ACCESS ADVICE For best results, start IVs on flat anatomy, away from areas of flexion to prevent dislodged catheters. Avoid the wrist by a hand's-width so as not to hit arteries or the radial nerve, which are bunched close to the veins.

The goal of intravenous access is inserting a catheter in a single attempt, with minimal trauma, and making sure that it can dwell in the site for the length of time it'll take to complete a procedure. As the most direct route for administering medications, IV access has not changed a great deal since its inception, but a safer technique and imaging technologies have without question refined the practice.

Insights at the site
As an infusion nurse, it was once a dream of mine to have X-ray vision with which I could see beneath my patients' skin. Now that dream has come true, in the form of vein-finding technologies such as infrared viewing devices and compact, portable ultrasound units.

STEADY PUSH A safety catheter uses a needle to puncture the skin and guide the catheter into the vein. When a flashback of blood is seen, the catheter is advanced.

These technologies have been in use at large hospitals and teaching facilities since the late 1990s. As their costs have fallen, they've found uses in many more clinical situations than just training. They've certainly benefited the pre-op nurses — and the patients — at the growing number of facilities that are using them for guidance in establishing IV access.

But quicker IV starts with reduced patient discomfort are only part of the advantage of vascular visualization. It's not always easy to start an IV, and for patients who "have no veins" — elderly, pediatric, diabetic and renally compromised patients are often particularly challenging — the technology can mean the difference between efficiently delivering the necessary fluids and medications and repeated sticks that aren't much better than blind luck.

Vein-detection devices are not at this point the standard of care for establishing peripheral IV access, but the Centers for Disease Control and Prevention has advised that, when it's available, ultrasound should be used for the placement of central venous catheters. The Agency for Healthcare Research and Quality's list of clinical safety guidelines also recommends ultrasound for central lines. It makes sense then that imaging technology would likely improve IV starts.

The products that are currently available on the market — ranging from devices that project images of the underlying vasculature onto patients' skin, to handheld ultrasound transducers and monitors, to hands-free video-equipped helmets — are all very useful. One ultrasound device even incorporates sterile, single-use, snap-on gel caps on its wand to better maintain infection prevention at the insertion site. As with any purchasing decision, research your choices. Ask the manufacturers whose equipment you're considering for references in order to seek out the experienced opinions of longtime users.

BASIC ANATOMY
Do You Know Your Veins?

ON TARGET Metacarpal and dorsal veins are easy to spot, even in the elderly, making them good sites for IV starts.

• The upper cephalic vein lies above the antecubital space. It's often difficult to visualize and stabilize, but can accommodate 22- to 16-gauge catheters. Reserve this vein for midline or peripherally inserted central catheters.
• The accessory cephalic vein branches off the cephalic vein and is located on the top of the forearm. It's easy to stabilize and can accommodate 22- to 18-gauge catheters.
• The forearm's median vein empties into the basilic vein after originating in the palm. It's easy to stabilize and can accommodate 24- to 20-gauge catheters.
• The median cubital vein is located in the antecubital fossa. It's generally used to draw blood and isn't an ideal location for IV starts, as related complications are hard to detect and render the veins below the site useless.
• The basilic vein lies along the medial side of the arm. It's easy to see, but difficult to stabilize, making it an often-ignored location for IV starts.
• The lateral cephalic vein is located along the lateral side of the arm. It's easy to access and can accommodate 22- to 16-gauge catheters. Puncture the vein 4 to 5 inches above the wrist to avoid the radial nerve.
• Metacarpal and dorsal veins on top of the hand are easy to spot and can accommodate 24- to 20-gauge catheters, making them good sites for IV starts.

Source: Nursing, August 2007: tinyurl.com/maw8syn

STRAIGHT FLUSH Once it's clear that the vein is patent and securely holding the catheter, the needle is withdrawn.

Stick with safety
Once you've located a patient's vein, the next step is gaining access to it. Recent decades haven't seen many changes in the practice of IV catheterization, but the switch from steel "butterfly" needles to safety catheters that began in the early 1990s was a revolution.

According to a recent market research report, U.S. healthcare facilities use 330 million IV catheters per year. Almost 90% of those are engineered with active or passive safety mechanisms, which have become standard since the mid-'90s.

A quick refresher: Although steel needles (with their plastic wings on the sides for stability) were easy to insert, they also dislodged easily, especially when they were subjected to patient movement. The large-bore (often 20-gauge or 18-gauge) needles also posed one of the biggest risks of sharps injuries to perioperative nurses, not to mention the infection transmission risk their hollow channels carried. In contrast, the plastic safety catheter's use of an internal needle to puncture the skin and guide the catheter into the vein before the needle is withdrawn makes the process much less risky.

While the design and construction of the safety catheter is largely intended to protect the provider, some versions of the product have seen the addition of a silicone coating on the catheter. This is said to improve its slide, allowing it to penetrate with less pain. With the rise of safety catheters, we've also noticed an accompanying improvement in needles' quality of materials and consistency of sharpness. Back in the pre-safety-catheter days, 25 or 30 years ago, it wasn't unheard of to discover that the steel needle you were working with — from a major manufacturer, no less — was dull, which did no one any favors.

Some of the newer peripheral catheters include a tiny wire inside the hollow needle that's inside the catheter. This feature offers an additional level of guidance to increase the likelihood that catheterization will be successful, but it also increases the cost of this staple supply. So does a product whose components are made, as many central venous catheters are, of antimicrobial materials to better ward off the threat of infection. For central lines these innovations can be life-saving, but for most peripheral IV starts they might just raise the cost of what is ordinarily a quick and inexpensive process.

SEE CLEARLY Ms. Moureau demonstrates the use of ultrasound in finding veins during an educational session.

Access success
Safety features often represent increased costs. And, let's face it, we most likely wouldn't pay the added price if we weren't required to use them by OSHA's Bloodborne Pathogens Standard, which includes the Needlestick Safety and Prevention Act. Hardly any provider enjoys adapting to new routines and techniques, but they carry the weight of benefit. From a safety perspective, needlesticks during IV starts have been reduced industry-wide. When coupled with the efficiencies gained through vein-finding technology, great strides have been made in improving IV access.