IV Start Tips to Boost Your Success Rate

I’ll be the first to admit it, I’m terrible at starting IVs. In the ICU our patients either have central lines or are so ill or volume depleted that finding a vein is like searching for a needle in a haystack. And even though I was moderately proficient at starting IVs as a student, the lack of practice in my current workplace has made me feel less-than-confident in my skills.

So I thought it would be a great idea to round up some IV start tips and share them with you here. Let’s get great at doing IVs together, shall we?

To start, I turned to an IV starting ninja…my paramedic husband. I figure if he can start an IV on a sick patient in the back of a moving ambulance then he can probably start an IV anywhere. Here’s what he shared as his go-to method for starting an IV:

Have your supplies ready

• First,  you need to understand what gauge sizes mean. If the gauge is a larger number, this means the diameter of the needle/cannula is smaller. So a 22 gauge IV is smaller than an 18 gauge. You also want to choose the appropriate size IV cannula for the task at hand. Generally, fluid resuscitation and blood transfusions like bigger gauge needles.Otherwise, choose the smallest size you can in relation to the vein to help prevent irritation. Think about it…a big ol’ IV in a smaller vein is just going to irritate the heck out of the tunica intima of that vessel. So if you’re going with a big IV, choose a big vein like the antecubital, cephalic or basilic.
• Set up your extension tubing and saline flush prior to starting your IV. Once you get your catheter in place, you don’t want to waste time putting things together while your IV sits there unsecured.
• Attach your needleless connector to your IV extension tubing and flush the whole apparatus with normal saline. Leave the saline syringe attached because you’re going to flush the IV once you get it inserted.

Be a vein-finding master

• Place the arm in a dependent position and give gravity some time to work its magic.
• An inflated blood pressure cuff makes a fantastic tourniquet and doesn’t pinch arm hairs or skin like those little rubber straps that come in the IV start kit.
• Go by feel when searching for a vein, more than trying to visualize it.  You’ll have a much greater number of veins to choose from since many perfectly good veins are just under the surface…you may not be able to see them, but they’re great for IV access.
• Practice finding veins by feel on yourself, your friends, your family and agreeable patients. Use the same hand/fingers for this and train yourself to recognize what a vein feels like (the index finger is the most sensitive, so it’s a good one to use). A good vein will feel bouncy upon palpation, whereas tendons will feel hard (and will also move if you have the patient clench their fist or roll their wrist).
• A hot compress or towel can help a vein dilate to be more palpable or visible.
• Flicking at the vein can help it “pop up” a bit, so try that if you’re having a hard time palpating a vein but you know it’s there based on your understanding of anatomy.
• Ask the patient to pump their fist. This can help veins engorge so they are much easier to find.
• Try to avoid the antecubital if you can. IVs in the AC often don’t last long as the patient will bend his/her arm repeatedly resulting in a kinked catheter which obstructs the flow of fluid/medication and ultimately results in a non-patent catheter. However, if you need to infuse a lot of fluids or blood fast, the AC is a good vein to choose because it’s so large, but anticipate changing to another vein as soon as possible.
• Ask the patient what their experience has been. if they tell you a certain vein is better or a certain vein always “rolls” then believe them!

Inserting the catheter like a boss

• To prevent the vein from “rolling” you need to secure the arm firmly as seen in this photo…you want to create traction on the skin with your non-dominant hand while your dominant hand inserts the catheter.

Why does my arm look like a long alien arm?

• With the bevel up on your needle, insert your catheter at about a 15-degree angle (possibly a greater angle with deeper veins…practice and experience will be your guide!) Be confident and smooth…you’ve got this!
• Once you get flash, level out the catheter so it’s at a less acute angle. If you fail to drop the catheter down, you’ll likely go all the way through the vein (this is called “blowing the vein.”)
• Gently advance the catheter, retract the needle and attach your connection tubing. Release the tourniquet and secure your line.
• You did it!

For a very thorough explanation of some difficult IV start problems, check out this video by Sean Dent, an awesome nurse practitioner with a very active YouTube channel that I just know you’re going to love!

This website has some great tips for basic IV starts. I like how the author stresses the importance of your attitude surrounding this important skill. Most notably, he emphasizes that you should relax, approach the patient with confidence and do your best to get the patient to trust you.

For all your intravenous infusion questions (and the ones you didn’t even know you had yet) check out the Infusion Nurses Society website. It is a goldmine of knowledge!

Do you have a tip for starting IVs? Let us know in the comments below!

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