This was the most requested topic from this week’s poll!
Some of the many responsibilities of a NICU nurse include drawing our own labs and starting our own IVs. We do not have the luxury of paging the phlebotomist like the other units do in the rest of the hospital. And that goes for every NICU—since it’s such a unique and specialized unit. Fortunately, this means that NICU nurses get really good at starting IVs on our teeny tiny micro-preemies who have fragile, practically non-existent veins.
In nursing school, I wasn’t given much practice with IV starts except for during my ED rotation. I remember the nurse who I was paired with asking me what the one skill was that I wanted to focus on that clinical day. I told him that I really wanted to attempt to start an IV on a patient for the first time, because up until that point, I hadn’t been given the opportunity. I kid you not, he made me start at least 10 IVs that day. We went around the entire emergency room helping out all of the other nurses, asking them who needed IVs. This was such a great experience because it really helped me to become more comfortable with my skills and technique.
For those who haven’t really learned much about inserting IVs, or haven’t had much practice, follow these simple steps to help you master your IV skills. Disclaimer, most of these tips are NICU specific:
Learn the anatomy of your baby and spend some time shopping around. It is essential to look methodically for suitable veins to avoid unnecessary pokes.
Choose the site carefully, aiming to avoid an excessive number of attempts.
Apply a tourniquet (or rubber band) around the limb of choice, proximal to the body.
Inspect and palpate the vein that you plan on using.
Use heel warmers or warm blankets for difficult-to-find veins. The heat really helps to make them pop out at you!
Use a vein viewer to help you find those super deep veins. However, sometimes the light distorts the vein, so use this gadget with caution.
Choose a vein that is as straight as possible. Squiggly veins with valves are very difficult to hit and you might cause trauma if you’re not careful.
If possible, lower/dangle the baby’s limb below his body to help with the blood flow.
Choose the appropriate size needle—in the NICU we use a 24 gauge (yellow packaging) for our peripheral IVs.
Scrub the IV site vigorously. ChloraPrep is the preferred disinfectant used to clean the skin prior to insertion. Cleaning will also help make the vein stand up and say “hello!”
Pull traction on the skin below so the vein doesn’t roll. AKA pull the skin taut.
Insert the needle SLOWLY in a 10-15 degree angle. Most veins are very superficial.
Make sure that the bevel is facing upward.
Once you see flashback, advance the catheter until you are completely in the vein.
Remove your tourniquet and watch your chamber fill up beautifully!
Important IV MANAGEMENT TIPS:
Every hospital has a different policy in place that delineates how many attempts a staff member can have until he/she must defer to someone else. In my NICU, an RN can attempt to start an IV twice. After FOUR TOTAL unsuccessful attempts, we HAVE to page the MD for further instruction.
Unlike central line placement, starting a peripheral IV is not a sterile procedure. You may use aseptic or clean technique.
An IV start is a very painful and traumatizing procedure for the infant. It is important to provide pain relief several minutes before you attempt to start the IV. This can be done via non-pharmacological measures such as oral sucrose and a pacifier.
Swaddle the rest of the baby’s body except for the extremity being used for the IV. This provides containment, comfort, and has a calming effect.
Provide a neutral thermal environment and prevent cold stress. Cold veins collapse and shrivel up, which is not ideal for IV insertion.
You will be monitoring the IV like a HAWK and performing an hourly touch-look-compare assessment. IVs in neonates typically only last 24-48 hours due to their weak and fragile vasculature. If phlebitis, induration, leaking, extravasation, or swelling is noted, remove the IV immediately and notify the provider.
Compared with adults, the veins in babies are smaller and poorly supported by surrounding soft tissue. A premature or sick infant may require multiple IVs during a prolonged stay. Thus, if the baby is going to be on an IV antibiotic or pharmacologic regimen for a long period of time (e.g. at least a week), the bedside RN should ask the MD to see if the baby qualifies for a PICC line. PICC lines are used for long-term treatment rather than a temporary solution for a short course of IV meds. They last so much longer than peripheral IVs and would be much more beneficial to the baby needing chronic IV therapy.