As nurses we know that starting IVs is hard, and when we blow veins it can be extremely frustrating! In this article I’ll do my best to cover all the reasons veins blow and the solutions to those problems.
There are a number of reasons that veins blow…
- Advancing the catheter too early in the venipuncture
- Using too large a needle for the chosen vein
- Advancing the needle through the vein
- Advanced age (geriatric patients)
- Hitting a valve
- IV drug abuse
- End stage renal disease (ESRD)
- Chemo (cancer patients)
- Diabetes
Let’s start with the most common, advancing the catheter too early in the venipuncture.
First, think about the structure of a vein. Walls are made up of 3 layers and depending on the location of the vein can be quite thick. The LUMEN of the vein is the center where blood can flow. When we insert an IV needle into a vein and see flash, the BEVEL of the needle is in the lumen of the vein.
Anatomy of a vein
Because of how IV catheters are constructed, the catheter sits a few millimeters behind the bevel of the needle, so when the bevel is inside the lumen of the vein, the catheter is most likely still in the wall of the vein.
Anatomy of an IV catheter
Many nurses will advance the catheter at this point, and blow the vein. This is because the catheter edges “pull” on the vein wall, causing damage. The added pressure from the tourniquet and this “tearing” of the vein wall will cause the vein to blow.
How do you fix this problem? When you first see flash, PAUSE, LOWER the angle of your needle, advance it another 2mm-6mm (depending on gauge), THEN thread your catheter. This will ensure that the catheter and the bevel are both inside the lumen of the vein.
Using too large a needle for the size of the vein will also be problematic, hopefully for some obvious reasons. This will sometimes blow a vessel simply because the needle is cutting too large a hole and the smooth muscle (tunica media) cannot hold the vein wall together. If the vein does survive this initial trauma, the bevel will often be too long and puncture the other side of the vein (the opposite wall), causing it to blow. If somehow the vein has survived those two possibilities and you manage to thread the catheter, it is extremely likely that the vein will develop mechanical phlebitis very quickly due to the catheter rubbing on the inner wall (tunica intima) and cause it to blow later, sometimes during therapy. This can cause infiltration and extravasation depending on the ordered therapy.
When you’re palpating, try to assess the size of each vein and what it will support. Couple this assessment with the ordered therapy, then choose the smallest catheter possible that will support this therapy.
Advanced age (geriatric patients) can be a challenge as well. These patients tend to have thinner skin, less connective tissue, and thinner/weaker vein walls. Veins in these patients will often blow at the first hint of trauma, even if you think you’re doing everything perfect.
First, try to enter the vein quickly (without advancing your needle through the other side of the vein of course). You’ll typically need to reduce your angle of insertion as well since most of these elderly veins will be near the surface of the skin. If you find that the veins are still blowing, this can be due to the pressure created from the tourniquet, mixed with thinner, weaker-walled veins. Reduce the time the tourniquet is on as much as possible, and apply it as lightly as you can while still getting the veins to distend. When threading the catheter, do so SLOWLY. If you hit a valve, this may blow the vein as well (which we’ll discuss momentarily).
Hitting a valve is such a common way of blowing veins. This happens because valves are stronger than vein walls, so when you advance your catheter, hit a valve, then keep advancing, it will often push out the side of the vein or cause so much damage to the wall that the vein blows.
When you’re palpating, try to feel for valves along the vein you want to cannulate. Valves are almost always found at a vein junction (bifurcation), and can feel like a slight bulge in the vein where it is otherwise straight and smooth. When you advance your catheter, try to advance it slowly, and stop at the first sign of resistance which would likely be caused by a valve. If you feel resistance and can no longer advance, STOP, remove your tourniquet, remove your needle, hook up your tubing with saline flush, then flush the IV while advancing the catheter. This will open the valve and allow the catheter to pass through. Once the catheter is fully advanced, pull back on the syringe and re-check for blood return to make sure it is still inside the vein.
IV drug abusers are not only a challenge because of lack of access, but also because their veins tend to blow much easier due to repeated abuse. Often a vein will feel great on these patients but in reality the walls are so thick and the lumen is so small that it is impossible to cannulate. Always try to use the smallest needle in the largest vein possible. Ultrasound may even be necessary to find the deeper veins that have not been used by the patient.
ESRD, Chemo, and Diabetic patients all pose similar issues of lack of access and delicate veins. This can be due to harmful drugs like chemotherapy, or reduced peripheral circulation due to diabetes. Take your time with these patients. Wrap their arm in a warm blanket, or use a makeshift heat pack for 15 minutes, then apply your tourniquet and palpate for a vein. Use the same tourniquet strategy as you would for an elderly patient with delicate veins, and always advance your catheter slowly in case you accidentally hit a valve.
Heat pack using a glove and warm water…
