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The Journal of Emergency Medicine, Vol. 27, No. 1, pp. 69–73, 2004Copyright © 2004 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/04 $–see front matter

doi:10.1016/j.jemermed.2004.02.011

Technical Tips

VENODILATATION TECHNIQUES TO ENHANCE VENEPUNCTURE ANDINTRAVENOUS CANNULATION

Raymond J. Roberge, MD, MPH, FAAEM, FACMT

Emergency Department, Magee Women’s Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PennsylvaniaReprint Address: Raymond Roberge, MD, 5909 Hampton Street, Pittsburgh, PA 15206

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Abstract—Venepuncture and venous cannulation arehe most commonly performed invasive medical proceduresn hospitalized patients. Venodilatation can facilitate theserocedures and mimimize discomfort for patient and prac-itioner alike. This article describes useful venodilatationechniques that can be employed by medicalersonnel. © 2004 Elsevier Inc.

Keywords—venodilatation; techniques; venepuncture;annulation; intravenous

INTRODUCTION

enepuncture (VP) and venous cannulation (VC) are theost commonly performed invasive medical procedures

n hospitalized patients and are oftentimes lifesaving (1).hus, these are requisite skills for all medical practitio-ers. Most commonly, the superficial veins of the upperxtremities are utilized for these procedures due to theirasy visualization, accessibility, and the higher incidencef thrombophlebitis and thrombosis associated with theower extremities (2). Each failed attempt at VP or VCan increase patient discomfort, delay necessary thera-eutics or testing, create hostility between the patient andtaff, or result in stress to staff members performing therocedure. In addition, additional attempts at invasiverocedures expose the staff to increased needlestick ex-osure with subsequent risks (e.g., hepatitis, human im-

Technical Tips is coordinated by Gary M. Vilke, M

and Richard A. Harrigan, MD, and Jacob W. Ufber

ECEIVED: 16 April 2003; FINAL SUBMISSION RECEIVED: 19

CCEPTED: 3 February 2004

69

unodeficiency virus, etc.). Therefore, techniques aimedt enhancing success when performing VP or VC are ofome importance. Procedural success correlates withuch features as technical skill, experience and size ofeins. Factors such as obesity, dark skin, intravenousrug abuse, prior chemotherapy, and the extremes of agean increase the difficulty associated with VP or VC1,2). The sympathetic nervous system is the most im-ortant vasopressor system in the control of venous ca-acitance (3). Venoconstriction can be caused by numer-us factors such as hypothermia, hypotension, caffeiner nicotine use, medications (e.g., noradrenaline, 5-hy-roxytryptamine, ergot derivatives), pain from repeatedttempts at VP or VC, or fear of the procedure, and canake venous access more difficult (1,4). Logically,

arger diameter veins may be easier to identify and enter,nd this article describes a number of simple venodila-ory techniques that have been reported to assist in theuccessful venepuncture or cannulation of veins in adultsnd children.

VENODILATORY TECHNIQUES

ll of the described techniques utilizing the upper ex-remities assume that a tourniquet has been applied prox-mal to the puncture site beforehand, at a pressure that isreater than venous pressure but less than arterial pres-ure (5).

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se of Gravity

arked shifts of regional extra-thoracic vein blood vol-me can occur with positional changes (4). For example,–15° of arm elevation can empty the dorsal veins of theand, and 5 s of elevation can reduce upper limb bloodolumes by 44% (6,7). If veins are not readily apparentr appear small in caliber, the first venodilatation ma-euver should be limb dependency (i.e., placing the limbelow the level of the heart) (2). Gravitational forcesxerted in this manner serve to slow venous return,eading to increased venous volume and subsequent dis-ention of veins of the upper extremity (8).

ist Clenching

pening and closing of the fist augments venous returny virtue of muscular compressive forces exerted onessels to enhance arterial blood flow (5). This aug-ented blood flow subsequently results in local venous

istention (2). Increased blood velocity from fist clench-ng also increases venous flow to the basilic and cephaliceins (10). Research has shown that this form of isomet-ic activity also results in vasodilatation that is mediatedy muscarinic receptors in the human skin (9).

ein “Tap” and “Milking”

apping a superficial vein once or twice augments veinistention (8). The mechanism by which this occurs isnclear (2). Given the rapidity of venodilatation after thistimulus, venodilatation theoretically may be related tontidromic effects of nociceptive C-fibers or release ofhemical mediators such as nitrous oxide found in theenous endothelium (11,12). Applying a mild, slidingressure (“milking”) along a short length of vein, fromroximal to distal, displaces blood distally resulting inein distention (2). Care must be taken not to applyverly vigorous stimuli, especially to those with fragileuperficial veins (e.g., elderly, those chronically on ste-oids) so as not to injure the veins or to result in pain-elated reflex vasoconstriction (2).

pplication of Local Warmth

lood flow in human skin increases greatly in responseo direct heating (13). Cutaneous blood flow, normally% to 10% of cardiac output, can increase to 50% to 70%uring periods of heat stress. This increase in cutaneouslood flow is attributed initially to withdrawal of sym-

athetic vasoconstrictor activity and an increase in sym- n

athetic vasodilator activity (14). Reported methods tonduce local venous thermo-dilatation include immersinghe upper extremity in warm water for a few minutes,pplication of a warm, moist compress or chemical warmack, placement of the hand in a carbon fiber mittenpreviously warmed to 52°C), or use of a small, wheat-lled, bag microwaved on “high” for 2 min before ap-lication (1,2,5,8,15,16). Skin temperatures of 39°C–2°C induce optimal vasodilatation (13,17). Care muste taken to avoid excessive temperatures that can inflicthermal damage to the extremity.

smarch Bandage

he Esmarch Bandage (EB) is a flat, rubber tourniquetvailable in various widths (e.g., 3-inch, 4-inch, 10-inch)hat has been used for many years by surgeons forurposes of limb exsanguination (upper or lower limbs)reparatory to surgery (see http://www.spectrapor.comor EB viewing). The Esmarch bandage is initially com-letely stretched and wrapped in layers from distal toroximal limb. Alternatively, the EB may be stretchedfter each individual wrap, but pressures generated arehree-to-four times greater (18). Median pressures with-inch and 3-inch EBs have been reported to be approx-mately 200–300 mm Hg, respectively (19). Animal ex-eriments have demonstrated EB-generated pressures inxcess of 1000 mm Hg (20). Reversal of the normalistal-to-proximal pattern of EB application (i.e., begin-ing at the upper arm and continuing caudally to theesired limb level) results in the shunting of blood fromhe upper part of the extremity to the distal, with subse-uent significant distention of veins, thereby facilitatingenous access (21,22). A patient in shock from a stabound of the heart, whose veins were not of appreciable

ize, had two 14-gauge angiocatheters placed in his handfter application of a reverse EB (22). The EB also haseen very useful in identifying superficial veins on pa-ients with edema of the upper extremities. Applying theB in a distal to proximal fashion allows shunting ofome edema proximally, thus exposing previouslyasked veins. The EB should not be employed if limb

rauma is evident and, as is true for all tourniquets,hould not be left in place for more than 5 min as this canead to venous tortuosity and fragility (2,23)

hys-Davies Exsanguinator

he Rhys-Davies Exsanguinator (RDE) was developedwo decades ago and is considered comparable to thesmarch Bandage (EB). The RDE consists of a perma-

ently inflated, double-walled rubber sleeve shaped like

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Venodilatation Techniques 71

sausage roll that is rolled up the limb and held untilsphygmomanometer cuff is inflated, at which time

he RDE is removed (see http://www.schuco.co.uk/ndex2.asp for RDE viewing). As with the EB, applica-ion of the RDE in a proximal-to-distal fashion displaceslood distally, resulting in venodilatation (24). A volun-eer study in normotensive, healthy adults found compa-ably significant filling of antecubital fossa veins for bothhe RDE (with venous tourniquet) and EB (with venousourniquet) in excess of that attributable to a venousourniquet alone. The RDE was deemed easier to applyhan the EB (25).

enous Distention Device

vacuum device applied to the upper extremity waseveloped for potential use in intravenous cannulation.he original design incorporates a cardboard mailing

ube 41⁄2 inches in diameter by 23 inches in length withrubber sleeve on one end. The closed distal portion hassmall aperture and a one-way valve attached to a

queeze bulb used to aspirate air from the device, thusreating negative pressure leading to venous distention.he vacuum device is applied for 30–60 s to100 mm Hgnd a proximal blood pressure cuff is inflated to 100 mmg above systolic blood pressure over the device sleeve

nd upper arm. After venous distention, the device isemoved and intravenous cannulation undertaken. Ve-ous engorgement, measured by volume displacement,as noted to be significantly greater for the vacuumevice with tourniquet than for standard tourniquet user blood pressure cuff tourniquet application. Use of theacuum device for 30 s resulted in significant increase inenous turgor, but at 60 s use, mild to moderate discom-ort and petechiae formation were noted (26). Anothertudy of this vacuum device, in patients who either hado prominent veins or were obese, demonstrated statis-ically significant success at intravenous cannulation27). The vacuum device is of simple design and hashown promise in clinical trials, but does not seem toave gained widespread acceptance (2).

ocal Application of Nitroglycerin Ointment

wo decades ago, the use of topical nitroglycerin (NTG)s an aid to venepuncture and venous cannulation wasescribed in randomized studies and anecdotal experi-nces (28–30). A blinded, randomized study in adultmergency Department patients demonstrated statisti-ally significantly fewer attempts at intravenous cannu-ation of dorsal hand veins required in patients receiving

TG ointment locally (31). Other studies have demon- c

trated the efficacy and safety of this technique in chil-ren, infants and neonates, as well (32–35). NTG rubbednto the skin of the dorsum of the hand, left for 2 min andhen completely wiped off, results in rapid distention ofhe superficial veins of the dorsum of the hand, evenhen veins are not initially observed (31). The person

pplying the NTG should wear gloves so as not to sufferny of the potential side effects of the drug (headache,ypotension). The NTG ointment should be completelyemoved and the skin cleansed thoroughly with an alco-ol preparation pad or the adhesive required for anchor-ng the intravenous cannula will not adhere to the skin.TG ointment has been used successfully on the dorsumf the hand to obtain intravenous access in hypotensiveatients without worsening their hypotension (31). Thiss probably related to the fact that absorption from theorsum of the hand is poor compared to other areas of theody (i.e., chest, abdomen), so that only local effects areoted with short-term applications (36). The maximumransdermal flux of NTG for a 1-inch application to theorsum of the hand for 2 min is approximately 25 �gequivalent to 1.5% of a standard 1-inch application ofTG to the chest wall for several hours) (37,38). In the

uthor’s experience, local NTG has also been very suc-essful in obtaining intravenous access in patients whore intravenous drug users. NTG ointment can be usedoncomitantly with local anesthetic ointments to provideoncomitant venodilatation and anesthesia (39,40).ransdermal isosorbide dinitrite ointment has also beenhown to dilate veins on the hand, but takes significantlyonger (on average, 39 min) to achieve significant veno-ilatation comparable to NTG (41). The concomitant usef nitrates with sildenafil (Viagra), a drug used in theherapy of penile erectile dysfunction, is generally con-raindicated due to the potential for enhanced vasodila-ion leading to hypotension. Caution is therefore advisedn using NTG ointment for peripheral venodilatation inatients taking sildenafil, though it is unlikely that thextremely small dose of NTG absorbed after 2 min onhe skin would have any significant interaction or addi-ive effect.

ollateral Vein Infusion

hen larger veins are not readily observed, smallerollateral veins may be visualized. These diminutiveeins can be entered with smaller intravenous catheterse.g., 22 gauge) and intravenous fluids infused while aroximal tourniquet is maintained in the upper part of thextremity. This results in distention and subsequent vi-ualization of larger veins sharing the territorial distribu-ion of the smaller veins (42). Infusion of 300 cc of

rystalloid solution in this manner results in the appear-

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nce of larger veins (43). Additionally, warming theolution before infusion may improve results, ostensiblyy inducing warmth-related venodilatation (2,44).

ini-flush Method

ccasionally, upon entering a vein and noting a flash oflood, the intravenous angiocatheter cannot be advancedue to small vessel diameter, vasospasm, vessel angula-ion, or the presence of a venous valve. At this point, ifartial cannulation is ensured, the catheter needle isemoved and slow administration of a small amount ofntravenous fluid through the partially placed catheter isndertaken. This maneuver may augment venous caliber,llowing the angiocatheter to be slowly floated into theein (45).

xternal Jugular Vein Dilatation

f venous access is not possible in the extremities, thexternal jugular vein (EJV) offers an alternative site foreripheral access. The EJV is superficial, affords easyccess, and terminates at the subclavian vein so that itommunicates with the central venous circulation andan, if needed, serve as central venous access (46,47). Aumber of techniques have been described that enhancehe distention and prominence of the EJV in normovol-mic patients, thereby improving the potential for suc-ess of venepuncture or venous cannulation. The Val-alva maneuver (forced expiration through a closedlottis) for 30 s (at a pressure of 40 mm Hg) has beenhown to result in an 86% increase in the area and 41%ncrease in the circumference of the right EJV (48).imilarly, use of the Trendelenburg position or hepaticompression augments venous return towards the righttrium and can result in EJV distention (49,50).

CONCLUSION

ttempts at venepuncture and venous cannulation can benhanced by augmentation of the venous caliber. A num-er of relatively simple methods are available to induceocal, peripheral venodilatation that may increase theuccess rate of these invasive procedures. These tech-iques can be especially valuable in situations whereenous access may be lifesaving, as well as in limitingatient discomfort associated with the trauma of repeatenepunctures. Enhanced peripheral venous access alsobviates the requirement for more invasive proceduresuch as venous cutdowns, central venous lines, and in-

raosseous access, and their associated complications.

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