.svg?sfvrsn=be606e78_3)
Patients dread the IV start as much as anything else about the surgical experience. Maybe that's why some nurses ask needle-phobic patients to wiggle their toes seconds before they insert the needle into the skin. Don't laugh: Making patients wonder why they're being asked to wiggle their toes takes their mind off of the IV stick. And maybe that's why many facilities have a 2-stick rule. You know the drill (no pun intended): If the pre-op nurse's sticks miss twice, you call in the anesthesia provider to attempt access.
Are painful, awkward IV starts a problem in your ORs? Chances are that they are. More than half of the 118 surgical facility managers Outpatient Surgery Magazine recently surveyed say their patients complain of painful IV starts sometimes (52%) or frequently (6%). That's a lot of bad memories for a lot of surgical patients. Here's a simple step-by-step approach to improve your staff's chances of first-stick success.
1 Choose your weapon
Inserting an IV catheter takes practice and skill. Over the years, the products have changed, but the technique has not. Aseptic technique is the rule. After receiving an order to initiate IV therapy, consider the infusate to be given. This determines catheter placement and size. Crystalloid fluids are safe to be administered in a relatively small catheter — a 22-gauge catheter allows for approximately 1 liter per hour of fluids. These fluids can be administered with a catheter in the hand dorsum or forearm. Stay away from the wrist for 2 reasons: The flexible joint may cause infiltration and an abundance of nerves make it painful to place there.
Colloid fluids (blood) need to have an 18-gauge catheter or larger. Placement is a consideration as well. Larger catheters should be placed in the forearm or near the antecubital fossa. Larger veins are better for vesicant medications, trauma and blood administration, but phlebitis is more prevalent in the AC fossa.
Steel-winged needles should be limited to the hand dorsum and for very short use. Procedure IVs can be supported by the steel-winged needle, but only if the patient does not have to move during the procedure. The steel needles run a higher risk of shearing the vein and causing significant infiltration or extravasation of fluid.
Assess the patient and determine that the patient is aware of the order to receive IV fluids. In my GI lab, all patients who are having a procedure will have an IV placed, and they are made aware of this at the time that preparation instructions are given. During colonoscopy, the patient may be asked to change his position and, unfortunately, sometimes this means turning prone in order to increase abdominal pressure to reduce looping of the colonoscope. This puts the IV in danger of being dislodged or infiltrating into the surrounding tissues. For this reason, we use a butterfly catheter, as it is less likely to cause infiltration. The antecubital fossa (cephalic or brachial vein) is used as a last resort because of the increased risk of phlebitis.
Now that you've selected the access type, gather the remaining equipment: IV fluid, tubing, access, chlorhexidine or alcohol swabs, tape, clear dressing material, gloves, tourniquet, gauze 4x4s and an IV pump or stand.
2 Place the tourniquet
the tourniquet 4 to 6 inches above the projected insertion site. This may change depending on where you find a suitable insertion site. In a frail, elderly person, a BP cuff at 30mmHg to 40mmHg will often suffice for a tourniquet. Also beware of the over-bulging veins. They may rupture with the pressure of the needle puncture and blow out. If you notice overly prominent veins, loosen the tourniquet a bit so that the intravascular pressure is reduced.
You need a broad-based tourniquet — you can use a blood pressure cuff that you can get to hold a certain pressure — but feel the radial pulse to be sure you do not occlude arterial inflow. The pressure of the tourniquet needs to be above venous pressure but below arterial pressure.
3 Inspect for your best target
You want a vein that's firm, bouncy, pliant and palpable. There are times when a very visible vein may not be palpable, but it can still be cannulated. Make sure that there's a straight segment through which you can thread the catheter. If there are any bumps, knots or non-pliable areas in the segment under inspection, look elsewhere. Often, a valve in the vein may be prominent and interfere with the threading of the catheter. Rubbing the patient's arm or hand helps to stimulate blood flow, thereby increasing intravascular space because of venous resistance due to the tourniquet. If you feel the need to tap the vein to entice engorgement, do so with modest vigor. Slapping the vein hard can cause vasospasm and loss of the access site.
Over time, your palpating fingers will become more sensitive (trained), making vein selection easier. If you have difficulty palpating the vein with gloves, skin markers can be used to mark the area of the vein for cannulation. When you can't see or feel a vein, vein-viewing technology can make your job easier. Using infrared light, these portable devices project a real-time digital image of the vein pattern right on the patient's skin.
PRACTICAL PEARLS
Quick Tips for Smooth IV Starts
- Avoid IV placement in areas of flexion like the wrist. Metacarpal veins and those of the forearm (basilica, dorsal and cephalic) are primary, particularly for short, procedural infusions.
- Warmth won't "bring the veins to the surface." Veins don't move, for the most part, as they're held in place by the tunica externa, which is made of collagen. In the elderly, the collagen may not be as strong as in youth, so veins may roll. Heat will dilate veins in the body's effort to shed heat and maintain homeostasis.
- Ask patients to clench and relax their hands to move muscles and increase the blood flow through the venous structures below the tourniquet, thus causing further distention of the vein.
- The needle penetrates the skin before the needle enters the vein. If the needle goes through muscle, you're way off the mark.
- Tapping a vein hard with your finger will cause it to spasm and inhibit cannulation. Spasms cause movement and variations in capacity, not static increases in volume.
- Infiltrating lidocaine into an IV site is just as uncomfortable as inserting the IV access. Topical creams take too long to take effect. Sprays may be useful for some patients. But if the needle you select is appropriately sized for the vein and you use good technique, there should be little discomfort.
- If the vein has been punctured through the far side, take the catheter and needle out and apply pressure. A hole in the side of a vein is a hole in the side of a vein — and provides an avenue for infiltration of fluids and medications, and further tearing of the vein with increased pressures from infused fluids.
— Lisa Hardee, MHS, RN, CGRN
4 Clean the area
After you've selected your site and put gloves on, clean the area with chlorhexidine or alcohol, whichever your facility policy dictates. Make sure that the area is scrubbed for 15 seconds, then allowed to dry. While the site is drying, open the access device and examine it to make sure that there are no manufacturing flaws, such as burrs on the needle or tears in the catheter.
5 Angle for insertion and advance until flashback
Hold the vein taut with your non-dominant hand by pulling toward you. This will immobilize the vein and skin, and prevent tissue migration upward with the needle introduction. Hold the catheter device at a 20-degree to 30-degree angle above the anticipated puncture site and deftly insert the needle through the skin into the vein. Immediately lower the angle to be almost parallel to the site and advance the catheter. With a butterfly or catheter, you can accomplish this in a single motion, though you'll need a bit of practice with a catheter. Make sure the catheter is advanced into the vein and you obtain a flashback of blood. Angio-catheters are threaded separately and pushed off the needle introducer into their final position. Butterfly catheters are usually inserted fully before the introducer is removed.
When you obtain a blood flashback through a catheter, it's because the needle is in the vein. You still must advance the IV assembly another 1.5mm to 2mm to get the plastic catheter into the vein. Hold the needle absolutely still and just advance the catheter. Sometimes the plastic catheter or its hub can be adherent to the underlying needle and its hub. It's always a good idea to check the IV assembly first: Slide the catheter off the needle once to loosen it before going near the patient.
6 Secure in place
Once the access is in place, tape it down. Butterfly needles and butterfly catheters have end caps that prevent blood backflow, so there's time to put the dressing on the site and connect the IV tubing to the access hub. With angiocaths, have a 4x4 ready under the catheter hub and remove the introducer part way. With your non-dominant hand, place a finger on the skin over the vein to where the end of the catheter should be. This should occlude the vein and prevent blood backflow from the catheter. Remove the introducer and connect the IV tubing to the catheter hub. Now you're ready to apply the dressing.
.svg?sfvrsn=56b2f850_5)