ONE AND DONE Starting an IV on the first stick is more efficient for your workflow, and less unpleasant for your patients.

Practically every patient who arrives for surgery at your facility gets fluids and drugs intravenously, so you'd think that starting an IV line would be a simple and speedy undertaking every time. Your experience in pre-op, however, tells you differently. In my experience as an infusion nurse who teaches the practice, I've found that many difficult IV starts and placements stem from these 4 common missteps and complications.

1. Pick the right site. Starting an IV is definitely a technique in which, the more practice you have, the better you get. But nurses tend to stick to old habits, which can be a problem when those old habits complicate outcomes.

Case in point: Certain areas are not ideal for surgical IVs, even though practitioners in a hurry have been starting them there for ages. The radial side of the wrist, for example, has a large, easy-to-find vein, but placing a catheter there also risks injuring the nerves or tendons nearby. The antecubital fossa (the inner elbow) sports 3 large, prominent veins, but as it's an area of flexion, placing an IV there could prove irritating to the patient if the catheter is intended to remain for any length of time. Plus, if infiltration should occur, it could spread into deeper tissue and go unnoticed until the patient reports irritation.

Instead, seek out veins in the forearm, above the radial wrist and below the antecubital fossa. The back of the hand may also present a good, stable surface, but don't put too large of a catheter into the veins there. And keep in mind that locating the right site for IV placement to avoid injury risks isn't just anecdotal wisdom, it's a standard of care. Disregarding the recommended practices of the Infusion Nurses Society could land you in legal liability in the event that a sub-optimally placed IV contributes to post-op complications.

2. Detect difficult-to-find veins. When your patients arrive in pre-op, they've been under NPO orders all night. So it's no surprise that many patients, even those with the best, healthiest vasculature, seem to present with "flat veins" that are hard to palpate. Fasting doesn't do any favors for those with difficult-to-find or difficult-to-access veins either.

Nurses tasked with starting IVs should be well accustomed to the venous anatomy of the forearm, in order to readily identify their options. Among edematous patients, for example, whose veins can be difficult to see and feel, larger veins sometimes have a faint green outline that makes them look smaller than they are. But knowing that the vein is there will let them identify a vessel obscured by retained fluid or subcutaneous tissue.

When faced with a patient who has small or flat veins, nurses might consider placing a warm pack on the arm for 5 or 10 minutes, which can often help to enlarge the veins and make them more palpable.

If a single tourniquet doesn't raise veins, a blood pressure cuff on a low setting or a double-tourniquet can force the blood to pool. If this doesn't assist in locating a vein, check the cuff: The problem may not be that the patient lacks patent veins, but that it's not properly applied. Just as you don't want the cuff to be too tight, you don't want it to be not tight enough.

Recent years have seen the introduction of several useful vein-finding technologies. Devices that incorporate LED lights or infrared imaging can improve venous navigation and IV placement. While they may not be as helpful for obese or edematous patients, the development of portable ultrasound scanners can fill the need for deeper visualization. For this technology, you may need to designate and specially train a few staff members to be expert users for best results. Vein-finding technology isn't just for learners: It can help anyone avoid missing veins and subjecting patients to multiple sticks.

TACTILE TECHNIQUE Use your fingers as well as your eyes to locate and determine the size and patency of veins.

3. Advance with caution. You'll find that some patients have more delicate veins, such as the elderly, those who are taking steroids or those who've been subject to long-term IV access. Their veins may not be difficult to see or palpate — they may have arms like a map — but they're fragile.

You'll have to exercise much more caution when starting these patients' IVs. The big risk here is "blowing the vein," when the catheter goes through the vessel and breaches the opposite wall, which can lead to hematoma. If, while placing an IV, you see the blood flow stop immediately after you catch sight of the backflash, that's a likely sign that you've gone through.

In theory, it is possible to salvage a blown vein (see "How to Rescue an IV That is Otherwise Lost"). With a small catheter, you could potentially pull it back, then advance beyond the breach into the vein. But this is not advisable. A breached vein can lead to fluid infiltration and tissue irritation and damage. Also, if they later require a hospital transfer, the continued use of that IV for other (leaking) meds could do damage to the surrounding tissue. Your best option is to start again at a different vein site, maybe even in the other arm.

Even better, though, is avoiding blown veins to begin with. Start with a catheter that's a bit smaller than the vessel. A catheter that's too big won't easily enter the vein, plus the rubbing will irritate the vein wall. You're aiming for an insertion that's less angled, and closer to the surface, than usual. A common problem is, nurses hold the angle and don't notice the flash, so they go through.

Technological advances can assist on this front, too. One newly developed IV catheter incorporates a guide wire, similar to that long used by midline catheters and PICCs. Advancing that wire helps to guide the catheter safely into the vein. Another safety IV catheter delivers a dual-flash effect to verify the needle and the catheter placement, providing thorough assurance.

4. Be confident. Botched IV starts leave patients in discomfort and dissatisfied. They create workflow inefficiency and are infection control risks besides. You're better off getting the job done with one stick.

As mentioned above, improved technique comes with practicing the process. Position the patient's arm so you can clearly see the potential site and yourself in an ergonomically stable and comfortable posture. Use your eyes as well as your fingers to locate, size up and determine the patency of the vein, outlining and pressing along its length. It should be soft and bouncy to the touch and refill easily. It won't have the pulsations of an artery, and won't be hard or flex like a tendon.

Hold the skin over the vein taut so it won't roll, and aim for a 15-degree insertion angle. When you see the backflash of blood, immediately lower your angle closer to the skin and advance one-eighth of an inch, which will allow you to insert both the needle and the catheter into the vein. Be aware that it is easy to lose your access by preliminarily pulling back when only the needle got in.

Once the catheter is in the vein and you've seen a good blood return, flush the catheter and make sure there's no edema at the site to ensure that it's definitely in the vessel.

Above all, believe from the beginning that you're going to achieve first-stick success. If you start off fearing that you'll fail, your lack of confidence will affect your efforts, and your patients.

SAVING A FAILED ATTEMPT
How to Rescue an Otherwise Lost IV

RESCUE OPERATION John Murphy, MD, demonstrates his "posterior wall perforation recovery maneuver."

Ever get a flashback and then when you remove the needle there's nothing? If you're using a valveless IV catheter — one that has no valve to block the flow of blood when you're in the vein — the "posterior wall perforation recovery maneuver" might help you rescue what would be an otherwise lost IV.

See osmag.net/SAQe3h for a video demonstration of how to rescue an IV that is otherwise lost.

• Anatomy of the problem. You've punctured the vein with the needle and gotten a flashback. You've dropped the angle of the catheter and advanced it another 5 to 10 mm to make sure not just the needle tip is in the vein, but the catheter as well. You've removed the needle or at least drawn it back maybe halfway out of the catheter and, to your surprise, there's no more blood flashing back.
• What happened? Most likely you've perforated the posterior wall of the vein and now the needle and the catheter are sitting in the tissue behind the vein.
• The rescue. Simply remove the needle completely, as demonstrated in the video (osmag.net/SAQe3h), or withdraw the needle until it's halfway out of the catheter sheath. Now slowly pull back the catheter until you get blood flashing back into the catheter. As soon as you see blood in the catheter again, stop withdrawing the catheter. Instead, push the catheter back in and half of the time you'll recover the previously lost IV.

— John Murphy, MD

Dr. Murphy ([email protected]) is a staff physician at the Bonnyville Health Centre in Bonnyville, Alberta, Canada.