Since I’ve started chemo, I’ve been getting weekly and some times daily IV starts. This gives me kind of an interesting point of view on how different people start IV’s, and their techniques. I have three primary oncology nurses that I deal with, two experienced nurses and one who is relatively new to chemotherapy. Funny enough, her and I started into chemotherapy on the same day, so she is still technically “in training” but they let her do her own thing for the most part. She starts a great majority of my IV’s, so I see a lot of her technique. She does fairly well, but I get concerned over her ability sometimes. It seems she likes to palpate the vein to make sure it’s there, and this relays to me (as an experienced IV starter and teacher of technique) that she isn’t confident with her own skills on an otherwise healthy adult.
It’s amazing how just watching someone can give me an idea of how confident they are in themselves and their skills, but that’s another post.
This brings me to the whole point of the post. I have several tenets of IV starts that I think are important for your own well-being, and that of your patient:
- Don’t spend too much time looking around – the more time you look, the more your patient’s confidence in you degrades
- You don’t ALWAYS have to palpate the vein – many times, “aiming for the blue line” will work
- When you select a site, don’t keep palpating it with your ungloved hand – if you know where you want to go and don’t want to lose the site, I’ve found using the corner of the alcohol prep as an arrow to where to put the needle as invaluable
- The start should be at a low angle – you can always adjust if needed, but a high angle will increase the chance you will pass through the vein and never get a flash till you back out, and unless you are VERY skilled, you will not get the catheter to thread properly
- The skin penetration should be quick and fluid – the faster and smoother, the least likely that your patient will react to the pain. Indeed the hardest part of the whole IV start is the skin penetration itself.
- Set up before you begin – having a flush ready or a bag spiked before you even bring out the needle will make the whole start that much faster
- Occlude hard – I’ve found that pushing on the vein distal to the catheter, unless you have a strong thumb or fingers, will not stop the blood flow into the catheter. If you occlude on or very VERY near the distal end of the catheter you will have a much easier time stopping the blood flow. Also, it’s a general myth in medicine that as little as 5cc of air can cause an embolus, it may, but the chances are very slim. Some air between the lock and the catheter in the hub is ok, so long as you minimize the amount of air in the whole system you will be fine. The body will press into solution the oxygen and nitrogen, so unless you dump a huge quantity into the venous system, don’t worry about backing blood all the way back up to the end of the catheter hub, you will only make a mess.
- Withdraw and dispose of sharps properly – don’t let them stay on the floor, or the bench seat, don’t stick them in your jump bag or anywhere else other than a sharps container.
- If you miss, don’t worry, but don’t be vindictive – don’t make it your personal mission in life to get an IV on someone when you’ve already missed more than twice, unless they REALLY need it. Then again, if they need it that bad, we have other means and locations of access (IO devices, external jugular, etc). It makes me a little upset when a medic tries forever to get an IV peripherally when they should have moved on to other more invasive routes. I’m guilty of it happening to me, I got tunnel vision on one task and neglected all others. Learn from my mistake, miss two times, that’s a sign, look somewhere else. They may not even need it that badly to begin with, so re-examine your motives and their stability. I’m not a fan of precautionary IV’s unless I think I may actually need to use it, so save your needles for the sick ones.