Intravenous access

Ned Radich, MD
Anesthesia Consultants of Fresno

Every medical student is eager to learn intravenous catheter placement. Fortunately, this becomes routine during internship, often performed while half asleep. Yet, IV access can still be a major stumbling block.  What are the options after receiving that dreaded call from the pre-op nurse that "we can't get an IV?"  Assuming that the usual upper extremity sites have been exhausted, we've resorted to foot veins, or even the external jugular, which are awkward for the patient.   Recently, we've had success using ultrasound to locate peripheral  veins. This is quite helpful in obese patients or those with dark skin.  I'd recommend starting with the most shallow setting (< 2cm), which provides the best resolution and makes the vessel look larger (a nice confidence booster). A key point is that unlike placing blocks under ultrasound guidance, when attempting IV access, your gaze has to switch back and forth from screen to catheter. Otherwise you'll miss the initial blood return, and go right through the vessel.  I’d also recommend gentle probe pressure as veins are compressible and don't overdo the gel. What are the downsides of this technique? Obviously, an ultrasound machine is required, which is hopefully accessible to most practices (if not, start lobbying!).   There is definitely a steep learning curve using ultrasound, necessitating direct proctoring initially. If not yet comfortable manipulating a needle with U/S, it can still be used to help locate blood vessels, which makes this worthwhile for difficult arterial lines as well.

One final alternative-if all else fails, intraosseous kits are now available for adults.  They’re easy to place, have a surprisingly high flow rate and can be utilized for most medications.  Costing only about $700/kit, it's a worthwhile investment.