A 59-year-old obese female patient with hypertension, coronary artery disease, type 1 diabetes and anxiety presents for a vitrectomy and retinal membranectomy. The patient is somewhat dehydrated, and has no visible or palpable veins. How's that for a challenging IV start? As more patients with heart disease, diabetes with vascular complications, obesity, pulmonary compromise and angina present for outpatient procedures, you should expect to encounter similar IV-related difficulties. Here are 5 tips to overcome them.

1 Find the sweet spot
The patient's hand is likely the best site for starting an IV. However, the smaller, fragile veins in the hands of elderly patients may be tough to locate. In these and other high-acuity patients, the wrist may be your most likely spot for success. The wrist is typically more accessible, and placing an IV there also lets the patient bend her arm and move her hand, which becomes more important when a catheter is going to remain in beyond a few minutes.

You can search for veins on the top of the wrist first, but your chances of locating a good vein there are slim. If intravenous access through the top of the wrist fails, flip the arm over and look on the underside. This spot usually has some veins that are closer to the surface. These veins may not be especially large or firm, but with careful, gentle technique, you'll have a high probability of IV start success. Using your free hand, place your thumb below the vein and slide it down lightly, which pulls the skin tight and, in most cases, prevents the vein from rolling.

2 Apply heat
Even if you're using proper equipment and technique, some obese, elderly and high-acuity patients present with veins that are seemingly impossible to access. No amount of alcohol wiping, vein flicking or tourniquet squeezing will reveal a suitable site. In these cases, a bit of warmth might give you just enough vasodilation to gain access to a vein.

To increase skin temperature at the potential IV site, use a forced-air warming blanket, or try applying a warm compress or heating pad. There's no recommended duration of time for applying heat, but vasodilation should occur within 10 to 15 minutes. If it doesn't happen by then, it's likely not going to happen. A combination of the warming methods can also be used to warm up the extremities and IV site.

Recently, I've achieved similar results by filling disposable exam gloves with warm water, tying a knot in each glove, just as you would with a water balloon, and directing patients to interlace their fingers with the glove's fingers. Don't fill the gloves to bursting, but with just enough water that patients can gently interlock their fingers while keeping as much of their palm as possible in contact with the surface area of the glove. As patients grasp the gloves filled with water, which should be no warmer than 100 ?F, their veins should dilate. Of course, don't try this if you're also placing an electric heating pad or other electric heating device on the patient.

3 Think smaller
Once you've located a vein that you can work with, use a smaller caliber cannula for high-acuity patients with smaller veins. Smaller, 24-gauge cannulae can be inserted in larger veins, but not vice versa. And there's no real advantage in sticking a patient with a larger, 30-gauge insulin-type needle with lidocaine that burns and may obscure the insertion site in order to place a small IV.

With more complex cases moving to ASCs, there are more instances — a hernia or gall bladder procedure, for example — where a 24-gauge cannula may not be ideal for the duration of the case. A 24-gauge cannula can be initially used in the holding area, however, to hydrate the patient, perhaps in combination with warming methods. You may even try to induce the patient with that first IV, as the inhalation of some anesthetic agents may help the veins dilate. Hydration is the primary goal, and you want to hydrate the patient just enough to get the veins to the surface before trying a bigger cannula at a different insertion site.

Using a smaller caliber cannula doesn't necessarily decrease the pain associated with a small needlestick, however. To take out some of the sting, you can use a topical ointment like prilocaine to numb the site before inserting the needle and catheter, perhaps placing an occlusive dressing over the area where the topical has been applied, which keeps it in contact with the skin. Plastic wrap can be used for this purpose as well.

4 Choose your catheter
Using a plastic butterfly-type catheter (as opposed to the traditional metal catheters that have been around forever) to insert an IV for high-acuity patients makes securing the catheter easier and more efficient, and provides you with additional sites for potential injection.

Some butterflies incorporate extension tubing, which frees up your hands during the IV start. After inserting the catheter and removing the stylet, simply apply an occlusive dressing or even some tape over the "wings" just below the needle hub, which secures the catheter without having to connect IV tubing or a heplock. Some butterfly catheters come with an integrated side port for attaching IV tubing, which gives you another injection site very close to the vein.