# 263 Where's that vein?
There are now several technologies which have been adapted to the eternal pursuit for a usable vein. When present, they can only find a vein, but evaluate it also. They encourage the clinician and lessen the fear of the patient. However, … we must deal with the emergency as and when it occurs; –—such technology may not be with us.
Cold or Warm?: If the patient is cold, he must be made warm. Local warmth may suffice. Moist heat is believed to 'penetrate' better. Traditionally, hot towels have been used. Check that it is not so hot as to likely scald. Forced air warmers work well and are comforting. Immersing the hand or foot in a basin of warm water is effective. Are your hands cold?
Vasodilators: If hemodynamically stable, the brief use of nitroglycerin ointment or spray over the vein may enlarge it sufficiently. Remove when through. Covering with a warm moist washcloth may hasten the effect. As examples of the principle, a patient who is already on Flolan®, will have dilated vessels. In the pediatric O.R., it is common to induce with Sevoflorane and place the IV when the vessels are dilated.
Tourniquets: The common elastic tourniquet is often not tight enough to dam the flow and create a reservoir of blood, particularly with obese arms. There is fear of 'pinching' the skin. A manual sphygmomanometer is ideal as it is wide, soft, and compresses efficiently and comfortably; pressure can be accurately controlled. Invert the cuff so that its tubings run upwards and away, leaving the entire area from the fossa to the fingertips for use.
Gravity: Often forgotten, lowering the intended IV site below the body or table increases filling behind the tourniquet. (Don't wait until the patient is arranged on the MRI gantry to start the IV; it may not be possible to lower the arm.) Sit or kneel below the patient and dangle his limb, a usable vein may now appear.
Stability: Don't handicap yourself; if you're going to do precision work, give yourself the advantage of stable seating and good lighting. Standing, swaying over the patient, perhaps even too low for your back (because it's a kid) doesn't work well. Restless and agitated patients can be sedated or immobilized before the stick. You may even splint the arm before the start. Ideal prep = ideal start.
Activity: Have the patient exercise his tourniquetted arm to increase blood flow and filling. (Doing so overly long may hemolyze a blood sample.) IV drug addicts have offered to have a very tight tourniquet and then do push-ups to raise a vein!
People use simple patterns to wipe the veins with alcohol or other disinfectant. Instead of back'n'forth or circles, I suggest the only reasonable way is to stroke distal-to-proximal and repeat; push distal blood past the valves to create a greater pull below the tourniquet.
Uncommon Sites: It may be necessary to use a less-desirable and relatively non-standard IV site (e.g., ventral wrist, as veins may be curvy or any leakage may cause a compartment syndrome). Any non-standard IV site requires additional surveillance to monitor for leaks or other adverse consequences. Such sites should be removed when a standard site becomes available as rehydration 'fills the tank'.
Infusion Augmentation: When little is available, use the little. Scorn not the vessel that seems only 'baby-sized'. Use a 24-gauge cannula or a 25-gauge winged-needle to infuse a quantity of IV fluid with tourniquet still in place. This will cause other vessels to appear. (This is similar to a Bier's Block for regional IV anesthesia.) Do not use any of this diluted blood for testing.
Also, if it may be difficult to navigate the cannula within the vein, have ready an extension set with a syringe of fluid attached. When the cannula tip is within the vein, steady the cannula, you or a helper can then connect the extension to the hub and carefully infuse fluid while progressively inserting the cannula as the fluid expands the vessel and centers the tip within the lumen, thus you may 'float it in'. Be sure to remove the tourniquet before starting the regular infusion.
Use of Vessel Dilators: With a suitable vein, it may be possible to gain access with a Seldinger technique, so that the initial cannula is replaced, after mechanical vessel dilation, with a larger cannula for the desired flow rates. The Arrow RIC (Rapid Infusion Catheter) is a commercial example of a kit for this purpose. If a single lumen is not enough, a multi-lumen catheter may enhance infusion capabilities.
Tricks may satisfy one's pride, in starting a line, but if perceived difficult, it's wise to use available technology to minimize complications. If a substandard vein may be worked beyond its likely capabilities, keep a close eye on the site and the line for problems. If the patient is increasingly unstable, go for an intraosseous and plan for a central line.
One, or more of these techniques used together, may help you through a difficult access situation. Use skill, have good luck, and know your available resources in personnel, technologies, and organizational capabilities.
Trimble, Tom, RN CEN. I.V. Starts . . . Improving your odds! Emergency Nursing World ! © 1996-2018.
All Tips: 2013 2014 2015 2016 2017 2018 - Updated! (5/20/218)
