Anesthesiologist Can Insert Iv but Cant Get a Blood Draw

DEGREE OF DIFFICULTY When you can't see or palpate the vein, many techniques and tools are available today to help you start an IV.

Anybody can start an IV in a spongy, lead-pencil vein. But here comes Ms. Difficult Stick with her small, rolling, spider veins. You can flick and tap her fragile, flat veins all you want to coax them out of hiding, but they're down and they're staying down. She's dehydrated, elderly and obese. Oh, and she's absolutely terrified of needles. "Nobody appreciates getting a needle put into their body," says Debbie Rich, RN, BSN, MM, the infection control practitioner at Massachusetts Eye and Ear Infirmary in Boston, Mass. "The IV stick can be very traumatic."

Years ago, before the advent of products and techniques that lessen the pain and increase the success rate of your IV starts, you might have had to postpone or cancel Ms. Difficult Stick's case. Or make the call to anesthesia for help after a couple of failed attempts. As Barbara Reiheld, BSC, BC-NE, the outpatient surgery manager at Robinson Memorial Hospital in Ravenna, Ohio, says, "If you miss 2, you lose your confidence — and so does the patient."

Today's good news is that you have several places to turn for help with difficult IV starts. For easier insertion, you can use smaller-gauge needles and catheters, preferred by two-thirds (66%) of the 138 facility leaders who took our "Challenging IV Start" survey last month. A few respondents favor catheters that have a clear sheath, which makes it easier to see a blood return. "And they seem to be a little more flexible," says one nurse manager.

Popular pain-sparing options include a small wheal of lidocaine 1% at the IV insertion site (43%) and numbing the needlestick site with a diluted lidocaine solution (17%), according to our survey. "I really like using lidocaine 1% plain injected just off to the side of where I'm going to insert the angiocatheter," says Rae Ann Moe, BSN, VA-BC, a staff nurse at Madison (S.D.) Hospital. Harold Oster, RN, of West Boca Medical Center in Boca Raton, Fla., says starting IVs using an intradermal injection of lidocaine 1% "should become a standard of care." Not all agree. "Some patients complain about the numbing injection more than the IV start when we didn't give anything," says Charlotte Overcash, BSN, PACU manager at the Obici Ambulatory Surgery Center in Suffolk, Va.

HANDS DOWN About one-fourth of our survey respondents prefer to start IVs in the arm — 57% prefer the hand.

X-ray vision
Perhaps our most notable survey finding is that, compared to years past, a growing number (17%) of facilities are turning to portable vein-finders to find a good vein for venipuncture. Real-time visualization has made it easier to see vein structures and get it right the first time. Handheld and worn devices employ a range of visualization technologies. Some display a real-time digital image of the vein pattern directly on the surface of the patient's skin. Most respondents reserve the vein-finders' use for tough sticks: obese, dark-skinned, diabetic, elderly and pediatric patients. "We use it on patients without any visible or palpable veins," say Cheryl Pulitano, RN, and Sharon Uhrmacher, RN, of the Riverwalk Endoscopy & Surgery Center in Ft. Myers, Fla.

At the Physicians' Eye Surgery Center in Charleston, S.C., staff are required to use the vein-finder after 1 unsuccessful stick. "Most staff do not use the vein-finder to guide the stick, but to assess the best site," says Jenny Blanton, RN, the director of nursing. "Having the vein-finder available has improved the IV skills of every nurse at our facility."

Massachusetts Eye and Ear is a surgically driven hospital, averaging 100 cases a day — all of which require an IV start. "We have a high demand for nurses who are highly skilled in starting IVs," says Ms. Rich. "Yet even after starting IVs for many years, we all miss occasionally."

For the hard sticks, pre-op nurses at MEE turn to their secret weapon: the vein-finder. "When you have a tough stick, the vein scanner is really a fantastic tool," says Ms. Rich. "We keep it right here in the unit. It 'lights' up the veins when you can't see or you can't feel them."

Nurse training is another key component of proficient IV starts at MEE, says Ms. Rich. After new nurses attend specialty classroom training on IV insertion, they're paired with certified IV nurses for hands-on training. They practice starting IVs on dummy arms with red dye coursing through their "veins." After they've started 10 successful IVs without problems, they're ready to stick real patients in pre-op, working one-on-one alongside a certified IV nurse. MEE funnels patients with good veins to the newer nurses to build their confidence. "Starting an IV is a skill," says Ms. Rich. "Once you have that skill, it usually only gets better."

Improvise to start the IV
"Some patients just obsess on the IV start," says Janet M. Daily, BA, RN, CAPA, of the Chester County Hospital in West Chester, Pa. Perhaps that's why every pre-op nurse, it seems, has a secret weapon in the fight against tough IV starts: palpation, flicking, tapping, applying warm blankets, lowering the arm, asking patients to make a fist and applying a tourniquet.

Milissa Roper, BSN, of Pardee Hospital in Hendersonville, N.C., shares her step-by-step system. After she warms the patient's arms, she lets 1 arm hang off the side of bed. She places a tourniquet tightly about 6 inches above the selected vein site, and then injects 0.05 cc of buffered lidocaine. She then immediately inserts a safety IV catheter, raises the arm above the patient's heart and connects the tubing. "I have the best luck squatting or kneeling close to the selected vein to get a good look at what I'm about to stick," says Ms. Roper.

"Rub the arm hard, and a lot. When you locate the vein, tap, tap, tap," says Cheryl L. Robb-Genevich, MSN, CRNA, a nurse anesthetist from Southfield, Mich. Adds Ms. Overcash: Before you apply the tourniquet, have the patient lower his arm, open and close his hand a couple times, and then make a fist. Once you've located the vein, tap it and rub in a downward motion with an alcohol wipe to visualize it. Why a fist? Clenching and relaxing your hands moves muscles and increases blood flow through the venous structures below the tourniquet, causing further distention of the vein.

Ms. Daily prefers a blood pressure cuff to a tourniquet. Speaking of tourniquets, ever hear of the "double tourniquet technique?" Take the patient's blood pressure, and then calculate the difference between the systolic and diastolic. Put the arm in dependent position, place the tourniquet 4 to 6 inches above the site, then put the blood pressure cuff over the tourniquet and pump it up to the difference between the systolic and diastolic. "This will bring up a vein nicely," says a respondent.

Sometimes it pays to be aggressive when tapping or flicking the veins. "Most patients are not bothered by a more forceful tapping and flicking," says anesthesiologist Charles A. DeFrancesco, MD, of the Delmont Surgery Center in Greensburg, Pa. "Gentle love taps often don't do the trick."

A little verbal judo doesn't hurt, either. Wiggle your toes and look over there. Does a relaxed patient mean relaxed veins? Yes, our respondents say, diversionary tactics can improve first-stick success. "Asking about where they live or their injury before the stick can be a pleasant diversion," says Ms. Daily.

Most of our respondents follow a 2-stick policy, meaning they call in an anesthesia provider to start the IV if the pre-op nurse can't get it done in 2 tries. At the Riverwalk Endoscopy & Surgery Center, the policy allows 3 nurses 2 attempts each. "After 6 attempts, we notify the doctor, who decides whether to continue or cancel the procedure," say Ms. Pulitano and Ms. Uhrmacher.

Finally, it pays to listen. "When the patient tells you she's a tough stick, believe her," says Shauna Hutchinson, BSN, clinical manager of the Surgery Center of Kalamazoo in Portage, Mich. "Have the patient suggest locations that have worked in the past."

What's the best site for an IV?
The best site for starting an IV? Depends on the patient and the procedure, but in our online survey, the hand was by far the preferred place to start an IV, chosen by 57% of our respondents, followed by the arm (27%) and then the wrist (8%).

"Start in the hand and move up the arm," says Ms. Rich. "I try to avoid the wrist, because it is very painful for the patient." Barbara Wynne, RN, BSN, manager of Gamma Knife in Memphis, Tenn., prefers the hand, but she considers areas with less chance of IV occlusion during the procedure.

"Many of our staff use antecubital first, but I think they should begin in the hand or wrist, especially if the patient is a hard stick," says another. "Frequently I'll visually inspect the area where I want to start an IV, and then place a tourniquet on to see if I can palpate anything. This works well for me, and I've been doing it for 36 years this way."

Anesthesiologist Can Insert Iv but Cant Get a Blood Draw

Source: https://www.aorn.org/outpatient-surgery/articles/outpatient-surgery-magazine/2014/december/the-art-of-the-iv-start

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