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ALL SMILES The best IV starts are the ones patients don't remember.Talented surgeons, a staff full of Florence Nightingales and Starbucks in the waiting room won't matter much to patients if they're stuck more than pincushions during IV starts. It's true: Patients who've been poked and prodded multiple times in pre-op will remember that experience long after they leave your facility, no matter how successful their surgeries. Make sure patients never complain about IVs again with these 6 proven steps for first-stick-success, which I've developed from starting more than 20,000 lines throughout my career.
IV Insertion in a Patient With Excellent Veins
(A) Injecting 1% lidocaine with a 30-gauge needle.
(B) The proper position of the left thumb, retracting the skin distal to the vein.
(C) Advancing the catheter into the vein using the right hand, while the left thumb remains fixed in its original position.
— Richard Novak, MD
1 Position the patient
Lay the patient down in supine and horizontal positions because blood will pool where gravity takes it. If patients are sitting upright or with their legs dangling, blood will pool in dependent regions, such as the veins of the legs, rather than the veins of the upper extremities where you're looking.
2 Locate the vein
Apply a standard rubber tourniquet to the upper arm. An elastic tourniquet is commonly used. (For attempts in the foot or ankle, place the tourniquet just proximal to the target vein.) Examine the arm carefully for the best vein. Do this by both inspection and palpation. The cord of the vein can sometimes be felt, even when it cannot be seen. Be patient. Rather than sticking the patient's arm in multiple places, don't start the IV until you've found the optimal location.
The antecubital vein is often the most prominent. Although this vein is at the crook of the elbow joint, the location isn't an issue in surgical patients because they're immobile, with their arms straight and extended during surgery. Forearm veins and veins on the back of the hand are excellent alternatives. On obese patients, often the only visible veins are located on the inner aspect of the wrist, so an IV cannula can be placed there. If you're unsuccessful in locating a vein in either arm, look for options in the foot and ankle region.
COMFORTABLY NUMB Lidocaine injections blunt the pain of IV starts.3 Grow the vein
Stimulate the skin over the target vein by tapping your forefinger at the site. This local stimulation makes veins grow, perhaps by releasing a regional venodilator or by blocking a regional venoconstrictor. The physiology behind the mechanism isn't important. The bottom line: This technique works.
4 Select the catheter
Choose a standard 20-gauge or 22-gauge IV catheter. For most outpatient surgeries, a 20-gauge catheter will suffice. If there's risk of blood loss, or a possibility of blood transfusion, an 18-gauge catheter is appropriate. Butterfly needles are not preferred because they require leaving a needle in the small vein, rather than the plastic IV catheter.
SETTING THE TONE
Why First-Stick Success Matters
HELPING HAND Many patients are understandably anxious before their surgeries. Successful IV starts can put them at ease.The initial procedure performed on surgical patients is the IV insertion. If it goes smoothly, patients gain confidence in the abilities of your surgical team. If it requires multiple attempts or is painful, patients' anxieties may increase, which creates negative first impressions of the care you provide.
For patients who have only 1 visible vein, it's very important that the initial IV attempt is successful. If it fails, you have to consider more challenging locations, such as external or internal jugular veins. Consider, too, that needle-phobic patients may not let you try a second time if the initial attempt fails. The only alternatives may be a mask induction of general anesthesia without an IV — which carries more risk than an IV induction of general anesthesia — or cancelling the case altogether.
— Richard Novak, MD
ON TAP Stimulate the skin at the target site to make veins more visible.5 Anchor the skin
Always anchor the skin over the vein by pulling distally with your non-dominant thumb, while inserting the IV catheter with your dominant hand. This anchoring and stretching of the skin prevents the vein from rolling or moving during your insertion attempt.
FEEL AND FIND
How to Locate Hidden Veins
HIDDEN TALENT Skilled caregivers have no problem starting IVs in elderly patients with small, fragile veins.If no sizable vein is apparent when attempting an IV start, apply a blood pressure cuff from an automated blood pressure machine on top of the elastic tourniquet. Activate the blood pressure cuff in "stat" mode, or repeatedly inflate the cuff in "manual" mode. The pneumatic blood pressure cuff is a superior venous tourniquet, and will be effective in making even small veins grow prominent. If you still can't locate a vein on either arm, check the feet and ankles for a potential IV site.
If you can't locate a vein in any extremity, the external jugular vein on the side of a patient's neck is an option. The external jugular vein swells when the patient, with his head slightly down, performs a Valsalva maneuver — forcibly attempting to exhale against a closed airway.
You don't need to start a central venous catheter in the jugular — a simple 1 ?-inch, 20-gauge peripheral IV catheter will suffice. Because the size and diameter of the jugular is larger than most arm veins, and because the jugular is typically quite superficial, skilled providers can cannulate the vein rather easily.
To access the external jugular, attach a 3cc syringe onto the hub of an intravenous catheter before attempting the insertion, and then aspirate back with negative pressure as you advance the device. Once the catheter enters the vein, the syringe will fill with blood. You can then fully advance the catheter into place. Fixate the catheter with tape instead of suture.
— Richard Novak, MD
6 Numb and enter
A local anesthetic skin wheal injection of 1% lidocaine is a simple and safe method to blunt the pain of an IV start. The lidocaine can be injected with a 30-gauge needle, which makes the injection of the anesthetic almost painless.
Hand IV Insertion in an Obese Patient With Difficult-To-Find Veins
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(A) An inflated blood pressure cuff placed over an elastic tourniquet, demonstrating the double-tourniquet technique, while 1% lidocaine is injected with a 30-gauge needle. |
(B) The left thumb is retracting the skin distal to the vein, as the fingers of the right hand advance the catheter. |
— Richard Novak, MD
During starts, blood begins to flow into the hub of the IV catheter when you first hit the vein. Upon seeing the blood, you must advance the catheter an additional 1mm to 3mm before attempting to move it over the needle and into the vein. When the needle tip first enters the vein, the catheter tip is not yet in the vein's lumen; the 1mm to 3mm advance moves the tip of the plastic catheter into the vein. During this time, so that the vein stays stationary, keep stretching the skin distally with your non-dominant hand.
PRE-OP PROBLEM
Who Should Start IVs?
STARTING LINE Anesthesia providers who start IVs have opportunities to connect with patients.At many facilities, RNs start IVs. If the RN has difficulty and fails after 2 attempts, a more experienced clinician, often an anesthesia provider, is consulted.
We do things a little differently at our surgery center and in our anesthesia practice: Each anesthesiologist starts IVs on his patients. Anesthesiologists spend only 5 to 10 minutes with patients when they're conscious. This time is for reviewing medical records, completing assessments, explaining the anesthetic options and obtaining informed consents. Spending 2 extra minutes with patients to personally start IVs is beneficial for a couple reasons: It ensures a high likelihood of success, and it strengthens the provider-patient bond when patients are understandably nervous about surgery. Anesthetists appreciate the opportunity to showcase their skills while comforting patients.
— Richard Novak, MD
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