Intravenous

One of the most basic steps of being admitted to the hospital, undergoing surgery, and presenting to the emergency department is the placement of an IV catheter. Routinely performed by nurses, only a few physicians do this regularly, most notably, anesthesiologists. I remember as a medicine intern being called to place an IV when I knew the nurses who attempted it were much more experienced than I. Yet now, this has changed; I commonly go and place IVs in situations where no one else can get access.

Nevertheless, sometimes even anesthesiologists are thwarted. I heard of an overnight urgent case recently where no one could obtain IV access. A dehydrated drug user with widespread skin and muscle infection needed debridement and had no IV. What do we do in such situations? When I encounter a difficult IV, I sometimes ask patients where they usually get blood draws; IV drug users usually know what areas work and what areas are too scarred to attempt. I also go for a set of rarely used veins; wrist veins, though sensitive, are usually enough to get someone to sleep. Foot veins, deep brachial veins, and external jugular veins all require a bit of skill to cannulate, and so they are often virgin sites. More recently, I've started bringing in the ultrasound early; I've had a couple great successes finding targets invisible to the eye but plump under ultrasound. I don't do a lot of things I've seen others do. I don't slap the arm to make the vein angry; I rarely warm up the arm. While both techniques may help, I don't find them incredibly effective, and slapping someone seems a little mean and the warm towel trick takes a while to work. My favorite trick is to give a little inhaled anesthesia which can dilate the veins. However, this is very limited in scope because I'd only do an inhaled induction in the right candidates under the right circumstances. Having an emergency without IV access is disastrous.

When most anesthesiologists (and physicians) fail to find a good vein, we usually go to the central line. Under ultrasound, most internal jugular and femoral targets can be cannulated. As long as there isn't scarring, infection, or anatomic abnormalities that preclude central line placement, it's usually pretty reliable. Although not incredibly comfortable to an awake patient, they can be made tolerable and are a great backup. Few of us think of the intraosseous line, and I've never placed one outside of simulation and practice. By drilling a needle directly into the bone marrow of a large flat bone, we can infuse IV medications. This is a painful last resort, but it has some advantages. IO needle placement is incredibly fast and can infuse as rapidly as a large bore catheter. I'm sure some day in the future, I'll need to consider it as an option.