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.