Author: Charlotte Davies, Dan Paschoud / Editor: Liz Herrieven / Codes: CC10, SLO6 / Published: 14/01/2020
The next patient to be seen is a 45-year-old IVDU with a possible pulmonary embolism. They’re difficult to bleed, so the Nurses and Techs have not obtained bloods, or access. You realise you need a CT scan, so access is down to you… …
Tricky IV access. We all see it all the time. Some people are great and “lucky”, and some people always struggle. I struggled to become confident with IV access. Initially, I didn’t like “hurting” people by sticking a needle in them – and then I realised the best way of not hurting them was to do it well. I was most put out when as an FY1 struggling to gain access, the Urology Consultant I was working with put a grey in, with no sweat. What’s the secret? Here’s a few tips and tricks to get you going.
And, and and… THe most important one I’ve learnt since entering HST.
Asking “Do they REALLY” need a cannulae?
— Alex Nevard (@AlexNevard) June 14, 2019
IV isn’t always the only option. IV fluid doesn’t clear alcohol any quicker, yet we still seem to try it. An oral fluid challenge may be as effective as an IV challenge, depending on how unwell the patient is. There’s thousands of papers citing oral antibiotics are as good as IV for cellulitis. Macrolides like clarithromycin have good oral effectiveness – as good as IV – and we know IV paracetamol doesn’t work any better than oral (it really doesn’t!). Furosemide works in about an hour if you give it orally and peaks in about 30minutes IV (it used to say that in the BNF but now I can’t find it). IV metoprolol may work quicker than oral bisoprolol – but bisoprolol is preferred by most as it lasts longer. There are plenty of options for administrating analgesia that aren’t IV – intranasal, sub-cut, intra-muscular or even oral! We really try not to give IV analgesia to our sickle cell patients – not because we’re mean, but because repeated IV cannulations make cannulation even trickier when it is needed.
We’re really good at (mostly) not cannulating children unless we need to. Before you cannulate an adult, ask yourself if you’d cannulate them if they were a child. If not…why are you cannulating them as an adult?
A major interest and passion of mine is the push to reduce the amount of IV cannulas inserted in EDs.
I’ve been pushing for ages to start this project at work.
We need to reduce “just in case cannulas”#ICEN2019 pic.twitter.com/KuE24HVlMS
— Jess (@EMS_Junkie) October 17, 2019
I asked on Twitter what everyone’s tips were for gaining access. For the responses, have a look at this fabulous twitter thread.
An idea is forming! What are your tips for gaining IV access when it’s tricky??
*responses may be embedded into a blog*
— Charlotte Davies (@OneLongPlait) June 13, 2019
The responses broadly fall into a few groups:
a) Self Positioning and Preparation
You need to get yourself into a cannula zen zone. Go in with a positive can do attitude and convince the patient that you are the person for this job! Whilst you’re generally talking to the patient – and relaxing them – ask them what works.
Get comfortable. For some people that’s sitting, kneeling, crouching – what ever works for you. But take time to get it right.
b) Patient Positioning and Preparation
Get the basics right… patient in good position, with pillow under arm etc. Get your self in a good position, that is steady and comfortable. Good lighting and breathe and begin. A good tourniquet is useful to
— Sarah E (@drsarahedwards) June 13, 2019
Make sure the patient is comfortable. If they need a pre-cannula wee, and it’s safe to do so, let them wee! Talk to them, which will help them relax. Give them a positive suggestion that their veins are nice and juicy with good blood flowing. Then get the patient’s arm warm. Lots of techniques have been suggested – warm water in gloves, warm towels, hot water bottles, normal saline from the fluid warmer etc.
Once your patient is comfortable make sure that you use gravity to help.
If they’re really oedamatous, you may need to massage oedema gently out to give you the best shot at the vein.
Take your time, and get setup properly (like golf/bowling/archery), get them warm, and use gravity. If it’s “time critical” (peri/arrest, seizure etc) then deep breath, take more time and get it first time (same with IO/Airway Management/chest decompression)
— Wez (@wezroberts) June 14, 2019
For us lot out in PH world, it’s sometimes like an episode of Macgyver. If it’s a cold winter night I usually have a hot water bottle with me. Failing that, a bag of NaCl from the warmer. Take your time looking if non- time critical. Cardiac arrest- go for the jugular.
— Moonbeam (@SkyWithoutAnE) June 14, 2019
A large (or XL if available) glove filled with hot water from the tea cart, diluted to safe temp with cold. Tie a knot, leave it on the back of their hand for at least 5 minutes. Veins jump up, it has never failed me.
— Claire (@clairesuperb) June 13, 2019
In children, the patient preparation is so so so so so so very important! Topical anaesthetic gel (ametop, EMLA etc.) is a must unless there’s a good reason not to. Even neonates feel pain – sucrose drops are often used in some departments, although not analgesic and probably more of a distraction. Older children also need to be distracted. A play therapist will be invaluable here. Hypnosis can also be used – if in doubt, don’t forget the bubbles! Positioning is uber important. There’s some more resources available here.
c) Equipment Preparation
There is no question that you need to get your equipment ready. Make sure you’ve got it all ready and open – nothing frightens a patient more than hearing rustling and people popping out to get more stuff mid-procedure! Think about whether you want a small 22G, as a blue in is better than a grey out, or whether you need a grey at all costs. If you’re using a small cannula in frail patients, curving the needle slightly can help make sure you don’t go too deep.
Make sure you have a big enough cannula:
Interesting table on catheter length required to ensure have 2/3 of your catheter in your vein. Measure the depth to vein and cannula advanced at 45 degrees
— Warren Adie (@SMACCaddict) September 5, 2019
but do listen to this RCEM podcast before choosing your cannula size for a CTPA.
Choose your tourniquet really carefully – you need a good one. By a good tourniquet we don’t mean a rubber glove tied round the patient’s arm. Ideally an old fashioned re-usable tourniquet is preferable. A BP cuff can be a useful tourniquet as can an arm squeeze. But make sure the tourniquet doesn’t obliterate the pulse! Two tourniquets may also be useful.
Consider pre-filling the cannula with normal saline, to get much quicker flash back especially if the cannula is small.
— Mark (@DrMarkbuchanan) June 13, 2019
d) Look for different veins
Thoughts on this study?
Of 2354 ipsilateral PIV placements in breast cancer surgery patients, including those with axillary lymph node removal, there were zero complications. https://t.co/mTCEYbfuNS
— joshua (@reverendofdoubt) March 17, 2022
Secondly, the basilic vein in the medial upper arm is often missed. Think about the external jugular in adults or older children and the lateral border of the foot in babies. There’s often a “cheeky vein around the thenar eminence”. Remember to look under the watch and the chest wall may also be appropriate.
Patient head down (if safe).
– patient valsalvas
– EJV pops out
– purposeful movement with cannula into vein – DO NOT FIDDLE
– wait a second or 2 for flashback.
— William Niven (@willyniv) June 13, 2019
Children have some secret veins. Here’s mine in order of preference
1. Long saphenous – rarely fails to get me out of trouble
2. Vein of shame (little veins on palmar aspect of wrist)
3. 4/5th metacarpal space (its there – go blind)
4. Scalp. Shave that hair (tell parents first!)
— Alasdair Munro (@apsmunro) June 14, 2019
There is a fairly constant vein in line with the fourth metacarpal at about halfway between the wrist crease and the knuckle. I learned this for babies but sometimes you can do it blind in an adult.
And warm, take your time, gravity, and don’t be afraid to bail and just EJ it
— jennifer (@gasmummy) June 17, 2019
Always look at the feet. If it’s an emergency, look for any neck veins and use a single very confident stab with an 18G or bigger cannula, including the vein proximally with the other hand. Failing everything remember IO.
— Gareth Thomas (@garEMlyn) June 14, 2019
e) Reverse Biers Block method
There’s that reverse-Biers block method, tiny vein distally, tq proximally, fill veins with saline, now you have fuller veins proximally to put a larger line in.
— Rob Greig (@drrobgreig) June 13, 2019
Bigger IV Access at #ACOEP19
— Salim R. Rezaie, MD (@srrezaie) November 3, 2019
You know how to cannulate – you’ve been doing it since medical school. But make sure you’re decisive in your actions and go for it. You’ve spent all of the time in the preparation so now it’s time to get the cannula in. In frail patients, lifting it up as it goes in may be useful and don’t forget to hold the skin taut.
Practice your technique – some great tips below.
Here follow a few tips. Did you know for every successful ward cannula there’s another that failed? Good technique ⬆️⬆️ success rate
— Dr Helgi (@traumagasdoc) August 1, 2017
g) Attach your cannula
Skin glue, as reviewed by RCEMLearning in 2017, is a great option. There’s some great tips on DFTB about how to secure a cannula. You might think you know how to apply the tegaderm dressing – but the number of dressings I see where the plastic doesn’t stick onto the plastic indicates we don’t! Watch this video – it may change your cannulation dressings for ever! If the patient is really sweaty, the tegaderm won’t stick anyway – read this for tips.
Don’t forget to document you’ve inserted a cannula. Some trusts will like it if you document that it was tricky.
If it hasn’t worked, there’s no harm in getting a second person to have a look.
Think carefully about your extension set.
— EJ Smith (@ExternalJugular) January 10, 2020
Ultrasound is great when cannulation is difficult. I use it nearer a last resort as it doesn’t fit into the bay, is never charged and…isn’t good when the veins have collapsed. But, it’s undeniably a useful skill. For more information, look at our learning module – remember not to push too hard and to have a long cannula (also reviewed here). This technique is probably not great in children – ultrasound makes cannulation harder!
Explaining why you mustn’t press down with USS probe when inserting peripheral cannula
— Rob Greig (@drrobgreig) February 19, 2019
Never miss an ultrasound-guided peripheral IV again. Check out today’s post by Ryan Gibbons MD (@ryangibbonsEMUS) and Kimon Ioannides MD (@klhi). Edited by Ryan Woods MD: https://t.co/12WqSCCuZ5 pic.twitter.com/cE8mIA2adj
— Academic Life in EM (@ALiEMteam) September 19, 2019
This fabulous poster was brought to my attention by @vygonuk and I must admit its an elegant little project. Using long lines in difficult to cannulate cases, displaying that USS inserted venflons are often too short: https://t.co/XEv8A65cEs pic.twitter.com/wZrLLcAIn4
— Rob Greig (@drrobgreig) October 31, 2019
Cannulae being too short was the topic of a recent St Emlyns journal club review – check out the replies to the tweet for some more fabulous pictures.
a) Red Light is supposed to be as good as a cold light.
FAO Pediatricians/ anesthesiologists- invaluable tip for vasular access: a red bike light, cost 5 dollars, has saved me countless times for neonatal access. Don’t waste money with expensive devices. See pic of my finger veins as example #pedsanes #pedscards #pediatrics pic.twitter.com/bdoIUbIuvt
— David Greaney (@sleepypedsdoc) June 24, 2019
Some people love this, some people hate it. Learn how to use it here.
c) Cold Light
by Dan Paschoud
We’ve all been (or will be) there; a patient in cardiac arrest.
We need access…
We all have our tricks and tips that we’ve picked up over the years – a favoured tourniquet, a larger vein often overlooked by most, and fortunately the now rarely seen repeated slapping of an area in some vein (!) attempt to bring that hidden vessel to prominence.
We know that as cardiac output diminishes, peripheral vascular shutdown occurs.
So; as the minutes tick by the task of gaining an intravenous route for medications and fluids will become tougher. There are central lines of course, but these take time, finesse and appropriate preparation.
Intraosseous access is a technique that most are aware of, however there still appears to be a reluctance to use it, or reliance on the traditional vascular access that we feel more familiar with; to ‘have a go, and then IO’, but why is IO still considered plan B or C?
Clinicians I have taught often see this as tough, but when you think about it; bones are far more palpable than most vessels we have ever inserted a cannula into. In the in-hospital setting there are two main sites that we use for intraosseous access on an adult; the proximal tibia and the humeral head. Whilst both sites will provide vital access for these patients, I often see clinicians (in both practice and teaching) favour the proximal tibia. The common rationale tends to be that landmarking is easier and the lower limb area tends to be ‘less busy’ in cardiac arrest situations.
I cannot refute either of these points, but what I will say is that comparable to the humeral site the proximal tibia offers inferior flow rates and medications administered via the humeral site can take less than 3 seconds to reach the heart. When you consider the critical situations where we would typically consider IO access these two factors should bare consideration.
That’s why you use the yellow needle in Proximal Humerus pic.twitter.com/BMnnxzA7wY
— Sean Potts (@Pottsy47) June 27, 2019
So, how do we overcome these two hurdles?
It’s all about the positioning of both the patient and the practitioner.
Previously I have been taught this position for landmarking of the insertion site…
In the context of a cardiac arrest; you can probably imagine how challenging this would be. Stabilising the limb for landmarking and insertion in this position could also obstruct CPR provision and is difficult to maintain with CPR ongoing.
I recommend trying this instead; adducting and internally rotating the limb…
This position not only increases the prominence of the humeral head; it is stable and will not Impact CPR provision.
So, here is the arrest scene.
It’s the same question I have been asking myself since I was an angsty teenager:
Where do I fit in?
As you can see from the diagram, this inverse approach leaves plenty of room at both airway and the chest.
In an ideal clinical setting, you would have a CPR provider, and someone ready to take over CPR on the alternate side optimizing changeover, minimizing interruptions in CPR.
As with all cardiac arrests the key here is COMMUNICATION.
If situationally you have one side of the patient being used for CPR due to environment or because the team is using a step, then just ask someone to join you in the CPR 2 position.
Once you have picked the appropriate humeral head to approach (with consideration to contra-indications and relative environment) wait or ask for CPR relief on the side opposite yourself. There is a large sharp driven by power, so the team should be aware of what you are doing.
Now ask CPR 2 to help you position the patient for landmarking and insertion; stabilising the limb by the forearm in the position from image 2.
To landmark I now use an ‘inverted’ approach relative to the patient position, running my thumbs up towards me along the humerus until I feel the ‘golf-ball-on-a-tee’ denoting the surgical neck. I can now locate from this the appropriate humeral head site and insert my IO device into a site that will deliver optimal flow rates for vital infusions.
Full credit to the fantastic educators from the Teleflex procedural lab course that helped to me to develop competency and confidence in this important skill, and gave me the tips I have discussed in this blog.
How to Insert an IO:
- Check there’s no contraindications
- Clean the site
- Find your landmarks (humerus and tibia)
- Collect your equipment and size your needle
- Push down through the skin until you feel bone
- Drill until you feel a give
- Remove the needle, leaving the stylet
- Attach the dressing, then connect a flushed giving set
- Consider initial flush with lignocaine – check trust protocol.
— Linda Dykes (@DrLindaDykes) August 28, 2019
Teleflex has a wide range of educational resources free to access, and free to help teach.
Talking about IO access at #LTC2019 Biggest problems I see:
😬Positioning the arm after humeral insertion (often displaces needle)
😬Don’t insert a second in the same bone after a failed insertion (leaks out)
😬Getting a good flow rate with the rapid infuser
Top tips? pic.twitter.com/Ld2JTZMWme
— Caroline Leech (@LeechCaroline) December 11, 2019
This used to be taught as part of ATLS, but other techniques have now taken over. I’ve included it here incase you’re desperate. And maybe some hospitals still use it?
We hope you liked this crowd-sourced style of #RCEMBlog. We’re hoping to compile a few more blogs like this and we’re thinking one every two to three months. We’ve created our shortlist – please vote for your favourites on the google form/survey monkey, and we’ll compile and release the most popular first. We can’t do this without your help though. Keep an eye out on #RCEMBlogs for the upcoming topic, and send us your tips and hints for how to manage that procedure. Please complete our survey here, or get in touch.
Related Posts & References
- Montez, D. F., Puga, T., Miller, L., Saussy, J., Davlantes, C., Kim, S., & Philbeck, T. (2015). 133 Intraosseous Infusions from the Proximal Humerus Reach the Heart in Less Than 3 Seconds in Human Volunteers. Annals of Emergency Medicine, 66(4), S47.
- Stein;, J. P. M. D. S. F. B. H. C. C. M. R. T. (2015). Intraosseous infusion rates under high pressure: A cadaveric comparison of anatomic sites. Journal of Trauma and Acute Care Surgery, 78(2), 295–299.