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In Search of the Painless IV Start
Re: "Perfect Your IV Starts" (June, p. 46). Lisa Hardee, BSN, RN, MAHS, CGRN, states that the lidocaine skin wheal is just as uncomfortable as the IV needle itself. With the use of localizing for all IV starts, we've been able to reduce the painful IV to near zero. As for the "ouch" with the local: Done correctly, our experience has been about 25% not feeling the skin wheal at all. The remaining 75% describe it as less than a mosquito bite. Again, for IV insertion after localizing, many of our patients continue to say, "Wow, I didn't even know the IV was started!" or "I didn't feel anything." In short, the painless IV is achievable.
Robert R. Jirgl, CRNA
Dowagiac, Mich.
[email protected]
Ms. Hardee replies: I haven't been as successful as you with the use of local anesthetic. I've had patients complain bitterly about being "stuck twice." Football players are notorious for having syncope when we start IVs for EGDs. We just start out prone with these guys. I have used lidocaine before, especially when placing a peripherally inserted central catheter because of the large size of the introducer. At times, we've tried ethyl chloride with transient success. And believe it or not, I've been told that my IV placement was painless. Not every time, but it's not totally foreign to me. This is something to consider as a quality improvement project.
What research has been done to support the concept that warmth won't bring the veins to the surface?
Leanne R. Brand, RN, BA
Surgical Services Director
Valley West Hospital
[email protected]
Ms. Hardee replies: The fact remains that veins don't move — they don't "come to the surface." They distend and engorge with blood that is trying to complete its venous route back to the SVC (superior vena cava), but are inhibited/prohibited by the constrictive force of the tourniquet. This engorgement is what makes the venous structures more palpable. Perhaps it's a matter of semantics. Perhaps some nurses use the phrase "come to the surface" instead of the venous distention or engorgement that I use (and was taught 40 years ago). The phrase "come to the surface" indicates to me that the veins are actually moving though tissue structures and repositioning in another, more subdermal layer of tissue.
Another issue regarding the use of warmth: Dry heat is more effective than moist heat. Dry heat will cause venous distention within 2 to 3 minutes while moist heat will take 5 minutes, but start to dissipate quickly. The moist heat will lose its effectiveness due to convective heat loss and the cooling of the moisture in the cloth that has been moistened. This is well stated in the literature.
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