Thursday, April 21, 2011

The Difficult IV

Few things cause me as much anxiety as a difficult IV. When I place a tourniquet on someone's arm and can't see or feel a single vein, I can start feeling a few beads of sweat forming on my forehead. Some patients are notorious for having tiny spidery veins that make inserting an IV extremely difficult. Patients who are on hemodialysis, cancer patients, IV drug abusers, or anyone with a chronic illness who has been in a hospital for an extended period of time will have had all their good veins "used up" over the course of their admissions. This makes it very hard to find a good vein that is not thrombosed or weakened to insert an IV catheter.

Unfortunately patients judge our anesthesia skills based on our ability to start an IV. While this is patently unfair, there is little they know about anesthesiologists to make an assessment of our competency. No other physicians are judged in such a trite manner. A patient has no idea how knowledgeable his internist is. The internist may secretly get all his information from UpToDate and the patient wouldn't have a clue. They'll still brag to all their friends about how great their doctor's bedside manner is. A surgeon may royally screw up an operation but the patient is asleep when it happens. When he awakens, all he knows is that the operation is finished. But an anesthesiologist is unable to hide. His skill at putting in an IV is the first time the patient has had a chance to assess the anesthesiologist, usually about five minutes after first meeting.  Multiple attempts at placing an IV instantly brands the anesthesiologist as incompetent.

The patient who presents with difficult veins usually knows it. They may even tell you where their best vein is for inserting a catheter. One anesthesia pearl is to always listen to your patient when they tell you where to place an IV. They are usually right and will save you from fruitlessly stabbing the patient in all the wrong places before you eventually go back to the vein they directed you to in the first place. What's worse though are the patients who claim they've never had a problem with an IV before and why is it I can't get one in today. Statements like that really are not helpful or conducive to placing a successful intravenous.

People seem to have a mistaken belief that anesthesiologists have the best skills in putting in IV's. I can't help but groan when the preop nurse can't get an IV then cheerfully tells the patient the anesthesiologist will do it easily. While I may be the best physician at this task, I am definitely not the most skillful hospital personnel at it. Truth be told, the hospital's IV nurse can place IV's in a patient where I didn't even suspect a vein existed. I may put 3 or 4 IV's a day at most. An IV nurse will put in dozens. Also if you can wrangle one, a pediatric nurse is also excellent at putting in IV's. They're just used to working with tiny veins.

So what should one do when confronted with virtually no veins? First of all, try not to have a crowd around the patient's bed. Having a plethora of family members observing you fumble multiple attempts at inserting an intravenous can be really humiliating. Next remember that your first shot is your best shot. You may see one solitary vein on the entire patient and think you can get an 18 GA catheter in there. But that would be a mistake. While it may happen, many times that is the same vein everybody else has attempted and it will still be difficult. Always use a smaller catheter than you think the vein will accept. You can always start another IV after the patient is asleep and the veins are engorged from venodilation due to the anesthesia. Give yourself a set number of attempts at this endeavor. It does not help you or the patient to have four puncture marks on one arm and five on the other arm and still have no IV's to show for all your efforts. I let myself try three times. Then it's time to give yourself and the patient a break from this torture.

What should you do next? Frequently the patient is cold because of the ambient room temperature. Wrap the arms in warm blankets for five to ten minutes. This will diltate the veins sufficiently that you may see a vein that you didn't notice before. Think about having a colleague attempt an IV placement for you. Sometimes it just takes a fresh pair of eyes and hands to put in an IV. If that doesn't work, the IV nurse may need to be called. By now, you've probably delayed your case so a few more minutes waiting for the nurse is not going to make much difference. If all else fails, you may have to fall back to the choice of last resort, the dreaded central line.

There is no getting around a challenging IV in the course of an anesthesiologist's day. But having an algorithm and a course of action will help reduce the anxiety. Having a sense of humor may decrease the tension you experience with your patient. And try to remember that your ability to insert an IV says nothing about you as an anesthesiologist. So what if the patient thinks you're an incompetent boob. All that matters is the patient survives the surgery with no anesthetic complications. That's the marks of a good anesthesiologist, not if you can insert a 24 GA IV into a vein in his pinky.

18 comments:

  1. I'm currently in nursing school and when i get patients that have the worst veins they get so mad at me and want someone else to work on them but using a smaller catheter does work even with people that have incontinence and you have to use a catheter on them.

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    1. Ashlee....I seriously hope for the safety of all the patients out there that you are not a nurse. The fact that you have confused two entirely different catheters is amazing. Also, please learn how to write and not sound so retarded. You should not be allowed near any patients, and if you are, I feel bad for them.

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    2. It is a sad reflection on today's nursing education program but most nurses who started training within the last 5 years do not know that catheter means any tube inserted into any body cavity, vessel, or duct. If you say "hand me the Foley" most will freeze like dear in your headlights and what is even worse is that the majority cannot start an IV cath to save their own lives.

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    3. Excuse me, herd of anonymouses: She's a nursing student, just getting started. Instead of eating your young, try teaching her. After all, you'd like some new nurses on your unit to cover overtime, right? Right.

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  2. I am one of those patients that have the most impossible veins to find. They always collapse, roll around and generally cause all sorts of problems. I get a procedure done every M-W-F and it's going to last for a month or two, so I end up with at least 3 IV pokes every visit. Today, I had SEVEN before someone was able to get it started. I have no idea why this is, but I don't ever get upset with the nurse, I feel bad for him or her because I know it is upsetting for them too. The only thing I would mention is, if you have a patient who tells you that you need to use a pediatric catheter, LISTEN TO THEM! Every single time I tell a nurse this and they sort of blow me off, until they've poked me 3-4 times and blown every vein THEN they try it my way and it works like a charm. Patient's know stuff too :)

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  3. If you're going to need IV's so frequently, have you discussed with your doctor the possibility of getting a PICC line? A well maintained PICC line will last for months and you won't need to get poked for IV's with each hospital visit. Plus you can draw blood from it too for lab work.

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  4. Why not use an IO prior to going to a central catheter?

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    1. An IO is traumatic and damaging; plus, it provides a very distal access site, whereas the central line will provide proximal medication and fluid administration. The IO is certainly an option, but if the time and resources permit, a central line is better.

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  5. I'd assume that drug distribution / kinetics / speed of onset are more reliable and predictable with central catheters in contrast to IOs. Besides, IOs are supposed to hurt like heck.
    My route = hands -> AC -> feet -> EJ -> central line.

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    1. EMS can't put in a central line, so my sequence is forearm (freedom of movement :D), hand, AC. If the patient can get away with no IV, then it stops there. If not, then feet, IO, then EJ. Haven't had to go that far yet.

      Except in an arrest; service policy is to place an IO immediately.

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  6. I've been having a very serious issue with getting an Iv done this week. first, tuesday, they tried four times for two hours. i let my arm hang.. try again.. doesn't work, im wrapped up in a blanket as well, but i still get cold very easily. I'm only 108 pounds and 5' 1". So today they has me come back, i took a hot shower, drank water all day yesterday till 11 50 last night, 6 hours before surgery.. still again, today, they were unsuccessful after again, 2 hours of trying. What can i do !? please help me! im so upset, and don't want to do the prosedure awake, they can't even find veins in my feet, like children have. please help me, i need advice!

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    1. Have the staff call the IV team nurses who have an ultrasound machine. They are an amazing help when confronted with difficult veins. I'm a nurse who doesn't hesitate to call them when needed.

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    2. Call a Paramedic in who is used to dropping lines in the back of a bouncing ambulance....

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  7. Anonymous, I have a few suggestions. You may have to ask the anesthesiologist to put in a central line, either in the neck or the groin, to get IV access. This may not always be feasible if you're in an ambulatory surgery center or you're having a minor procedure that lasts fifteen minutes.

    If you know you'll be having multiple procedures done, you may ask your doctor to order a PICC line. That way you'll always have an IV whenever you go to the hospital.

    Lastly you may ask the anesthesiologist to put you to sleep first using mask induction. Once you're asleep under anesthesia your veins usually get bigger, making it easier to put in an IV or at least you won't feel it. This will depend on your anesthesiologist's comfort level in putting you to sleep without IV access.

    Good luck with your procedures.

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  8. Dear Difficult IV Anon:

    Sometimes the anesthesia provider can give you nitrous oxide (laughing gas) to ease your anxiety and sometimes it will usually make your veins bigger as well.

    If you know where your veins are hiding, ask them to put on a numbing cream to your skin before the iv start.

    Ultrasound is becoming a great tool to start difficult IVs. Ask if they can use it.

    If you are having multiple procedures, a PICC may be your best bet.

    good luck

    Sleepy

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  9. I recently had an appointment scheduled to have a table tilt test performed and after seven attempts to start an IV had failed. My cardiologist canceled he examined my arms and feet then he ask if this happens all the time and, I told him yes he, said it is canceled and to keep my appointment with his office. every time I need an IV the nurses and anesthesiologist have a difficult time with this. is there something wrong with my veins that would cause this?

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    1. There is nothing inherently "wrong" with you veins. Your veins are your veins. There could be multiple reasons why your veins are more difficult to cannulate. Have you had multiple hospitalizations? If you are a small person or an obese person, your veins will be harder to find. Perhaps the room is cold. Maybe you were dehydrated because of NPO requirements before going to the hospital. Unfortunately some people will always experience difficulties in getting an IV started.

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