Placement of peripheral intravenous catheters is a fundamental skill for paramedics, nurses, and physicians. It is one of the most common procedures we perform and is vital for the treatment of many of our patients. With an IV place, we can draw blood, manage pain and nausea or resuscitate a critically ill patient. It is also one of the skills I have struggled with most in paramedic school thus far. Of my first five iv attempts, only one was successful, and it took about 20 before my success rate was much above 50%. Everyone has their own tips for iv placement but here are a few that I have found useful.
Note: these tips are not evidence based, they are what I have been taught and what I have figured out over my first 70 or so IVs.
Set up your stuff the same way every time. Every adult IV I start starts out with the same stuff on hand. An 18,20 and 22 gauge catheter, a saline lock with either a flush or vacutainer pre-attached, extra gauze and alcohol pads, an IV site dressing, tape, two iv tourniquets and extra flushes. Lay out your stuff wherever you can find a spot, a Mayo stand is ideal. However, you need to be able to it without a table so in a pinch the bed, a chair, the floor, whatever is handy.
Introduce yourself with confidence and talk to your patient. If I have not already talked to the patient, I say something like: “Hi, I’m Mitch a paramedic student and I’ll be starting your IV today.” I’ve only had a handful of patients have any problem with a student starting their IV and only one who wasn’t ok with it after talking for a minute. Talk to your patient; most patients have had an IV placed before and many can point you towards a good spot. Take what your patients say with a grain of salt. If a patient says they are a hard stick, often they have had one bad experience and will, in fact, be straightforward. Same goes for a patient recommended site if it doesn’t look good to you don’t go for it.
Place your tourniquet high on the arm and examine the whole arm if you don’t see anything you love look at the other arm. Give the tourniquet sufficient of time to work particularly in hypotensive patients. Place the arm in a dependent position to promote venous pooling. Feel more than you look but if you can see a vein you have a decent chance of successfully cannulating it even if you can’t feel it.
Keep a sharpie on you at all times. Sharpies are incredibly useful items and stay sterile. Some people will look at you weird if you mark directly over your site so I draw small arrows from above and below my intended site and I have never had anyone complain about this and it keeps you from having to touch a site you have already cleaned
Poke through the skin quickly and smoothly, if you don’t see flash right away don’t be afraid to “fish” around a bit. Most of the pain is from puncturing the skin, not moving the needle around afterward. Once you get flash, lower the angle advance the catheter and needle a bit. Advance the catheter promptly, going slow gets you nothing at this point. If you get flash but the catheter won’t advance. All may not be lost remove and discard your sharp. Attach your saline lock, try to draw blood if you can draw you can probably “float” the catheter in start flushing to open any valves and advance your catheter. Many times, it will slip right in, reconfirm placement and you’re good
Good tamponade skills are essential (at least until self-tamponading catheters become universal) learn how long your catheters are and press firmly exactly where the catheter ends having a bit a gauze pre-placed helps prevent messes. Don’t worry too much; patients will forgive you for a mess if you get the line and staff will too if you clean it up.
What to do when you miss: pop the tourniquet, take the catheter out hold direct pressure for a minute wrap the site with some Coban if you have it. Explain what happened and ask the patient if they are ok with you trying again. Alternatively, if the patient is sick leave your first catheter in and proceed to your next site(or an IO) as long as the catheter is not in the vein, it will prevent any bleeding, once you get a minute follow the above steps.
If you make a second attempt change something use a smaller catheter, try two tourniquets, get better light whatever tricks you know about and are comfortable with. If you don’t have any luck get someone else to try. Everyone has bad luck sometimes and often there isn’t a good reason why you didn’t get it, and someone else did.
I closing, you will miss, a lot. However, you will also get good at it with a little perseverance and proper technique. If I can go from a 20% success rate to an 80% success rate in a few months just about anyone should be able to.
disclamier: none of the above is medical advice. I am a SUTDENT and that means I know a fair bit less than nothing. Please don’t do anything you aren’t trained and credentialed to do!