Difficult IV's... suggestions?

[lisajean]

Greetings all,
I am at the end of my rope and need advice, ideas regarding IV's and blood draws. Actually it is my 18 year old daughter who needs regular blood draws and IV's. But not so regular that a PICC or port is indicated.
Short medical history: brain tumor, hydrocephalus and most recently autonomic dysfunction (which plays havoc with her BP and pulse).
We have tried all the usual tricks...being hydrated,lots of salt, dressing warm, heat packs at the site, calm biofeedback breathing, recline (as she will faint otherwise) well rested, gentle weight lifting, exercise shortly before to increase blood flow, letting the infusion room know she is coming etc.... even ultrasound guided IV.
Last week she needed an infusion and we finally left after 8 different nurses looked and 4 tried (at least 2 times each and dug with each attempt) with no luck in hitting a vein.
This has been an on-going problem that just keeps getting worse. The doctor on call told her nurses that they just had to keep trying despite the pain they were causing. Grrr!
If it was life or death then yes, but this was to get an iron infusion. So we left.
However in the long term we need to find an answer to this.
Any ideas? Is there a doctor who specialises in veins? Is it reasonable to ask that pain and stress be kept to a minimum? Are there any techniques that we may be unaware of?
thanks,
Lisa

[Beth]

why not a port? It seems the perfect solution, even if its not used regularly. It would only have to be flushed monthly...

[Discododi]

I think a PICC would be a very good solution. It would only need to be flushed regularly, and the site kept clean. It would definetly help to minimize the pain and frustration of future sticks.

Best of luck to you guys, Dodi

[just laurie]

A little friend of ours who is undergoing chemo has a port. It works for infusions and some draws and doesn't seem that difficult to access or keep clean.

Another thought is to ask about having an anesthesiologist get the line in. When I worked in a hospital they were the ones who were called for the difficult IVs. I don't know if they would do outpatient though.

One final idea (I'm really just pulling these out of thin air; smack me if they are too simplistic)...Maybe a nurse on the pediatric unit could find the vein better. They are usually really good at finding tiny veins because they look for tiny veins all the time. Again, I don't know if they would do your dd's draw since she is no longer technically a pediatric patient, but it might be worth asking about.

Hope something works soon! That is way too many pokes and digs!

Laurie

[PainInTheNeck]

I would back the idea of an Anestesiologist. Some of them are also pain specialists and understand and embrace how important it is to minimize trauma. I had an Anestesiologist who actually numbed my arm before he dug around to find the vein. What an angel!

[Kira]

I have TERRIBLE veins and frequently need IV access for labs (was going once a week for a while), treatment, etc. I would say I average about 5 blood draws and 3 IVs a month. My veins are NOT cooperative and I often end up getting stuck over and over and over again to get the IV, only to find out it won't draw and we have to start the process over again to get labs... Once I had 3 nurses looking for an hour and a half before they got one little tube of blood (the IV was already in but wasn't drawing). I had 4 people try (6 sticks) for an arterial blood gas once, and no one got it and the doctor ended up saying to just forget it. I blew through 6 IVs in 3 days last time I was in the hospital, because they were running my D10 at a whopping 500cc/hr for a while and it is so irritating to peripheral veins and the volume was big so the IVs would just blow over and over again. So I hear you loud and clear about how much it sucks.

Sometimes they have NICU nurses try the hard IVs, since they do them on the tiniest veins every day. I have never had anesthesia try to get an IV on me (other than in the operating room, probably), but it sounds like a good idea.

The hospital I go to has a special "IV team" that does the hard IVs, and they have had luck with me. They will give you a tiny shot of lidocaine to numb the area before they insert the IV, which is really nice since then you can't feel the digging around. I wish they would have done that when they were trying to get all of those ABGs on me, since that hurt like crazy. There is also a cream called EMLA cream that you can put on the area ahead of time, under a Tegaderm dressing, to numb the area. I have never used this but I know they do it for peds patients all the time. I would ask about local anesthetic ahead of time since you know she is a hard stick. It makes the whole thing much easier.

I have had the "port" conversation with my doctors and we are leaning that way. I am trying an oral solution right now to see if it works well enough to get me through the smaller attacks without needing IVs, but if not, we are going to talk about getting some kind of permanent access.

One thing we considered was doing a PICC first, to see if it makes much difference to be able to do treatments more aggressively and sooner than I am able to now... in other words, to be able to do them at home with smaller attacks and without the big delay in going to the ER. If the PICC is successful, then we would probably do a port.

PICCs usually go in the upper arm and last a few months, from what I understand. Ports go under the skin in the chest and last pretty much as long as you can go without infection or having it clot off. Ports are a type of central line, but they are completely under the skin, so the infection risk is lower. There are other kinds of central lines, also implanted in the chest, where the end of the tube(s) sticks out of the skin all of the time. People who need to use the line on a daily basis are more likely to have these. Some names of this kind are Broviac, Hickman, Groshong, etc. There is a higher risk of infection with the kind where the tube sticks out all of the time. However, there is a risk of infection with all of these lines.

You can use these lines to draw blood as well as to administer drugs, fluids, and TPN. You can swim, take a bath, etc with a port but shouldn't with a PICC or the kind of central line that has the tube hanging out. You can shower with PICCs or central lines but need to make sure they are well-covered and don't get wet, like showering with an IV in at the hospital.

I think when the time comes for me (probably in the very near future), I want to go with a port. I will try the PICC first, though, if my doctors still want to do that.

I hope you figure out the best solution for your daughter... getting stuck over and over is no fun!

[Tbackpain1]

I'm just curious, are these nurses/IV techs using the same sites over and over? When I was on the IV team, I would without fail get called to put an IV in, and 9 times out of 10 I was able to find a site, but when people called me, they were always looking for sites in the same places, either antecubital (in the elbow) or on the hand, and sometimes on the forearm. But if those sites are not viable, depending on the center's protocols, they can also set up IVs at other peripheral sites. I had to place IVs on some folks in their lower extremities, just because their arms were wrecked...its not ideal, but it can be done when its absolutely necessary.

Big things to do are what you've already done with your daughter. It might help if they try using a BP cuff and dropping her arm off the table to get the IV in. The BP cuff can exert more pressure than a tourniquet, and is often helpful for starting IV on folks with low BP or low fluid volumes. As others have mentioned, they can use local anesthetic (injected just under the skin, or topical, depending on the facility's protocols) to make the process less painful.

Calling in the house physican or an anestheologist would probably be best. Find out how many sticks per visit she can have before they are required to call in a physican. Each facility has to have some kind of protocol in place, because sticking a patient too many times is assault. Also, find out what size needle they're trying to use. For some, the larger bore cannula's are just too big and always will result in a blown site. In patients like your daughter, I would use the smallest cannula possible, 25gauge for blood draws, and a 22 gauge for IVs, unless the fluid volume being delivered needed something larger.


Best of luck with this. I've passed out from IVs and blood draws since I was little. No one thought I would be able to hack it as an RN in my family, but surprisingly, I have no problem with needles when I'm on the driving end ;)

Theresa

[just laurie]

Coincidently, I also worked at a hospital with an IV team. They did nothing but IVs, which made them very good at doing IVs. It probably decreased the IV skills of the rest of the nursing staff, which would be a disadvantage should those nurses transfer to another hospital, but for the patients at that hospital it seemed to work well.

Laurie

[lisajean]

WOW,
Thanks for all the helpful replies! I knew I could count on you guys :) .
I believe it is too risky to do a port or picc based on the limited number of "sticks" my daughter now requires. Plus, she is only 18 and struggling already with numerous issues. Not to mention that the only picc she ever had took numerous techs over two days to finally place a working one. We really don't want to add to the situation with an obvious line in place. It just makes her more aware of her disability which is not good for her mental health.
That being said adding unneccessary pain to her life is not a good option either.
I agree that it is time to speak with an Anesthesiologist. They never seem to miss but it is after my daughter has been semi sedated so they can use a large bore needle with less pain/fear.
We have tried very small bore needles which can work for a blood draw but blow too fast for an IV and if a small bore works the drip is so slow that my daughter becomes agitated from sitting so long in the IV infusion room, like 4 hours for one bag of fluids. (although very nice it is just not where an 18 year old wants to be).
Kira, hugs to you. I hope that a port will be helpful to you. I would want one too if I was in your situation:( .
We meet with my daughters cardiologist on thursday. I will let you all know what the plan is.
Thanks again'
Lisa

[just laurie]

When my friend's 3yo had her port placed, the surgeon said, "I have daughters, so I put this one where it can't be seen in any swimsuit you're likely to let her wear!" The access is under her arm, with a small tube to a vein or something in her shoulder area. The access is a bump about the size of a quarter, but it is not at all noticeable unless her mom is showing it to you. Maybe if a port does become necessary your dd's surgeon could hide it like this. That is such a difficult age to have anything noticeably "different", so I understand that concern.

Hope something works out for your dd!

Laurie

[joy]

I don't know you Lisa but I understand the love and concern you have for your daughter. My own has been in hospital several times this last month. Due to her being dehydrated from an unknown infection and a combination of other things, she did not have a spot on either arm or hand that was not blue and swollen after her week in hospital this time. Here's hoping that one of these suggestions will do the trick and your daughter will not have to fear having this done everytime. It's bad enough for some people when all goes well. When everything goes wrong, well it's just awful!

[mpsgirl]

I jusut wantes to caution depending on the type of Cardiac problemns a Poret might pose addt'l risks of infection.. I receive weekly 4hr infusions for the rest of my life (have been doing them for a year and a 1/2) and although I have IV troubles just about every week I am not really considered a candidate for a Port or PICC due to risks.

[Kira]

Awww, thanks Lisa... Hugs to you and your daughter, too.

Hoping you can figure out a way to do this with as little discomfort as possible...

[roz1950]

with me its 3 strikes your out. Took one time 8 pokes . never again

[tammyr]

Thought you'd like to know you were copy pasted on to mylot.

http://www.mylot.com/w/discussions/818861.aspx?p=0/?ref=tammyr
Hate that this happened to you.

[tammyr]

Mylot deleted the post in the above reply. Hope you have solved your problem with the IV's!

[mommy2lacigurl07]

A lot of times the anesthesia people have had to do mine too. They always have to start off with baby needles for me for surgeries and all and then chance them once im asleep. Im a difficult stick and I agree it isnt fun. Ive even had it so bad there was talk of trying to go in through my feet or the vein in my neck. So yea I know it really sucks. They never ended up going through my feet or neck though thank goodness.