in soft tissue prior to venous cannulation? I've found that depending on the manufacturer (i.e. mind ray over GE), the probes do not visualize the tips as well and just show you displacement. Is this enough for you all or are you walking in the tip in the soft tissue?
Click to expand...
Our sonosites have been good enough for me to quickly and easily do out-of-plane and drive needle down center of vein until hub hits skin.

Its not hard and doesn't add much time once you've practiced and success rate approaches 100%. I get aggravated when I see people fiddle around with U/S, get flash, then drop the probe and proceed to bungle the IV anyway.
 
Norepi said:
With y'alls ultrasound IVs - how good are your linear probes at visualizing needle tips in soft tissue prior to venous cannulation? I've found that depending on the manufacturer (i.e. mind ray over GE), the probes do not visualize the tips as well and just show you displacement. Is this enough for you all or are you walking in the tip in the soft tissue?
Click to expand...

Yes, I can see the tip in the vein even when using a crappy 10+ year old GE US with regular peripheral IV catheters.

If you are meticulous about lining up the vessel with the probe marker and trying to match the distance of the probe to the vessel with the distance from the catheter tip to the beam (make a 45-45-90 triangle), then you can expect to land the tip in the vessel. You'll see the top of the vessel deform, then the needle puncture through - if it goes out the back-wall, you can withdraw and locate it in the vessel lumen.

I don't look for flash. I locate the needle tip in the center of the vessel, then "walk" the catheter up the vessel (advance the tip under constant US guidance, sliding up the limb as you go) until the catheter is hubbed.

Big ups to the rapid IJ/easy IJ. It can be a lifesaver. Long 18 ga IV in the IJ, so fast, done.
 
Last edited:
Fox800 said:
Yes, I can see the tip in the vein even when using a crappy 10+ year old GE US with regular peripheral IV catheters.

If you are meticulous about lining up the vessel with the probe marker and trying to match the distance of the probe to the vessel with the distance from the catheter tip to the beam (make a 45-45-90 triangle), then you can expect to land the tip in the vessel. You'll see the top of the vessel deform, then the needle puncture through - if it goes out the back-wall, you can withdraw and locate it in the vessel lumen.

I don't look for flash. I locate the needle tip in the center of the vessel, then "walk" the catheter up the vessel (advance the tip under constant US guidance, sliding up the limb as you go) until the catheter is hubbed.

Big ups to the rapid IJ/easy IJ. It can be a lifesaver. Long 18 ga IV in the IJ, so fast, done.
Click to expand...
When I go brachial I use the 20g arrow art line with the attached wire. Get flash, lower the angle, thread wire, then cannula. Works well.
 
GassYous said:
I just use the ultrasound to find the vein and then to an iv like normal. I've tried through and through with a wire and my success rate is horrible unless the vein is big
Click to expand...

I feel like the “through and through” method is way less successful when it comes to veins. It works with arteries but personally I didn’t like going through vessels in order to cannulate them especially if using the U/S
 
You must log in or register to reply here.

Similar threads

C
IV tylenol
Replies
42
Views
3K
ToKingdomCome
T
M
Difficult Spinals coverage?
Replies
33
Views
3K
psychbender
psychbender
C
ACB new approach?
Replies
4
Views
1K
ans2021
A
C
US IV question
2
Replies
63
Views
3K
medicine2wallstreet
M
2
What's your induction plan?
Replies
4
Views
861
2Fast2Des
2
Top