How to Start IVs Like a Boss. Advanced IV tips & tricks - Nursejanx

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#1

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One skill that every nurse should have in their arsenal is being able to start an IV for any patient, at any time.

Here’s a master list of compiled knowledge and tips that you can use to become a genuine vein whisperer:

Be comfortable & relax before you start

This applies to everyone from EMTs, to paramedics, doctors, and nurses working in any type of setting. It’s the same in a calm hospital setting as it is in the back of a bouncing ambulance, helicopter, or otherwise on the fly.

Some say to sit, some say to raise the bed up to your height and stand (if you can). It’s all about your preference, so you do you. You need to be comfortable to spend some time and be able to be dexterous in that position.

Take a deep breath and relax. Talk to your patient to make it less stressful and tense for the both of you. If you’re nervous and shaking you’ve already lost the battle before you’ve even uncapped the needle. So keep calm and stick on.

meeseeks

Talk to your patient

Besides trying to calm and reassure your patient who’s about to have a needle in their arm, this is a good opportunity to discuss previous IV sites.

Sometimes patients know where they have good veins, and where others have tried and failed. It can’t hurt to get more info.

Wear tight gloves

Some say just tear the tip off the glove, but that’s really not necessary, not to mention dangerous. Just wear tight gloves and you’ll be alright (but not so tight that you lose feeling in your fingers).

If you absolutely have to feel without gloves, at least put some on after you’ve located a vein before you play with needles.

Go by feel

Veins that you can feel are nice and spongy are typically better veins to throw an IV in. They are likely going to be sturdier than superficial ones that you can see but cannot really feel.

Go by sight

But hey, this world ain’t perfect, and sometimes you can’t feel a thing. In this instance, you may be able to place an IV by seeing a smaller superficial vein. The good news with this method is that your target is in plain sight, and should be relatively easy to aim at. Just know that it’s probably going to be a very shallow vein, and its chances of blowing are probably higher.

Choose the right size IV catheter for the vein

Don’t try to shove an 18 in some little old lady with a tiny superficial hand vein that you can’t even feel, but can barely see through her paper thin skin. You need to select an IV gauge that is appropriate for the vein that will be accommodating it. The catheter should always be smaller than the vein you’re inserting it into, otherwise, you’re going to blow it. And just FYI, 22’s are not the end of the world.

Aim shallow before going deep

Putting a needle into a vein is kind of like cutting hair… you can always take it further, but you can’t always go back. It’s better to aim shallow and take a little longer to hit the vein than it is to go in at too deep of an angle and end up going right through and blowing it.

Always start shallow, and slowly keep going deeper until you strike gold. Also keep in mind that if you can see a vein, then it’s not all that deep.

Bevel down?

Typically you should go in bevel up, but there is such a technique as going bevel down. The rationale is that for shallower veins where you keep puncturing all the way through, you need to reverse the bevel angle to avoid it.

Know the anatomy

This comes with practice and experience but you will begin to learn where to look for common veins. Sometimes finding veins is easy, but most often it isn’t, so knowing exactly where to start looking is helpful.

Anchor the vein

Pull the skin taut around the vein in question so the bugger doesn’t move or “roll” on you. If you need to re-evaluate your position once you’ve stuck, ease up on your grip and see where the vein is in reference to the needle. Then pull tight again and keep going.

I find that holding traction works best when you take your non-sticking hand and with your thumb and index finger, hold each end of the vein down and push them away from each other to stretch it out and hold it in place. Plan to stick in between the two fingers along the stretched piece of vein.

traction

Advance the tip of the IV slightly after the flash

When you get in the vein, you will have a little bit of blood but the needle is slightly ahead of the catheter. You should insert another few millimeters of the needle in before attempting to slide the catheter in so that it too is in the vein with the needle. Otherwise, you risk blowing the vein, or it not threading.

Pop the tourniquet immediately after the flash

Better yet, if you can avoid tourniquets all together, then that’s great. But for most people, you’ll need to put the tourniquet on to see anything. The instant you have a flash of blood in your IV chamber, you need to get rid of the pressure. The longer that stays, the higher the chance of the vein blowing under the stress.

Use a BP cuff as a tourniquet

If you work in an area with vital monitors on the walls, place the BP cuff on the arm and hit the “venipuncture” setting on the monitor. Most patients agree this is a much more comfortable tourniquet, and it’s better at making veins pop up.

If you don’t have automatic BP machines with a venipuncture setting, you can still use a manual cuff and set the pressure to around the patient’s diastolic BP, which is usually around 55-65mmHg.

Chloraprep and alcohol swabs

Chloraprep and alcohol really piss veins off. It makes them irritated and they dilate which is perfect for you to strike!

Warm compress

Peripheral veins shrink when people are cold because the blood leaves the periphery and returns to the core. Warm the arms with blankets, compresses, k-pads, whatever you have, and you will get bigger better veins to poke.

Tapping

Tapping is a polite way of saying you’re striking the patient gently on the skin over the veins. It will trigger inflammation in the area and make the veins pop up. You probably shouldn’t try this on patients who are pissed off, or confused though.

Gravity

Let the arm hang off the bed for a while, and the blood will pool and expand the veins. Whenever possible make sure the arm is below the heart level… gravity is your good buddy.

Fist pump

Tell the patient to make a tight fist, then relax, and repeat a couple of times in quick succession. The reason for this is twofold. One, you will encourage more blood-flow to the area with some muscle flexion, and two, you will be able to differentiate between a vein (which shouldn’t change much in feeling during this action) vs. something else like a muscle, tendon, ligament, or bone (which will probably change in feeling quite a bit during this action).

Avoid valves

Valves make it damn near impossible to thread an IV thru. You can use floating techniques but it’s probably best to avoid the issue if you can. Look for where veins join together (good probability of a valve there), and “knots” on the vein that you can see and feel.

You can also run your finger up the vein, pushing the blood out on the way back towards the patient while holding down pressure on a distal piece of the vein so it can’t refill with blood. Where the blood flows back to and stops, you know there lies a valve.

But if you get good at floating in IVs, valves aren’t so scary :wink: Check out this article and video on valves, How to Test a Vein for Valves.

Navigating IVs through tortuous veins

Sometimes you find that you have great blood return because you’re in the vein, but you just can’t thread the catheter in all the way. If the vein is twisty and tortuous, you can try rolling the catheter from side to side while simultaneously pushing and pulling it in and out. This can sometimes help you get the catheter around some of the twists and turns in the veins if they’re not nice and straight.

Ultrasound and AccuVein

These are not typical tools for IV starts but they may come in handy for the ultra-hard sticks. Technology is amazing, and these tools can make an otherwise near impossible stick fairly easy as they will illuminate your target.

IV Floating techniques

If you find that you are unable to fully advance the catheter, odds are you’ve run into a valve, or the vein turned. Try twisting/rolling the catheter if it’s curvy, but if it is straight, back up just a bit, and try to float it. There are two forms of floating.

One involves slowly and gently pushing on the flush as you are threading the catheter in. This can help thread IVs that are just not going in without a good bit of force. You should only be doing this if you have already gotten a flash and blood return because otherwise, you’re not in the vein. So step one, get the IV in the vein and get your beautiful blood return. Then connect your flush and pull back making sure you still get good blood return. At this point, start gently pushing saline in, while slowly advancing the catheter until it is fully inserted to the hub. This is my favorite method of floating, and I’ve had 100% success with it.

The other method is quite the opposite and involves pulling back on the flush until you get good blood return and maintaining that suction pressure as you advance the catheter forward. This is done to keep a valve “open,” so that you can thread a catheter through it. Some people swear by this method, but I prefer the first method.

Practice, practice, practice

Get to know who is good at placing IVs where you work at and every time someone needs an IV go with that person to start it. Watch a few, then try a few, and with more and more experience you will see yourself rise to become the next IV boss.


More Advanced IV Tips & Tricks:

Tourniquet etiquette

One of the biggest mistakes I see people make is that they have a tourniquet on tight as hell, and they leave that sucker on throughout the entire process. This is the best way to make a vein blow.

The goal should always be to have the least amount of pressure in the vein as possible. If you don’t even have to use a tourniquet, that’s great! Sometimes you can put one on very loose, just enough to see some veins.

In all situations, you want to get rid of the tourniquet IMMEDIATELY once you see a flash of blood start to fill up your chamber. The longer you have the tourniquet on, the pressure in the vein is going to keep rising, and once you poke a hole in the vein you’ve significantly weakened its structure.

TLDR; Use a tourniquet only when necessary, keep it as loose as possible, and remove it ASAP once you are in the vein.

Valves

If you’ve managed to get into the vein and not blow it from tourniquet pressure, the second most likely reason you’ll blow a vein is due to valves.

Check out the figure above. Our veins have valves all along them to prevent the back-flow of blood and keep it moving towards the heart. Think of them as little french doors that open every time your heart beats to allow blood to go through, and then close every time there is a pause so that gravity or other forces doesn’t pull the blood back away from the heart.

If the valves are open, you can advance a catheter through them rather easily, but if they’re closed… not so much. By trying to force something through a closed valve, you are going to rupture it, and your vein is going to explode.

How can I avoid valves altogether?

There are some things you can do to avoid valves or get through them. First, you should always test the vein to see if it has valves in the area you are trying to stick. The fastest way to find a valve is to assume that any visible or palpable “knots” along a vein will be a valve and to look for where veins come together or branch apart. All these spots are common valve areas. But if you’re not sure, here’s a reliable method for finding sneaky valves.

Start by holding distal pressure with your finger below where you’re going to place the IV, and then with the other hand, use another finger to press and push the blood proximal to the patient from where you are still holding distal pressure. Basically, you’re trying to push the blood out of a piece of the vein without letting it refill with blood.

Now without releasing the finger holding distal pressure, release the second (proximal) finger that you pushed the blood out with, and you should see the blood flow back until it stops somewhere. Wherever it stops flowing, you know there’s a valve there, because the valve stopped it from going further back. If the entire vein puffs back up with blood all the way back to your finger still holding distal pressure, then you should be free of valves in that entire region of the vein that you tested.

You only need about 1.5 inches of valve free vein (just look at your catheter), so this is your best bet to not have to worry about valves. It’s kinda hard to explain in writing, so please check out this instructional video below for a better understanding of how to locate valves.

How can I navigate through valves?

Sometimes you don’t have the option to avoid valves altogether and you have to go through them. It’s rare, but it happens. I remember a guy who had a single good vein, but every inch or so there was a valve. In this case, we had no choice but to get the catheter through the valves.

How do you do that? You float it! Floating in an IV is super fun once you’re good at it. Firstly, you need to get the tip of the catheter into the vein and establish a good back-flow of blood. Once you’ve got the tip of the catheter in, you need to advance it just a couple of millimeters further so that the entire catheter tip is in the vein, instead of just the tip of the bevel.

Next, you can slowly start advancing your catheter (not needle… never needle) until you start to feel the slightest bit of resistance. At this point, you’re poking a valve, so STOP ADVANCING THE CATHETER. Back up just a bit from where you felt resistance, and connect your flush.

Start pulling back to get blood return in your flush as you would if you had just placed an IV (despite the fact that half of your catheter might not be in the vein yet… that’s okay). Once you have blood return, start slowing pushing saline. This pressure from the saline flush will open the valve, and while continuing to slowly push saline, you can simultaneously wiggle and advance the catheter through the valve.

Miscellaneous Pro Tips

Remember IV catheters have a bevel

You could do everything else right, but if you start to thread a catheter before you have the entire bevel in the vein, you can blow it. You always need an extra couple of millimeters more than when you first get a flash of blood. The first part of the bevel might be in, but if you start threading before you get the rest of it, the sharp jagged edge of the bevel can tear the vein wall, and that sucker is gonna explode.

Never advance the needle further than necessary

This might seem obvious to most, but you only have to insert the metal needle far enough to get the entire bevel of the catheter into the vein, that’s all. The further you insert the metal needle, the higher the chance that you’ll accidentally pierce through the vein. The plastic catheter is softer and is the only thing you should be threading into the vein.

Tight skin saves IVs

With older patients especially, loose skin can make it hard to advance a catheter. Always hold the skin taught when advancing your catheter, or it will scrunch up and likely tear something… and it’s probably going to be the vein you just stuck.

Wiggle Power

Wiggle Wiggle Wiggle :musical_note: :musical_note: :musical_note:. You don’t have to sing Jason Derulo and Snoop Dogg (we do), but you should twist, twirl, & roll the catheter as you’re advancing it while floating, or if the vein is a little tortuous, or if you’re just being cautious. This helps the catheter navigate through little turns, bumps, or other obstacles in the vein.

Shallow First!

Once again, this may be super obvious, but always start shallow with your approach angle and gradually go deeper. The vein might only be a few millimeters tall, and if your approach angle is too steep, you could go right through it and blow it.

I’ve read articles (obviously written by noobs) that say 15 degrees minimum, all the way up to 45 freaking degrees. That’s insane! I’d say 15 degrees max for an initial approach angle, but probably even less most of the time. Just remember, you can always go deeper, but you can’t undo a punctured vein because you started out too deep.

Buddy System

IV buddies are seriously underrated. Going into a room with a colleague takes the pressure off of just you and can help you relax. Plus, two sets of eyes makes finding a good vein easier and faster. Sometimes you need all your focus to just stick the vein, and have the other person help attach the flush, hold skin, help float the IV, reassure the patient, etc. IV starts are way easier with two people than by yourself.


#6

This is great! Bevel down though? That’s the most bizarre one I’ve read haha :rofl:


#7

Haha, I agree it sounds weird and I haven’t had cause to try it out yet, but a nurse practitioner who worked for years in the emergency department told me about it and swore by it. He said he only had to do it a few times, mainly in old ladies with paper thin skin and those little blue veins. He said he thinks it helped him not go right thru the vein because of the less intense bevel angle. Still sounds odd though, I agree.


#8

Just Googled it, and apparently it’s a thing. I’ve never had to do it though, because I usually aim super shallow like 5 degrees sometimes so I don’t pierce it on both ends.

But, if you really have to jump through rings of fire just to get a tiny 22 or smaller size IV in a little finger vein or equivalent, then I’m gonna assume they probably need a central line.


#9

Agreed. At some point, we’re just sticking for pride.

Kinda off topic, but there’s a guy at my hospital who shows up to codes and loves IO’s so much that even if there’s a perfectly good 18 in the AC, he’ll still break out the drill.


#12

Can I add, that you need to be super careful with IV drug users and people with similarly valve-y/shitty veins. Not only might they have diseases (always wear gloves), but it’s super easy to blow the vein if you try to insert either the needle or just the catheter in too far.

First, try to not advance the catheter at all without trying a float technique. If you are stubborn and won’t do this, then at the slightest bit of resistance, I would stop advancing anything and THEN start to float. If you even tap a valve in these patients you’ll probably blow the damn thing.


#13

Piggybacking on @john1ve, I will say there is also another type of patient that has horrible veins to stick, and that’s generally old people with those hard as hell ropey veins. I don’t know if it’s calcification, plaque in the walls, or what, but I swear to God it is so hard to get the catheter into the part of the vein that actually has the blood.

You can stick the vein and move the entire thing around with the needle so you know you’re in it, but yet you still might not see blood. It’s the weirdest thing. I think the needle is in the hard part of the vein wall and you just haven’t gotten to the blood yet. Here’s an image so you see what I mean:

I know this is an artery and not a vein, but I think sometimes the needle is in a plaque layer or something similar. Until you get through that thick layer, you won’t get to the blood.


#14

@loganator and @john1ve, I agree with you that both types of veins are annoying. My buddy and I still haven’t figured out a solution to that thick vein wall problem yet. Sometimes you get lucky and sometimes you don’t.


#15

Wow, thanks for all these tips! Definitely learned some new stuff.


#18

Just got back from a skills fair where the guy teaching IOs was, as usual, so proud of drilling that he basically said that in a code situation, he will start an IV regardless of whether or not the patient has a working IV… even a 20 or greater in the AC. But I guess it’s nice to have multiple options.


#19

Some tips:

  • Move the vein closer to the needle.
  • If you’re fishing, try advancing the needle into the vein from the side.
  • Try sticking quickly to prevent veins from rolling out of the vein.
  • Also sometimes try advancing slowly but steadily as sometimes you can thread the vein without pushing it out of the way.

#20

Traction…

Inadequate vein traction is the number 1 reason I see new people miss. The whole rolly vein excuse is a result of bad traction.

For those of you who might not know, holding traction (in the context of IV starts) is the act of taking a finger (usually the thumb of the hand not holding the needle) and pressing and pulling down on the vein and skin towards you as you insert the IV catheter with the other hand. By having the skin super taut, the veins are more secure within the tissue and less likely to move out of the way or “roll”.


#21

That’s why medics have power tools.
Vroom Vroom.
EZ-IO baby


#22

Just had an off night, but then again the patients were all definitely prime candidates for a central line. I got the vein each time and hit 9 veins in total, but I was only able to advance the catheter on one, and I had to float it. What are the odds that 9 freaking veins are impossible to simply insert a catheter without a complicated float maneuver? I think the only reason that one worked is that I was too paranoid to even try advancing the catheter without floating it. It also didn’t help that one was MR and jerking like crazy, and the other lady weighed about 400lbs plus jerky movements.


#23

Successfully started the first couple IVs of 2018 these past few days. Off to a great start!

image


#24

Been having some great results with the Accu Vein finder recently. It almost makes IV starts too easy though…


#25

So I take it you like using the Accuvein? I’ve seen it light up some people’s veins but how does it do for people with darker skin?


#26

I heard some people say it doesn’t work well, but I haven’t had problems. Sometimes I do feel like it sees a darker bit of skin like a scar or discoloration and it lights up like it’s a vein, so it may give some false positives. But it does work, especially for more superficial veins.

The deeper ones might not show up though, and you’d want an ultrasound or something else for those.


#27

We just failed last night with the Accuvein. For some context, this patient had ESRD and DM, and only one arm for us to try. The last IV was placed using ultrasound and was in the AC. Sometimes a US-guided peripheral IV is all you can get.


#28

Nice! It’s a cool toy for sure. I guess I need to spend more time with it and give it some more testing. Gotta love technology!