Thursday, April 28, 2016

IV insertions - Upside Down and Backwards to Boot

A good scrub nurse always sides with the surgeon in a dispute with anesthesia and should always be attentive to what's going on in the operative field. Nevertheless, there can be some interesting things happening on the other side of the ether screen (oops..I'm showing my age here.) I probably should have said anesthesia screen.

One of the anesthesia attendings was always up to something different which at times bordered on outright foolishness. He loathed endotracheal tubes and intubating, preferring the old school mask, but that's a story for another post. He even asked others to call him by his first name which was unheard of back in the day. His name was "Bob," but I always called him by the proper, Dr. Frolic. One of his favorite tricks was to insert an IV catheter backwards so that it was pointing to an extremity rather than the heart. He then berated and belittled anyone that told him that he put the IV in backward.

I think this got started by his attempts to find a good vein by looking in difficult to access or unusual sites. Every old nurse or doc  knows that the back of the forearm can be a gold mine in the search for a good vein because not many people look there. Dr. Frolic loved this site and had the patient flex their arm at an acute angle at the elbow and rotated their shoulder toward the head of the table. With the patient twisted up like a pretzel, it was easy to loose track of the correct insertion orientation.

The number one objection to his technique was that the IV would not infuse properly because it was facing  resistance from the return  bloodflow. The venous blood would be flowing right into the open end of the IV catheter.  Dr. Frolic was quick to point out that the vascular resistance in the vein was the same regardless the direction of the catheter. The forces of gravity driving the infusion and vascular resistance were the same regardless of IV catheter direction. By further explanation he said there was actually a therapeutic advantage to the backward IV because the rapid bloodflow toward the IV catheter tip served to disperse the medication better thus reducing vein irritation and possible phlebitis. He used a spitting into the wind analogy to illustrate his point. He told the person (usually a nurse) that objected to his technique to go outside and spit a big glob of mucous into the wind. "It will come back at you in a slew of smaller mucous pieces," proving my dispersion point. "If you spit a mucous glob in the direction of the wind it will stay in one discrete piece. Now which would you prefer entering YOUR venous system."  End of discussion.

The other objection to his technique was that with a small vein, the IV catheter could occlude the venous lumen. Dr. Frolic dismissed this argument by explaining to the objecting nurse that veins are elastic so this was not an issue. I did notice that the good Dr. always selected "garden hose" type veins usually in the back of the arm for his insertions so the lumen of the IV catheter would not totally occlude the vein making this objection  a moot point.

Dr. Frolic's backward technique did indeed work for the duration of the surgery. I don't know if there were any long term problems associated with backwards IVs. In the good old days IVs were frequently left in place just for the duration of the surgery. Very few meds were given IV so venous access was not a big issue like it is today.

This fact points out another dubious benefit for the backward IV site because it faces the foot of the OR table. At the end of a case, the surgical drapes are always pulled down from the direction of the anesthesia screen to the foot of the table. If the IV tubing is attached to the drape, it is simply pulled out with the removal of the drape. Dr. Frolic used to refer this as the automatic IV discontinuation feature whenever he neglected to make sure the IV tubing was free of the drape. To legitimize or provide credibility to his whacky methods, Dr. Frolic would come up with technical sounding names. He called his backward IV trick: "ulnar splinted retrograde transcutaneous venous cannulation."

Another IV insertion trick in Dr. Frolic's bag involved inserting the IV with the bevel of the needle facing DOWN. His argument for this technique was that there was less of a chance of penetrating or damaging the side of the vein opposite insertion. The sharp bevel tip of the needle was further away from the opposite wall of the vein reducing the chance of injury. The other advantage to this technique is that the complete lumen of the needle or catheter is within the middle of the vein. If the needle is inserted "correctly" or bevel up, a portion of the needle lumen could be blocked by the wall of the vein at entry site.

Much later in my nursing life, I did try Dr. Frolic's needle bevel down insertion trick. The one adjustment I found necessary was that the needle insertion angle through the skin had to be at a much more acute angle than with the traditional bevel up technique. This also required a more rapid reduction of the angle once you were into the vein. His bevel down technique did work especially well when drawing blood. The blood flowed into the vacutainer more quickly and there was less injury to fragile veins. He may have been on to something with the bevel down method, but I would not wanted to try it as a student with an instructor watching.

I never really had the gumption to attempt a backward (away from the body core) IV insertion. I did not think his spitting into the wind analogy had much science behind it. From my observations, his backward IV did work in the OR, but I don't know how it functioned long term. Sometimes important breakthroughs are discovered in a serendipity manner, but foolishness for the sake of foolishness is not a great idea. If the truth be told, as a youngster, I was not really very foolish but I'm making up for it later in life!


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  5. Ugh, no comments except spammers. Another great post, my friend.

    1. Thanks Kathy,
      Now that my blog is getting lots of hits, the spammers have taken over. I guess I should enable comment moderation, but I enjoy comments so much that I don't want to restrict them in any way.

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