DIFFICULT IV: 5 TIPS TO KNOW
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- เผยแพร่เมื่อ 20 เม.ย. 2023
- In this video I will demonstrate a technique for IV access in a patient in whom several previous attempts by different personnel failed. While we could use an ultrasound to insert a central venous catheter or a deeper seated IV, such as a brachial vein, here we demonstrate a simple technique of using an Esmarch that can be very effective for peripheral venous access in most patients with difficult veins.
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Medicine is an ever-changing science. As new research and clinical experience broaden, changes in treatment and drug therapy are required. The authors and publishers have checked with sources believed to be reliable in efforts to provide accurate information within the available or accepted standards of care. However, given the possibility of human error or changes in medical practice, neither the authors nor the publisher, nor any other party involved in the preparation of this platform warrants that the information contained herein is in every aspect accurate or complete, and they disclaim all responsibility for any errors or omissions for the results obtained from the use of the information contained in this work. Readers are advised to confirm the information contained herein with other sources. For example, readers are advised to check the product information of each drug mentioned, and that any information contained on NYSORA's TH-cam channel is accurate.
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I'm an ICU RN and PACU RN and ever since I watched your videos, my PIV insertion success rate has increased to a 95% 1st attempt success rate. Bending the IV and taking time for the tourniquet to work is the key. I went from primarily using 20g ivs to 18g ivs. As well I placed my 1st 16g IV in a septic patient all because of your techniques. Thank you so much.
Is there benefit of using larger needle?
Hi James, Glad you are enjoying the content and it is helpful. Appreciate your feedback!
@@InspireNewGeneration is there a benefit to a larger pipe? This answers your question
@@InspireNewGeneration yes a larger pipe means a greater flow, which can be useful for situations where massive fluid therapy or transfusion are needed
I am also PACU RN
Hello Dr Hadzic. I am a French anesthesiologist, and since I have seen your old video, I systematically bend my intravenous catheter, which greatly improves my success. my colleagues are amazed, but it works. Thank you for your wise advice.
GREAT TO HEAR! GREETINGS AND THANKS FOR THE FEEDBACK. IT MAKES OUR EDUCATIONAL EFFORTS WORTHWHILE! BEST REGARDS TO YU AND YOUR COLLEAGUES.
Yes the chances of DP decreases with that technique
I am a military nurse and have worked in Anesthesia and ambulances. An important method to get peripheral veins a vue is to use heat packs. Especially in an outdoor, prehospital setting or in an A&E setting with elderly patients with insufficient peripheral perfusion.
I am going to give the Esmarch a try, though!
(Oh, and bending needles: I have been taught to do that for IV insertion, but also for local analgesia in small procedures)
ER RN/Paramedic here-
I've used a manual blood pressure cuff, pumped up just above the diastolic reading to really get the distal vein engorgement in very difficult IV starts. The one bad thing about that- if you hit the vein but are unable to cannulate it, you will have a more impressive hematoma to deal with.
I self cannulate to treat my depression, and I also use a manual BP cuff, it's so much easier than applying a tourniquet, and gives me much more control.
I've only had a hematoma a few times in the past 3 years, mainly from pushing the needle too slow, which pricks the vein, but doesn't plug it with the cannula. Or from pushing too far and exiting the bottom of the vein.
The tip to leave the cannula in, after a failed attempt, that helps excess blood to leak out, preventing hematoma.
There's been so great tips on this channel.
I am currently binge watching your channel because it will be my saviour during my renal medicine placement atm! Thank you! I used to suck at venipunctures but now I manage to bleed literally anyone, even one time my reg and the parent by bedside were impressed because the patient was known to have a difficult access. :")
Near impossible IV? Let's put an 18g in the hand. Amazing.
Excellent videos!
Just wanted to say thanks again for that "bend the needle" trick. I had to put an IV in a distal tibial vein today, and couldn't get the angle right even with the patient plantarflexing her foot. A little curve in the needle gave me the extra 5° I needed for a successful insertion.
That is so great to hear. We are always happy to hear our content is useful to you. And well done! Have you subscribed to our newsletter for more educational content? www.nysora.com/newsletter/
Greetings from Germany! Some weeks ago we got an 90 yo woman in the ER who felt down the stairs and laid there for some hours. She had massive decollement wounds on both hands and forearms and her head. External jugular access was no option due to the high insertion angle from a prominent mandibula and skinny neck. So I bent a short 18G to cannulate 1st a tibial leg vein and 2nd at her shoulder as seen in your videos. Your advice was great! :) btw: bending needles is common practice here too.
Hi Whcscomlat! Thank you so much for your kind words; we really appreciate your feedback.
We’re excited to share that NYSORA’s Difficult IV Access App is now available on the Apple Store and Google Play. Written by anesthesiologists, it’s packed with countless tips and clinical videos on how to successfully access tough veins.
We warmly invite you to test drive the app for one week for free and let us know what you think. We believe this app will be immensely helpful to you and your colleagues. Download the app for free, share it with your colleagues, and let’s all improve our IV skills together. www.nysora.com/iv-access-app/
Thank you so much! 2:23 actually the needle is not aligned with the vein and I realised this was intentional to prevent the vein from rolling. Good technique!
Hi Alptekin, Thank you for your comment. Greetings!
Yeah that was interesting I’ll probably go through the bank before I turn the catheter
Yeah that was sexy the way she came at it from the side 🥵
I am a qualified medical dispencer. practice makes the person more and more better. how much you will old in this profession you will learn new and new techniques every day
As an Oncology RN our patient cohort is difficult. We use a heat pack whilst talking with them……also relaxes us both. I put the tourniquet on whilst I prepare my equipment. Usually works. I do have my favourite veins.
Thanks!
Nice video thank you..!
Glad to hear this! Thanks!
Thank you
Good job❤
Thank you very much for your advice. I will apply them as soon as I have the opportunity. However, in older patients with very fragile veins, I prefer not to use a tourniquet. I just press firmly on the vein with my index finger, wait for its volume to increase, and a few centimeters lower I insert the catheter in a quick but delicate movement. Pain and vascular damage are minimal.
I’m a registered veterinary technician that works in emergency and critical care. I have a question; does bending the catheter compromise it in any way? And does it affect its ability to slide off of the needle? Thanks!
A couple of comments. Excellent video and series. The Esmarch technique is a great idea. I'd like to add another technique which I have incorporated for a long time. This is to use forced-air warming to make sure the patient is warm and perfusing their distal extremities. Distal limb blood flow varies greatly depending on a variety of factors - anxiety and hypovolemia of course, but thermoregulatory state is as important, if not more so. Forced-air warming of the entire patient for about 20 minutes can make a huge difference. This is much more effective than just warming the arm or hand. When I've been called to place an IV on a patient on the ward, the first thing I do is feel the temperature of their hands while looking for veins. If the hands are cold, 20 minutes of "Bair Hugger" will make all the difference. BTW, I bend the needle all the time too. I would disagree with the idea of "inserting the needle quickly". One gives up tactile feedback and unless you are incredibly accurate every time, there may not be enough time to see blood return before puncturing the other side of the vein. Do veins actually "roll"? I don't think so.
Thank you for sharing your experience! Greetings!
I also think that rolling is intuitively wrong, the likely hood that a thin walled vein would resist the penetrative force of the Needle 💉 seems unlikely. Unless there’s been statis leading to hypertrophy or significant blunting upon entry or previous IV access leading to some sclerotic changes to which the vein is moving with.
We’re excited to share that NYSORA’s Difficult IV Access App is now available on the Apple Store and Google Play. Written by anesthesiologists, it’s packed with countless tips and clinical videos on how to successfully access tough veins.
We warmly invite you to test drive the app for one week for free and let us know what you think. We believe this app will be immensely helpful to you and your colleagues. Download the app for free, share it with your colleagues, and let’s all improve our IV skills together. www.nysora.com/iv-access-app/
Excelente todos los videos de esta serie, muchas gracias, igualmente por los subtítulos que ayudan mucho.
Hi Daniel! Thank you for your feedback. Glad you are enjoying our content. Greetings from NYSORA!
We’re excited to share that NYSORA’s Difficult IV Access App is now available on the Apple Store and Google Play. Written by anesthesiologists, it’s packed with countless tips and clinical videos on how to successfully access tough veins.
We warmly invite you to test drive the app for one week for free and let us know what you think. We believe this app will be immensely helpful to you and your colleagues. Download the app for free, share it with your colleagues, and let’s all improve our IV skills together. www.nysora.com/iv-access-app/
Thank you so much.
You're welcome!
Is there a reason for the routine use of the brachial vein for the Ultrasound Guided piv? I would rather look for the basilic or cephalic vein first?
Thank you very much sir 🙏
Hi Chennakesavula, Thank you for your comment.
Is there an alternative to esmarch? We don’t have that in the ward. I tried the bent needle technique before and failed.
Elderly people do have sometimes thick vein walls and almost without a lumen, so it could be reasonable to use ultrasound not for guidance but for identification of the most suitable for successful puncture vein with the largest lumen ...
Can we use BP cuff instead of tornicate for difficult IV line
warming the extrimity ,use of gravity,use of alcohol while rubbing towards the torniquet, allowing some time for the veins to fill with blood, bending the needle, narrow angle, fast insertion,use of Esmarch , EJ,IO
wow a lot of alternative techniques i can try in my situation where the resources are limmited . Thank you so much .God bless you !
Thank you for your videos! I am a CCMA student in the USA. We use tourniquets, but I have never heard of "s mark". I see and understand how it works, but I am wondering if this is used in hospitals only, or maybe the USA just doesn't use them yet? Is it an old or new practice?
Esmarch is the spelling. These are used in surgical/ortho cases where they need to squeeze blood out of a limb prior to surgery.
Dang right! Would rather have a natural childbirth than have multiple failed IV attempts! Going to tell these tips to other providers who try this and fail on me!
I have been using the three tourniquet technique very successfully. I don't believe I have missed an IV start with difficult veins using this technique.
Top! Greetings
As a paramedic if I ABSOLUTELY need to get IV access for a unstable patient for medications I’ll go for the EJ if no other option is viable and I exhausted other methods. And obviously if the patient is unresponsive and absolutely necessary I’ll go for the humeral EZ-IO.
But thank you for your tips and videos, much appreciated!!
Thank you so much for your kind words; we really appreciate your feedback.
Yeah in the ER I throw in EJs if I can’t find anything else with the utrasound
@@jamesdent5737 wish we had ultrasound, I know some pre-hospital agencies do have them, but where I am in New York, Suffolk we are always years behind everyone else, for instance, heaven forbid we have a major trauma, we only have sodium chloride, which obviously won’t do anyone any good.
I've had 7 I.O.'s, 4 in my shin and 3 in my shoulder. Shoulder is preferred, if the choice is those 2.
I now have a mediport though and medics have thought the tube in my neck is a bulging vein. It's not.
@@michellenainkristinabusch1221 I’m so sorry to hear that, horrible. Where I am we can only do humeral and tibia IO’s, and once we went to humeral I only choose that, easier and more direct to the heart. Hope you don’t need anymore IO’s, and sounds like it since you have a port.
Nice information. I have become dependent on ultrasound 😅 trying to remedy this
Hi Cardi! Glad to hear this! Thanks!
We’re excited to share that NYSORA’s Difficult IV Access App is now available on the Apple Store and Google Play. Written by anesthesiologists, it’s packed with countless tips and clinical videos on how to successfully access tough veins.
We warmly invite you to test drive the app for one week for free and let us know what you think. We believe this app will be immensely helpful to you and your colleagues. Download the app for free, share it with your colleagues, and let’s all improve our IV skills together. www.nysora.com/iv-access-app/
I have started using some of these techniques on the ambulance and have seen more success. In particular I tie the tourniquet first thing. While that dwells I get all my other iv stuff setup. Opening the packages, putting the extension set together and priming... after all that then I start looking for a vein.
Hi Dan, Glad to hear this! Greetings from NYSORA!
I’m going to try this technique 😊
Saya harus belajar banyak ini
What about intravenous drug abusers??? We usually Don't found any vein for cannulation except central veins. Is there any technique available?
On older patients, I've found that using a blood pressure cuff, set to below the patient's systolic pressure, instead of a tourniquet helps.
Where do I get this rubber tourniquet
As someone who has attended the ER frequently (chronic pancreatitis) I wish my nurses/Drs would read this. My most recent admission his a record of 18 attempts before they got access - and 10 of those attempts were using an Ultrasound machine.
IM sorry you have to deal with that! If they have a hard time with ultrasound, these techniques might not be beneficial. I hope you don't have to go through that again!
We’re excited to share that NYSORA’s Difficult IV Access App is now available on the Apple Store and Google Play. Written by anesthesiologists, it’s packed with countless tips and clinical videos on how to successfully access tough veins.
We warmly invite you to test drive the app for one week for free and let us know what you think. We believe this app will be immensely helpful to you and your colleagues. Download the app for free, share it with your colleagues, and let’s all improve our IV skills together. www.nysora.com/iv-access-app/
What product are they using in 70 year old difficult Iv start
Say you dont have access to the esmark. Could you use wide coband wrap?
I’m a Home Infusion RN. I don’t even no what an Esmark is, lol. After watching these videos I use Cuban and it works perfectly. 😊 5:07
Any suggestions for the catheters that have the button to retract the needle? 99% of my nursing career has been the ER with the non-button catheters. Now I’m on a very nice and calm research unit and unless it’s a fat juicy vein, I miss! WTH🤷♀️. I will say I could be doing the partially inserted IV because blood return isn’t as visible as what I am accustomed to with the ER catheters.
Hello sir... Thank you for your videos I'm an anesthesia student... I have a question for people with general edema in icu... They're really hard to find an iv access... Any tips?
Hi there! Thank you for your comment. We strongly recommend this source for the clinically proven standardized nerve block techniques: www.nysora.com/nysora-product-nerve-block-app/ This is the source used by NYSORA's students, fellows, and over 10,000 clinicians worldwide". Greetings!
Dear sir why veins not clear in nephro patient?
Everything was good. I have found the only issue with bending the needle is accidentally dulling the tip on something while bending it. Everything else was great!
I'm baffled that medical staff don't know that if you raise the hand the blood volume in the veins goes down, so the natural remedy to thin veins is to have the hand pointed to the floor, just let it hang and only then use a band above the insertion site. Blood pools due to gravity, use it to your advantage.
I'm not a medical professional but a substance user who's currently using a bit of Cocaine once a fortnight. (got off heroin in 2004) but anyway, i was looking at this cos i love all things medical especially this subject because although i'm self taught, i will have some bad habits but I tend to be better than the phlebotomy nurses in UK as they are restricted to only veins on the arms. So I need an anethetist to get it. They are the best. Or i can do it but they no longer allow me too.
I’ve had all those tricks except the needle bending is not allowed where I live. That’s a lawsuit waiting to happen. Even my EJs are scarred to the point of having 3-6 attempts on any given Tuesday. I have had 3 ports but each one has gotten septic eventually. They’re either going to have to put another one in and risk infection or put me on hospice at this point in time. I can’t get an IO because I’m a paraplegic and the hospitals in my area won’t use my legs for any kind of access. One hospital stay for 33 hours I was stuck 35 times. That’s when they finally decided to go the port route.
Geez I watch the older version of this vid, I kinda forgot to do this yesterday on a 84 y/o pt with CHF on TID Furosemide. I was in on the dorsum hand, but immediately I inserted it, my angle was too high and it went through and through. Thanks for the reminder, I won't forget this again
Glad to hear this. Greetings from NYSORA!
Does heat have a place on this list? Wrapping the arm in a heated blanket to warm it up?
Сделайте, пожалуйста, субтитры
I’ve had bad veins my entire life and I can’t say enough about the vein finder. I have tiny fragile veins. I learned to use breathing techniques to not panic because of a life time of trauma. I think the worst is people “trying” four of five tries post surgery and I’m crying. Then they start suggesting that it’s my fault.
They have to try, most places have a protocol that you try twice and then ask for help. Like you said if you have tiny fragile veins it’s going to be difficult, there’s no way around it. Some people are hard sticks and some aren’t and some days your veins are super cooperative and some days they aren’t. Our anatomies are nuanced, we’re not robots.
I guess some situation you need 18g needle or larger.
Can i get blood samples from newly inserted cannula by flushing it with 1cm syringe of distilled water
usually in labor delivery once we stickIV in it bleeds back so much no need to flush...dont flush get blood then flush or attach line.......in emergency we just attach fluids we are not always flushing as it saves time...
@@germanshepparddogsandthenu5653 I'm saying if i inserted a cannula then after it closed by a clot i want to get blood samples and pt's veins are very bad also his arterial sites have hematoma and there is no CVC inserted
could the peripheral cannula work as CVC in blood sampling
🙏👍👍
Sorry, “S mark?” What’s that? I’ve never heard of it or seen one 😮
It's Esmarch...
Esmark is a 5 inch tourniquet that is used in the OR for total joint, etc
@@annapenna4871depends on the language, in my language we call the regular tourniquet shown in the video an esmarch, and the band called an esmarch in the video we call an "elastic wrap/bandage"
For me, its use my mediport or give me an I.O.
Just use the jagular
I have no veins its scary what will happen when I get old
Trying not to be racist, but doing an iv channel is much easier on a light skinned person than a dark one. 💀
I mean first 30 seconds 😅
I want my epidural in my hand like an IV drip I don’t want it in my back
Why don't u just come to the point
Greetings form Italy❤️
I frequently utilize ultrasound-guided IV placement for patients with challenging veins. In fact, I haven't missed an IV insertion in several months (not kidding). When I can't find an easily accessible vein, I rely on the ultrasound to successfully insert the IV on the first attempt, eliminating the need for multiple attempts (from other people who cant do it). My skills are widely recognized, and I am often called upon to assist with IV placements throughout the entire hospital.
Hi Chris, Great! Thank you for sharing this.
Nice. Same, but I was working for a hospital with closed minded management, now working for a private practice that appreciates my skills. Do you use local? My preferred is 2% not 1% via a 30g needle and 1mL tuberculin syringe.
@@bradandcelestejohnson473 Unfortunately, we cannot use local. I use a cold spray that numbs the local area to help decrease the pain. Works pretty well, to be honest. A lot of times, the patient doesn't even feel the poke.
@@chrism6904I'd be wary of the numbing spray. It contains ethyl chloride and it's pretty toxic. It's chemically related to methyl chloride, which randomly replaces parts of your DNA with methyl groups.
The toxicology of ethyl chloride shows its not as carcinogenic as methyl chloride, but it still causes extensive organ damage in animals.
Personally I wouldn't go into a room where ethyl chloride spray had been used.