Six Techniques To Nail The IV Every Time

Did you get the IV?

Sometimes it seems like your performance on the whole call can be reduced to the success or failure of the IV start. Rarely does the successful treatment of the patient hinge on a successful IV placement but sometimes it can certainly feel that way.

The best way to ensure that you’re ready when that make or break it IV start does come your way is to start a lot of them when the pressure is not on. If you wait until game day to practice, you’re a whole lot more likely to fail.

The single biggest factor that separates the IV virtuoso from the weekend hacker is practice and experience, so when the patient could use an IV, jump in there. The patient’s a kid. … Get in there. The patient is a frail, elderly woman on Coumadin. … Get in there. IVs are nothing to fear. Start practicing these six IV start tips. Before you know it, you’ll be an IV starting superstar.

1.) Pick your IV site in 12 seconds or less.

Sometimes we’re really looking for the best spot and sometimes we’re just stalling, but we tend to take to long to find the IV attempt site. It’s rare that the success or failure of an IV attempt hinges on finding just the right vein. It’s annoying for the patient and everyone else involved to watch you endlessly search for your IV site.

It’s not a halloween pumpkin.  You don’t need to search until you find the perfect one that speaks to you just right. Put your flashlight away. When 12 seconds has passed, pick the best site you saw, swab it up and go.

2.) Don’t just look, feel.

Sometimes the very best veins the patient has to offer aren’t visible to the eye. If you get in the habit of simply looking for veins your going to miss some great pickins’. Start by getting in the habit of feeling the good veins that you can see. With a little time, you’ll learn to feel the ones that aren’t visible as well.

Another trick for developing this skill is to learn to find all the veins in your own arm by feel. You can practice this while watching TV or sitting through Keanu Reeves movies. (Yes, he’s playing the same character in this one too.)

In case you were thinking it, no, feeling for veins doesn’t give you an extra twelve seconds. Feeling for veins isn’t an excuse to spend even more time massaging the patient’s arm when you should be making the IV attempt. Once you feel something that’s acceptable, grab that needle and go for it.

3.) Use solid traction.

A huge percentage of missed IVs are poor traction issues. Once you’ve decided on the exact point of entry, get in the habit of placing a thumb a few inches distal to the site and pulling traction. Pull harder than you think is necessary. The patient should feel a firm pressure. You’re trying to anchor down all that flesh and eliminate the possibility of movement.

We neglect traction because it makes advancing the catheter more difficult. Finding a spare digit to help advance the catheter off the needle can be hard with one hand busy pulling back on the skin. This isn’t an excuse to let go of traction at the moment of advance. Maintain that traction till the catheter is fully advanced.

One telltale sign that someone is guilty of chronic traction neglect is that they complain about patients “rolly veins”. “All my patients today have rolly veins”. No they don’t. You’re just not holding proper traction. All veins roll. (They’re round and suspended in tissue.) It’s your job to hold them still before you insert the needle.

4.) Use a shallow angle.

If you’re getting a brief flash in the chamber that stops before you have a chance to advance the catheter, you’re probably inserting the needle at an improperly steep angle. Some folks get the idea that they need to insert the IV needle at a 30 degree or even 45 degree angle. You’re not trying to dive bomb the vein there Red Barron. You’re trying to insert the needle tip within the vein.

Shallow out that angle. The closer the needle approximates the actual angle of the vein, the easier it will be to land the tip inside the vein where you want it.

5.) The catheter goes forward. The needle does not go back.

I see this one A BUNCH. (Sorry for shouting in here.) It’s even more common with the newer safety-glide type needle sheths. If you feel like you have good needle placement and you get a great flash but you just can’t advance the catheter without blowing the IV, this is probably your problem.

Once you’ve achieved proper needle placement and you’re ready to advance the catheter remember that the hand holding the needle does not move. Not an inch. Not a millimeter. The catheter needs to advance forward off the needle. The needle does not move backward out of the catheter.

The difference is subtle. From outside the vein (Where we happen to be sitting) the two moves look almost exactly the same. We try to advance the catheter but that first little push off the needle hub can be difficult. So, to help the catheter along, we move the needle hand back ever so slightly to get the catheter moving. As a result we pull the needle out of the vein before the catheter has a chance to find its home.

6.) Let the bad ones go.

Give yourself permission to fail sometimes. It’s not the end of the world if you miss an IV. Dispite what your partner tells you, nobody out there gets em’ all the time … nobody. And nobody learns good IV technique without blowing a few veins.

Pop off the tournequet. Pull out the needle and apologize to the patient. “I’m sorry, that one didn’t go where we needed it.” Then start looking for the next site.

IVs are uncomfortable for the patient. We didn’t get into this business to cause people pain and discomfort. That can make the sting of a missed IV even more difficult. Ultimately the patients pay for our failures. And some of them aren’t terribly gracious about it.

Learn what you can from the failed IV attempt, but once you drop that failed needle in the sharps box, forget about it. The previous failure has no bearing on your next attempt. Don’t let it haunt you. Document it. Include it in your hand-off report and own it, but don’t let it affect the next attempt.

Your last IV attempt is already in the history books. The next one is still a question mark. That makes the next one immeasurably more important. Go get the next one.

What other IV tips do you have? Why not type in a comment and let us know before you move on.

   

Related Articles:

Four Sloppy Iv Mistakes That You Should Avoid

Glucometer Errors

Five Assessment Findings That Should Concern You

Describing Pain

 

Comments

  1. Lynne Todd says:

    thats for the advice, i have been out of practice for years and just cannot seem to get the IV starting down, I am an RN on PICU and really having trouble with this.

  2. I am finishing my 5th year as a medical student, and am now learning to position IV’s.

    I was told not to go directly for the vein (I mean: do not put the needle straight through the skin and into the vessel) but to pierce the skin right next to the vein and try to get into it at an angle to avoid damagin it. Does this make any sense to you? I’m actually having an hard time learning this procedure and any tip on the best (and hopefully easiest) technique would be greatly appreciated.

    Thanks!

  3. Good advice!!! Also those that blow on fragile dehydrated, don’t be afraid to try without a tourniquet!!

  4. Jay Dinges says:

    Great advice! Much of the same stuff that I have been telling my students for years. With your indulgence I’d like to comment on one other thing that you didn’t mention. The tourniquet. Poor tourniquet use will set you up for failure before you even begin. One of the biggest mistakes is to apply the tourniquet too tightly and occlude the arterial flow. I often use a BP cuff that is set to somewhere between the systolic and diastolic of the patient. Doing this you KNOW that you have occluded the venous flow but have left the arteries to flow freely. This causes excellent venous distention giving you a better target. This trick combined with the techniques listed above and you set yourself up for the greater IV success. Happy sticking!

  5. Hi…I am an RN….one tip that may help you with IV starts. I hardly ever use a tournie…I warm the hand with warm moist facecloth wrapped in a towel or blue square underpad….get my supplies ready while the extremity warms up. If I see a site…I will not use the tournie, I find it puts to much pressure on the vein and they blow. Traction on the site helps also…these both are useful on the elderly, work equally as well on all my pts. Hope this helps

  6. I am the mom of 17 month old with heterotaxy and tricuspid atresia -post Glenn- so every fever brings us in for cultures and IVs. I appreciate that every nurse has stopped after two fails. That they let me help to hold her. That they seem to listen when I saw she’s a hard stick. She’s had few people get it first try. That they let me fall apart once it’s done and that they listen when I tell them she likes to remove lines. You guys have a tough job, especially when you deal with peds. We parents are not always at our best when our children are sick and in pain and scared. It’s already hard enough to be in the ED and anything you do to make our visit smooth, well I appreciate it. You guys are true super heroes.

  7. Methane Creator says:

    Dr Doom, I read somewhere that an alternative to doing IVs for Hydration is to use rectal irrigation. Your thoughts?

  8. As a recent patient, I’d like to offer one piece of advice. If the patient says one arm works better, listen to them. I had blood draws every 4 hours. One of the IVs gave out for taking bood, so they had to stick for several draws. Those that listened to me, got blood first draw, those that didn’t, sometimes took two tries at it.

    I was also able to tell when they hit a vein and when they missed.

  9. It is not so great when you are the patient getting veins blown. Had 4 blown because they used to big a starter, it was twice the size of any of my veins. I am sporting some of those lovely bruises. And when the ultrasound guy did the 5th, he dug, and dug on a rolling vein, still the unit was TO BIG for the very small vein. My veins are those of a child, not a 6.5 ft 300 lb man. IF YOU CAN’T DO IT RIGHT DON’T DO IT AT ALL! Patients should not have to endure your ineptness! I now have no usable veins for months now. A POX on your heads if you fail at what is your job! And I hope you are the patient getting the blown veins next time!

  10. Gail you are obviously not in the medical field and have no idea the difficulty of some IV starts. You’re probably one of those people who show up in the ER on a monthly basis for headaches, or Abd. pain x1 day. I consider your comment null and void. Go cry some where else.

  11. I will give a little more advice. If the patient tells you they are needle phobic ( the true recognized medical condition, not just fearful/dislikes needles), this is NOT a patient to practice on! Most of these patients will not give consent, so you will be lucky if they give you even one chance. You screw it up and not only will you NOT be given a second chance, you could even make their phobia worse (and possibly open yourself to an unknown hazard in a suddenly combative patient or worse, trigger a vasovagal reflex. More on that at http://www.needlephobia.com ). You also will not help them by dismissing their phobia by stating things like: “it will only hurt a little” and “it’s just a needle” (dont even say it once). Needle phobic patients often get belittled and shamed for their condition, so they have little trust for those of us in medical professions. This is one of those few times that it’s ok to pass off this skill to someone else, if you dont feel confident enough to get it the first time. I work in EMS and also have a moderate case of needle phobia. I encourage all EMS personnel to learn about this phobia and to use what they learn.

  12. wilJim I’m with you! Gail, you clearly do not have to cannulate anyone. I find it highly unlikely that a bunch of healthcare professionals would choose a cannula too big for the selected vein. Cannulae are also selected on the need. Eg, size 16-18G is usually used for fluid replacement and smaller sizes for drugs etc. But vein size is taken into consideration. I suggest you are not knowledgeable about cannula size.
    I have had my buddies cannulate me, deliberately miss etc with large bore cannulae in I knew what it felt like.
    It’s part of our job but sometimes veins are not easy to engorge/dilate let alone cannulate.

  13. Gail, You seem to have no common sense what so ever , your brain seems to be that of a child not your veins!!! How is a medical professional to become competent but to ‘practice’ on his/her patients . Do you think that we are provided with live models at the cannulation courses ? Of course not, they are dummy arms , you silly woman .

  14. KrizzyRN says:

    Thanks for you information. I think it’s accurate and helpful. As a pre-op nurse I can tell you one thing that is not at all helpful. I can’t stand when I introduce myself to a pt, say what I’m doing and they come back with a smart, “you have one shot.” This isn’t funny or cute. If you think you’re a difficult stuck just say that. Guess what, you’re not having surgery without an excellent IV. I just say, “you probably should hold off on comments like that, then if I miss you can request someone else.” Which will likely then be your doctor if the other nurses are tied up. Good luck with that.

  15. My tip for iv insertion and sometimes life in general is, sit down wherever possible. Especially if someone looks like they have difficult veins. The process is always painful for the patient, but it doesn’t have to be for you. Getting down on your knees, or bending over to an inappropriate height is a great way to injure yourself and stuff up your iv. If someone looks difficult, tourniquet goes on, the bed goes up in the air, arm hangs over the side (veins fill up, less visible to patient), then I sit down and stake out my target.

    Regarding Skeleton lady’s comment, a vasovagal causes unconsciousness via vasodilation (big veins, no complains), these sound like ideal conditions for cannulating a needle phobic patient.

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  17. I surely feel better after reading this article. I used to avoid the patients with IV starts then I realized that these patients I do need to practice my skill and master the technique. I’ve missed almost all of them but seem to be getting better and better with the next one. I now want more and more of them to practice, practice, practice. I also thought I was the only ‘clutz’ missing the veins. Thanks so much for lifting the ‘guilt’ weight off my shoulder. Now ‘go get em’ girl…..

  18. I might have to punch Gail in the throat for that comment.

  19. Sometimes, the issue is a tourniquet that is too tight. The blood needs to flow distal to the tourniquet and then be blocked on the way back to the heart. That way the veins can distend a bit. Also, choosing a small catheter is not alway the right choice either. I find that twisty or schlerotic veins just bend a 22g. A 20 or 18g is always my choice.

  20. Anonymous says:

    Start an 18g every time for your first six months and you’ll never miss with anything.

  21. Hi…

    I’m not at all medically trained, but I have spent about 2 weeks in the hospital getting 5 samples a day taken, and I’m an IV drug addict as well, so I’ve been stuck, stuck others, and injected myself hundreds of times, and have seen others tap some highly unlikely veins (ever seen an acute histamine reaction on the face of a kid who hit tar into the vein running in the center of his forehead? That’s a wild one!)

    Anyways, I might be able to offer some advice when it comes to starting an IV. First of all, have a short list of “go to” veins… For me, it’s the median cubital, median distal, the one across the center of the wrist joint, and the one coming off of the thumb. If well hydrated with enough salt & blood pressure, a tourniquet shouldn’t be necessary… Whoever gave the tip about tying off with a blood pressure cuff, I thought that was my brain child! I share that one with everyone… Perfect, harmless venal tie off without arterial stoppage… Another thing I’ll use sometimes is a stress ball… That pumps them up nicely…

    But one of the most important things you can do is to talk to the needle phone about something else, and when you’ve picked your spot, fly it in there with swift confidence! I’m rarely given traction, and my vein walls are all scar tissue, and the only way I can get a point in there (especially dull ones) is a quick snappy motion… Going in from the side only seems useful if the top of the vein is damaged… For needle phobes, it might help to have a partner distract them, or just get a supplies lined up where he can’t see, and hit them in the middle of a conversation. They won’t even know… Other ideas could be to tell them that, after discovering their fear, you’re switching to a smaller needle and that most of your patients have the same fear…

    Finally, if you get a chance to hit a junkie, practice up! If it were me, I wouldn’t care how many times you missed, you’re all sterile with non-lipophobic fluids… If time is an issue, let the junkie hit himself, because he knows his veins like the back of his hand… I’ll often hit veins that I can’t see OR feel, just because I know that it *should* be there, and I get some of the best flags in those spots (I guess you pro guys call the flow of blood into the syringe something different… Which is good… I wouldn’t trust an EMT asking his assistant for a clean point with a bee stinger…)

    Anyways, I hope that my input helped somehow. I know a lot of us junkies get second rate treatment by doctors (not so much nurses and EMTs)… A lot of us aren’t much different than you…I went to college, but just made some wrong turns. Treat us like humans & maybe give us some rigs or swabs or fresh tourniquets if you can, and maybe the karma will have your next patient be a bodybuilder with road map vascularity!

  22. Oh, I also will occasionally blow a puff of air over the injection site just as the tip penetrates the skin… I think people associate pain with heat, and the cool gentle breath throws them off. Probably not sanitary though. Perhaps an ice pack above the site would help trick the nervous system response.

  23. HG- THE RN says:

    Thanks! I needed some step by steps for students. I can’t pinpoint what I do, but it usually works! Gail- bless your heart, your veins are bigger then what you think, you may need some rectal irrigation in lue of frequent IV sticks.

  24. HG- THE RN says:

    Laughing entirely too hard at Junkie, by the way. Some of my best practice sticks were on IV drug users, who showed me the ropes in college during clinicals.

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