Nurses are excellent at placing peripheral IVs. Occasionally, some patients are too tough and the nurses turn to us. Not because we're any better -- they place plenty more IVs than we do -- but because we can use sites they aren't allowed to (EJ), perform invasive procedures (CVC & IO), and have tools they usually aren't allowed to use (ultrasound -- great video from the US guys!). These are all methods that work, but take time, and sometimes the US-guided peripheral just won't take.
Sometimes the nurses get the line (hurray!) but couldn't get the labs (oh no!) -- which is frustrating (or at least, it used to be). The recourse I see a lot of people take is the arterial stick, invariably a blind radial draw. Seems reasonable -- you can feel the pulse, it only takes a few minutes, and is successful ~80% of the time.** If you're savvy at US then it's even more likely to be successful. But I have seen many a tiny and/or squirrelly radial artery, and those do not like being poked.
Here is my fail-proof method:
Ultrasound-Guided Femoral Stick
This may sound drastic. I used to reserve it for sick patients -- those critically ill enough to have pharmacologic or endogenous sedation, or at least those who seemed sick enough to warrant it. But mission creep set in, and now I will do it on nearly anyone who needs blood drawn but not a catheter.
This may seem extreme, particularly when the radial is an option. But in my head, this takes a 5 minute procedure with an 80% chance of success into a 30 second procedure with a 100% chance of success. In the words of Dogbert, it's like sandblasting a soup cracker.
I tell the patient that it may sound crazy, but that I really think this will be better than digging around in their arm for 5 minutes -- which they invariably just went through about 3-10 times before the nurse called me over.
Of course this is anecdotal, but when I ask (awake) patients if this was better or worse than a other sticks (i.e. peripheral IV placement or blood draw) they invariably say the groin was MUCH less painful. There was one even one awake guy with a fully functioning brain and nervous system where we had a conversation through the entire fem draw, and he didn't feel a thing. Nothing! He didn't believe I had even poked him until I showed him the 20 mL syringe full of his blood.
I've started telling patients that while it may seem scary and will hurt a bit because, well, it's still a needle, but that enough patients have told me it's better than the arm pokes that I feel comfortable telling them it's less painful than any other option. And afterward, every awake patient has agreed.
The simple steps:
- 18g needle
- 20-30 mL syringe (smaller if you only need 1 lab)
- US with vascular probe
- alcohol or chloroprep
- gauze & tape
- lab tubes (& ice if getting lactate or BG)
- 3-way stopcock
- lab labels
- Get ALL your gear together -- including ordering your labs and printing the labels, so you don't have to run around for them later
- Clean the groin
- US for the vessels
- Draw the blood under US guidance -- as I'm not placing a catheter, I usually just cheat and go straight down in plane with the US
- Fill the syringe
- Withdraw. Close the needle safely
- Hold pressure over the site with gauze. If the patient is awake and has use of their ipsilateral upper extremity, I have them hold pressure
- SAFELY transfer your blood into your tubes use 3-way stopcock & vacutainer so you can't poke yourself (excellent 1 min video by Whit Fisher, or one of these)
- Ask the patient if that was better or worse than the usual draw
- Give the patient a Press-Ganey survey
Some of you may have noticed that I have yet to specify femoral vein or artery. That's not an accident. If it's a sick patient, I want blood and I don't care where it comes from. Vein is probably preferable to artery -- less chance of complication such as fistula or pseudoaneurysm, and just for convenience, less time holding pressure when you're done.
I've also had a markedly lower rate of hemolysis than I expected.
In fact, if I have a sick patient and they look like they will be a difficult IV placement at all, I routinely advise my nurses NOT to try to get labs at all -- just focus on getting the IV and I'll take care of the labs. Makes for happy patient, happy nurses, happy doc, happy blood.
*Similarly, Aaron Johnston spoke about procedural sedation for manual disimpaction on Rob Orman's ERCAST. Sounds crazy at first, but once you see it, everyone is convinced. Level of evidence: A for Anecdotal
**Level of evidence: M for Made up number
Image: Peter Cushing as Dracula. Before blowing up Alderaan as Grand Moff Tarkin, he was a B-movie vampire. "Don't make your patient a pin-cushion -- Peter Cushing"
response to radial arterial draws:
@thetopend @mdaware what, as opposed to Fast Functional Femoral (the lesser known #FFF) ??
— Michelle Johnston (@Eleytherius) November 1, 2012