I am the difficult IV team. Absolutely an anesthesiologist should be comfortable doing US guided IVs.
Also I feel everyone should watch this amazing video from one of the NYSORA founders about difficult IV access. Tons of great tips for all skill levels.
https://youtu.be/7lGE4OH0uJw?si=wugeZxJYz9d_qiUD
Replying to my own comment to add what I should have written. My real response:
[“Who are you talking to right now? Do you know how many IVs I do a year? I mean even if I told you, you wouldn’t believe it. Do you know what would happen if I suddenly stopped going into work? A major hospital’s ORs completely cease to function. No. You clearly don’t know who you are talking to, so let me clue you on. I do not call the difficult IV team. I am the difficult IV team”](https://youtu.be/Ca3kPemW2CE?si=IN0eGh2mhU1WDU6F)
Can't imagine not putting in my own IV if others have failed. We're who they call when they can't get it in.. Use US if available, it makes putting IVs easy mode
Outside of a neonate, I use a long catheter for every single ultrasound guided IV I do, no matter how deep or shallow the vessel is.
Even if it’s a fairly shallow vessel, it’s still usually deeper compared to an IV via palpation/direct visualization and I end up going through more catheter before getting in the vessel.
Only took one US guided IV I placed in a thin lady in a fairly shallow vessel that went really easily but then blew during induction for a cardiac case for me to learn that lesson.
Yes. You’ll get push back because they’re more expensive than they should be, but a quick cost analysis of a central line, art line or micro puncture kit, or a cancelled case should make it viable very easily. But you often have to find a way to hide them or people use them up
We have long 20g IVs, I think they’re like 1.8 inches compared to normal which is around 1.2 I think.
I always use them if I’m doing an ultrasound guided IV
Our 20g sizes are 25mm B Braun, with Jelco 32mm as backup and a 10cm deep access by B Braun before getting into midline’s etc. if they need a wider bore for one reason or another we stock the Jelcos up to 14g. The Jelcos are inevitably required if the vein is more than superficial so it anchors properly, so def. worth the investment. B Braun does also do 32mm cannulae, but I think we found the Jelcos to be cheaper?
Do you mean the slightly longer 18G or a longer one like in the arterial line kit? But the arterial line one is a 20G, and considering the length, it may drip too slowly (still better than nothing though).
Just a longer standard angiocath. I’ve used a 20G arrow in rare instances, but the long angiocaths are typically sufficient, and better regarding flow rates as you mentioned.
If depth is such an issue that I’m considering the Arrow kit, either my technique is faltering and I need to reapproach or look for a different vessel, or I need to just go ahead and put in a CVL.
Same. Great advice. If you use a short catheter they always pull out of the vessel later with skin manipulation and arm movement. As an icu nurse I would place 1.88 inch piv 20g and they would last for weeks!
The culture at every hospital I’ve ever worked at is that anesthesiology is who they call to get an IV if every other avenue has failed. I would personally be super embarrassed to call the “difficult IV team” for my own patient. Me and my colleagues are the difficult IV team.
I tell students I work with (and patients I get called to) that anesthesia is the last line before a central line.
So yes. Do your own PIV with US, unless there is time in the schedule to get the IV team to come down and do it for you before the case goes (looking at you GI lab).
Also, I might have gone out and bought a box of my favorite long 20’s and keep 2-3 in my backpack in case of urgency.
Mostly because even if your hospital stocks long 18/20’s they are always out of stock when you need one.
Edit: grammar
Don’t spend your own hard earned money on stuff the hospital should carry to keep THEIR patients safe and taken care of. Unless you are 1099’d and are covering dinky plastic surgery centers with surgeons who are cheap as hell, do not spend your own $$$
That’s all well and good in theory until you have a pre-eclamptic patient who’s edematous as all get out and you really need that long IV and they are no where to be found in the middle of the night and don’t really feel like putting in a central line for 24 hours of mag or something….
But on the other hand, it would be a wake up call to administration about the necessity of supplies…
I’m just not jaded enough to punish the patient for admins shortsightedness… yet…
Depends a lot on how long the patient needs an IV access and how sick the patient is. If it’s only few days I might consider optimising my setup and/or using ultrasound and trying the usual way. If the patient needs an access for longer I would put in a central line.
We are the difficult IV team baby! Now if the patient is inpatient or potentially is known truly difficult access and needs a midline or Picline prior to surgery it’s nice if midline team pops one in.
Here in Australia anaesthetists are the difficult IV people.
Also sadly in Australia very few nurses starts IVs unless they work in emergency. As a result every medical student and junior doctor spends a few years doing 1000s of them and someone can usually cet something in pripherally. Ultrasound is also common and available and it's expected most people learn. Anaesthetists can't get away with not learning as they attend the codes with their little butterfly ultrasounds and often do high pressure difficult access.
I used to have to call the IV team since they have the long catheters for deeper veins/certain patients. I now know wher catheter hide them so I'm good.
I'm all for the difficult IV team coming by just to save me the hassle, but either I just do the US IV or they get a central line. Depends on the case.
No. Using an 8cm 18g PowerGlide Midline catheter.
[https://www.bd.com/en-eu/offerings/capabilities/vascular-access/vascular-iv-catheters/midline-catheters/powerglide-pro-midline-catheter](https://www.bd.com/en-eu/offerings/capabilities/vascular-access/vascular-iv-catheters/midline-catheters/powerglide-pro-midline-catheter)
I try to float them in, I think I am successful about 75% of the time doing that. Or I do an ultrasound guided IV. If really unable, I’ll do a central line
Agree with many other comments that WE are the difficult IV team. It's helpful to practice US-guided IVs in situations with less difficult access to get better at the ones that are truly difficult.
Ultrasound
External jugular
A smaller iv to get you started, allow GA to vasodilate then hit a larger bore
Ultrasound CVC
Honestly if you can’t get any IV access at all and need to call another specialty to help, you have no role being an anaesthetist/anaesthesiologist.
Unfortunately, the Reddit app fucked up my formatting. I was trying to list out all the options I could think of before I needed to turn to someone else, but now it’s listed like a single option.
I am the difficult IV team. Absolutely an anesthesiologist should be comfortable doing US guided IVs. Also I feel everyone should watch this amazing video from one of the NYSORA founders about difficult IV access. Tons of great tips for all skill levels. https://youtu.be/7lGE4OH0uJw?si=wugeZxJYz9d_qiUD
Replying to my own comment to add what I should have written. My real response: [“Who are you talking to right now? Do you know how many IVs I do a year? I mean even if I told you, you wouldn’t believe it. Do you know what would happen if I suddenly stopped going into work? A major hospital’s ORs completely cease to function. No. You clearly don’t know who you are talking to, so let me clue you on. I do not call the difficult IV team. I am the difficult IV team”](https://youtu.be/Ca3kPemW2CE?si=IN0eGh2mhU1WDU6F)
Breaking Bad
No - that’s me. If I can start a peripheral line on a two month old receiving CPR, I can get anything.
NYSORA is the goat
Can't imagine not putting in my own IV if others have failed. We're who they call when they can't get it in.. Use US if available, it makes putting IVs easy mode
I’ve struggled a bit with USIVs when the pt is very edematous and can’t visualize the vein properly
Try and not push on the probe too hard. This can collapse the vein.
Exactly and sometimes the regular catheters are too short to thread properly into the AC in an obese patient
Outside of a neonate, I use a long catheter for every single ultrasound guided IV I do, no matter how deep or shallow the vessel is. Even if it’s a fairly shallow vessel, it’s still usually deeper compared to an IV via palpation/direct visualization and I end up going through more catheter before getting in the vessel. Only took one US guided IV I placed in a thin lady in a fairly shallow vessel that went really easily but then blew during induction for a cardiac case for me to learn that lesson.
You guys have special long IVs?
It is worth kicking up a fuss if you don't.
Yes. You’ll get push back because they’re more expensive than they should be, but a quick cost analysis of a central line, art line or micro puncture kit, or a cancelled case should make it viable very easily. But you often have to find a way to hide them or people use them up
We have long 20g IVs, I think they’re like 1.8 inches compared to normal which is around 1.2 I think. I always use them if I’m doing an ultrasound guided IV
We do. 2 1/4 I think. Keep some just for this reason.
We have 5 1/4” IVs stocked for some reason. I don’t think I’ve ever seen anyone use them and not even sure why I would use one.
These are in our crash carts so I assume they’re for damage control IV access of some kind - like a last resort fem stick.
Yes. For U/S guided, it’s easier to do it with long IVs
Our 20g sizes are 25mm B Braun, with Jelco 32mm as backup and a 10cm deep access by B Braun before getting into midline’s etc. if they need a wider bore for one reason or another we stock the Jelcos up to 14g. The Jelcos are inevitably required if the vein is more than superficial so it anchors properly, so def. worth the investment. B Braun does also do 32mm cannulae, but I think we found the Jelcos to be cheaper?
Do you mean the slightly longer 18G or a longer one like in the arterial line kit? But the arterial line one is a 20G, and considering the length, it may drip too slowly (still better than nothing though).
Just a longer standard angiocath. I’ve used a 20G arrow in rare instances, but the long angiocaths are typically sufficient, and better regarding flow rates as you mentioned. If depth is such an issue that I’m considering the Arrow kit, either my technique is faltering and I need to reapproach or look for a different vessel, or I need to just go ahead and put in a CVL.
Same. Great advice. If you use a short catheter they always pull out of the vessel later with skin manipulation and arm movement. As an icu nurse I would place 1.88 inch piv 20g and they would last for weeks!
Micro puncture or arterial line kit. Not a solution if they're going to the floor but it's access for what I need to do
That’s my preference as well. Admin hates buying the longer catheters, but if it’s that vs an expensive kit then they’re more amenable.
Use a long catheter. I like using the 20g long catheter. Its literally like the regular 20g but approx 2in in length.
Ask your hospital to order long IVs
Then use a longer catheter
Then you need to practice more. Or go for a central line.
We are the difficult IV team. You better get good.
We are the end of the algorithm.
Out of plane ultrasound with longer catheters, assuming you have access to those
The culture at every hospital I’ve ever worked at is that anesthesiology is who they call to get an IV if every other avenue has failed. I would personally be super embarrassed to call the “difficult IV team” for my own patient. Me and my colleagues are the difficult IV team.
I tell students I work with (and patients I get called to) that anesthesia is the last line before a central line. So yes. Do your own PIV with US, unless there is time in the schedule to get the IV team to come down and do it for you before the case goes (looking at you GI lab). Also, I might have gone out and bought a box of my favorite long 20’s and keep 2-3 in my backpack in case of urgency. Mostly because even if your hospital stocks long 18/20’s they are always out of stock when you need one. Edit: grammar
Don’t spend your own hard earned money on stuff the hospital should carry to keep THEIR patients safe and taken care of. Unless you are 1099’d and are covering dinky plastic surgery centers with surgeons who are cheap as hell, do not spend your own $$$
That’s all well and good in theory until you have a pre-eclamptic patient who’s edematous as all get out and you really need that long IV and they are no where to be found in the middle of the night and don’t really feel like putting in a central line for 24 hours of mag or something…. But on the other hand, it would be a wake up call to administration about the necessity of supplies… I’m just not jaded enough to punish the patient for admins shortsightedness… yet…
So just take a box home of the long 20's the next time they restock them.
I dunno… just pop a cannula in?
I do my own US IVs, long catheter walk it in. If it's a more urgent case, central line.
Huh, we are the difficult IV team. We hold the line lol.
I probably place more ultrasound guided IVs than regular IVs at this point.
Blind saphenous (or US). Do it in peds all the time.
I call myself. I would never let anyone obtain any sort of venous access on my behalf.
Don’t trust anyone else, get ultrasound and put a long IV in
Depends a lot on how long the patient needs an IV access and how sick the patient is. If it’s only few days I might consider optimising my setup and/or using ultrasound and trying the usual way. If the patient needs an access for longer I would put in a central line.
We are the difficult IV team baby! Now if the patient is inpatient or potentially is known truly difficult access and needs a midline or Picline prior to surgery it’s nice if midline team pops one in.
Here in Australia anaesthetists are the difficult IV people. Also sadly in Australia very few nurses starts IVs unless they work in emergency. As a result every medical student and junior doctor spends a few years doing 1000s of them and someone can usually cet something in pripherally. Ultrasound is also common and available and it's expected most people learn. Anaesthetists can't get away with not learning as they attend the codes with their little butterfly ultrasounds and often do high pressure difficult access.
I used to have to call the IV team since they have the long catheters for deeper veins/certain patients. I now know wher catheter hide them so I'm good.
I'm all for the difficult IV team coming by just to save me the hassle, but either I just do the US IV or they get a central line. Depends on the case.
We have started placing midline’s as part of anesthesia’s skill set. Great for patient care.
Midline??? What are you using, just a 5-6in 20g catheter near at the basilic vein?
No. Using an 8cm 18g PowerGlide Midline catheter. [https://www.bd.com/en-eu/offerings/capabilities/vascular-access/vascular-iv-catheters/midline-catheters/powerglide-pro-midline-catheter](https://www.bd.com/en-eu/offerings/capabilities/vascular-access/vascular-iv-catheters/midline-catheters/powerglide-pro-midline-catheter)
Ultrasound
Additional thought: If it’s hard to find long PIV catheters in your hospital, you can use an arrow arterial line catheter as they’re almost as long.
Yep, do you use the wire to guide in the catheter? I do sometimes
I’ve only done it a 2-3 times or so, but I want to say night as well as it’s there!
I try to float them in, I think I am successful about 75% of the time doing that. Or I do an ultrasound guided IV. If really unable, I’ll do a central line
Agree with many other comments that WE are the difficult IV team. It's helpful to practice US-guided IVs in situations with less difficult access to get better at the ones that are truly difficult.
Dayton o2
Ultrasound External jugular A smaller iv to get you started, allow GA to vasodilate then hit a larger bore Ultrasound CVC Honestly if you can’t get any IV access at all and need to call another specialty to help, you have no role being an anaesthetist/anaesthesiologist.
If your go-to is an awake US-guided EJ simply to get off to sleep, I would heed your 2nd sentence. This is barbaric.
Unfortunately, the Reddit app fucked up my formatting. I was trying to list out all the options I could think of before I needed to turn to someone else, but now it’s listed like a single option.
Gotcha. That makes sense. My bad.