Do you Need IV Skills to be a Student CRNA?

by admin

FAQ: Do I need to be good at IV’s before I get into CRNA school?

Answer: No, but it does help.

After 2.5 years in the ICU, a lay person may incorrectly assume I was an IV master. But as ICU RN’s know- we rarely get the chance to place IV’s in the unit. The patient either comes from the ER with great IV access or has a Midline, PICC or central line that has been placed by someone else.

In the ICU, IV placement is made even more challenging when patients are chronically ill and have a history of multiple IV placements. Other difficult sticks include dialysis patients, obese patients, and hypotensive patients. Doesn’t this sound like most of our population? My point is- even if you did get a shot at trying to place an IV while working in the ICU- you probably didn’t have a healthy young person with veins jumping out of their arms.

Wouldn’t this be nice?

 

So don’t beat yourself up if you aren’t very good at IV’s. The vast majority of new CRNA students are just as bad. I had a preceptor recently tell me that when the new students come in, they assume we need a lot of practice with IV’s but they are occasionally surprised by a student that rocks…so if you’re awesome with IV’s, you’ll have a leg up on the rest of us until it comes to the other 99% of new skills we learn as student CRNA’s.

As a student nurse anesthetist, you get exposure to IV placement in various ways that are dependent on your clinical site and/or preceptor. At some sites, you will get an opportunity to place an IV in your first patient of the day. This is because as students, you get to the OR very early. Very early. Meaning you have plenty of time to set up your room, meet your patient, and place an IV. Some sites do not allow students to place IV’s in awake patients. My most recent clinical site assigned students a “Pre-op Day” to shadow the pre-op RN’s and place multiple IV’s. Some of the procedures require the patient to have TWO IV’s. It’s pretty standard for these patients to receive one IV in pre-op and the second in the OR after they have been sedated. Usually, the student is allowed to place the second IV in the sedated patient. Anesthesia causes vasodilation, which greatly helps the student find a vein.

Here is as much advice I can pass on. Hopefully it helps someone.

Preparation

  • Gather supplies. Think about what you’ll need in the order you’ll need it.
    • Tourniquet
    • Some type of prep (chloraprep or alcohol) to clean the skin
    • Lidocaine and 22g needle (if your site uses local anesthesia)
    • IV catheters(preferably a 20g or larger. A 22g may suffice for some minor procedures). *If in doubt, ask your preceptor.
      • Grab a few different sizes and a few of each size- in case you miss!
    • 4×4’s or 2×2’s
    • Sterile dressing and tape
    • Marker or pen to date/time the IV
    • NS or LR and IV tubing.
      • Prime your IV tubing and hang it over the patient’s bed/stretcher.  Make sure the end is within reach and that the cap over the connector is loose enough to where you can remove it with one hand (because after you access a vein, one hand holds the unsecured catheter while the other connects the IV tubing).
      • Tip: instead of using the roller clamp to clamp the tubing, turn the most distal stopcock to the off position to stop the fluid flow. This allows you to easily un-clamp the fluid to check placement after you’ve accessed a vein without having to try to reach up over the patient and unclamp the roller clamp.

General Tips

  • Confidence
    • Ever heard of the phrase, “fake it ‘til you make it?” Even if you are nervous or unsure of your skill, hide it from your patient. Exude confidence! Let the patient know that you are an experienced RN- this is not your first rodeo! Avoid phrases like, “I’m going to TRY to get your IV” or “I’m not very good at IV’s.”

  • Maximize the Chances of Success
    • Raise the bed as high as you need it so you’re not bending over.
    • Stand on the same side of the bed as the patient’s arm you are targeting, even if this means moving the stretcher or temporarily displacing a visitor from their chair by the bed.
    • Remove BP cuff on that side and cut off armbands if they are in your way. *Replace arm bands ASAP after IV has been placed
    • Set up all supplies within arms reach. After you access a vein, you need to be able to do everything with one hand. I like to remove the back from the dressing and set it close by, sticky side up.

Finding a Vein

  • The tourniquet needs to be VERY tight. I place the tourniquet over the patient’s gown sleeve to avoid pinching their skin. Another option is to place a washcloth or 4×4’s under the tourniquet.  Don’t forget to warn the patient that it’s going to be very tight.
  • Extend patient’s arm down toward the ground (use gravity to your advantage!)
  • Have patient pump fist. I usually tell them to make 3 big fists and then relax their hand.
  • Look for veins that are most distal (hand, wrist, lower forearm). You can always attempt a vein higher but once you’ve punctured a vein, you are at risk for infiltration if you try to place something distal to that hole you made. *This seems obvious, but I’ve gotten a patient back to the OR that had an unsuccessful student attempt in the antecubital which was inadvertently followed by a second IV placed lower in the same vein by a CRNA. Needless to say, my fluids and medication traveled up the arm and infiltrated at the missed IV site.
  • Gently tap or flick the veins. I always saw people doing this and didn’t understand it but it really does help the veins pop out.
    • Know that some veins are visible and some are palpable. The ability to feel veins comes with practice. Start feeling your own veins and your friends’ veins to more quickly develop this skill.

  • If you don’t see anything, release the tourniquet, grab two warm blankets and wrap each arm. Come back in 3-5 minutes to look again. The warmth sometimes dilates the vein enough to where you can find it.  Some facilities have a vein finder or ultrasound to aid in the location of veins in difficult patients.
  • Feel the vein.
    • Some practitioners tear off the pointer finger of their glove or only wear one glove when trying to locate a vein. It is easier to feel a vein with your finger than through a glove. I usually find the vein first with my fingers and then put gloves on.
  • Once you find a vein, ask yourself these questions:
    • 1. Is the vein straight? It’s very difficult if not impossible to thread a wiggly vein.
    • 2. Is the vein long enough to fit the IV catheter (compare the length of the catheter to the vein).
    • 3. Do you see any valves that may get in your way of threading the catheter? *In some patients, you can see the valves, in others- you might not be able to see them, but if you can’t thread the catheter over the needle, you may be hitting one.
    • 4. Is the vein large enough for the size of catheter? Don’t try to put an 18g in a small vein, it’s just not going to happen.
    •  Tip: if the vein is extremely superficial, you can place a slight bend in the needle to make threading off the catheter easier.

Placement

  • When you find your target, use your chloraprep or alcohol to cleanse the area.
  • If you’re using a local anesthetic (LA): Make a tiny skin whealwith your LA and 22g just lateral to the vein (this way, the skin wheal will spread out superficially over the vein at precisely where you want to make your IV needle insertion)
    • Rub the LA wheal with a 2×2 or 4×4 or the cleansing solution (I’ve been told this helps activate the medication).

  • Tip: I like to place a sheet, blanket, towels or 4×4’s under the patient’s arm in case any blood spills.
  • Traction!
    • This is a very important concept that I never fully grasped before. With your non-dominant hand, pull the distal end of the vein down pretty securely. Warn the patient that you are going to pull gently on their arm. If you don’t do this, some veins will wiggle right out of the needle’s path.
  • With your dominant hand, use a fluid motion to puncture the skin and slowly advance the needle into the vein- your insertion needle is dependent on how deep the vein is.
    • When you see a flash of blood, flatten your angle and advance the needle just a hair, being careful not to transverse the vein on the other side! This ensures that the catheter is inside the vein and it will be easier to thread.
  • With your pointer finger or your non-dominant hand, hold the needle securely and attempt to slide the catheter off the needle and into the vein.
    • In the past, my most common mistake was that I inadvertently backed the needle out of the vein because I didn’t hold it well enough while pushing in the catheter.
    • Tip: Lift the entire needle and catheter up (parallel to the arm) while trying to thread. This helps when the problem is that you are bumping into the posterior vein wall.
  • When the catheter is threaded, remove the needle(most have a safety device that sucks the needle into the hub and prevents needle sticks.
    • The needle is physically blocking the blood from exiting out of the catheter so keep this in mind. When the needle comes out, simultaneous remove the tourniquet and hold pressure to the vein ABOVE the end of the catheter to stop the bleeding until you can get the IV tubing connected.
  • Attach IV tubing and unclamp. Make sure your fluid is wide open and flowing at a fast rate. You may need to carefully reposition the IV to get this flow.
  • Secure the IV.
  • Make sure you keep the fluid wide open and ensure the IV continues to flow well while you tape down the catheter hub.
  • Date and time your IV.

Troubleshooting

  • Do you get blood return but can’t thread the catheter into the vein?  It may be because the catheter is blocked by a valve. You can try attaching the IV tubing and “flushing the catheter in” which involves opening up the fluid and gently pressing the catheter into the vein. This works some of the time if the fluid pressure opens up the valve.
  • If you missed an IV and couldn’t get blood return, take out the needle and leave the catheter in. *If you remove the catheter, you have to hold pressure at the insertion site to stop the bleeding and it will bleed again if you place the tourniquet on the same side.
  • If a hematoma starts to form or you see infiltration, there’s usually no saving the IV site.  Remove catheter and start over.  You don’t want to take an “iffy” IV into a surgical setting because after the surgical team does its prepping and draping, your access is extremely limited.

As a student, it is the general/unofficial rule that you get one attempt in an awake patient. So as not to torture the patient, the second attempt should be made by the preop RN, CRNA, or MDA. If I miss the IV, I like to joke with the patient and tell them that I’m better at anesthesia than I am at IV’s.

If anyone else has any tips for newbies, we’d love to hear them. Fill out a comment below or e-mail me at admin “at” crnaacademy.com

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