getting IV access-worried

I have brittle asthma and have had many emergency admissions. I have never had accessible veins at my inner elbow so they always need to put venflons in/take blood from my wrist or hand. Even these veins dont always behave.

My worry is that I have a friend who I met in hospital who also has brittle asthma but is about 8 years older than me. She has just needed to have a portacath fitted to give permanent access as they cannot use any of her veins anymore. I am now thinking that perhaps I should be telling my GP and hospital to use my feet for veins when getting routine blood/theophylline levels so that my hands/wrists can be saved for emergency situations. I am worried that my veins will eventually give up if they are overused as they are alreeady pretty rubbish. Any advice would be welcomed

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Hi Karly,

You're right, it is a worry, and I'm sorry that you're struggling with this so much. It does just add an extra dimension of anxiety to an already anxious time, doesn't it?

I have had brittle asthma for about ten to twelve years now, and am beginning to get to the point where IV access is a real issue - and am currently going down the port/Hickman/fistula line of enquiry to see what the other options are. None of these options are ideal, as I'm sure you know; they all have their down-sides.

The important thing to remember is that this is a very individual thing - whilst I certainly know people who have had this issue arise relatively quickly, I also know people with various forms of chronic lung disease (like CF, for example, where they often have to have IVs for weeks on end) who have been having admissions and cannulations for many years, and whose veins are still going strong. Of course, there are always going to be times when it is hard, especially if you are in for a while or have a lot of admissions in quick succession, and some doctors are going to struggle more than others, but in my professional life I have come across very very few patients who are genuinely nearly impossible to cannulate. So don't assume it will certainly happen to you - it may well not.

In an emergency, if they need to give you drugs they will always get access somehow - whether by a cannula, a central or femoral line, or even by a cut-down (where they make a small nick in the skin, under local anaesthetic, so that they can see the vein and directly cannulate it). Using a portable ultrasound device to find veins, both central and peripheral, can also be helpful. Some of these things might sound drastic, and they are a last resort and wouldn't happen often, but in an absolutely urgent situation, if you were very unwell, they would manage to get access. There are also alternative ways of giving most life-saving drugs in an absolute emergency - such as intramuscularly, subcutaneously, or even down an ET tube if you are intubated.

In terms of routine blood tests for theophylline levels and so on - a routine blood test, if done carefully and with a fairly small needle, should not 'ruin' the vein for subsequent cannulation. You can help to ensure this by asking that they use the smallest needle possible, only attempt to get blood if they are fairly confident of success (to avoid 'digging around' and damaging the vein), by not allowing anyone to have more than a couple of tries before seeking senior help, and by applying plenty of really firm pressure with cotton wool for at least ten minutes after the blood test to avoid swelling and bruising around the vein. These measures should help to avoid damaging the vein too much.

In terms of using feet for both bloods and cannulation - it certainly is possible. I have usually only had my foot veins used for cannulation when I have been sedated or otherwise immobile, as if you are walking, the cannula doesn't tend to last long. Cannulation and bloods in the feet can sometimes be more painful, as there tends to be less soft tissue. Some people feel that cannulas in the feet increase the risk of infection and DVT, which I suppose is possible, although I can't find any direct evidence of this. It is certainly worth making sure that anyone who tries this makes very sure to use a good clean technique (preferably cleaning the skin with swabs soaked in betadine or chlorhexadine rather than those silly useless Sterets), that you take good care of it, and that the staff using the cannula are very careful with it, keep a close eye for problems, use clean technique and bandage it well afterwards.

If you are going to be on IVs for a while, for example if you typically need many days of IV amino to turn things around, or if you need a long course of IV antibiotics, it is worth asking about a long line. This is a large bore line (something between a cannula and a central line, to put it simplistically) which goes into a biggish peripheral vein (usually an antecubital fossa - inside of the elbow - vein) and can remain in there for upto several weeks. It may be that it would be difficult to put one in if your antecubital fossa veins are not easily accessible, but using ultrasound guidance they may be able to cannulate one of these veins that is too deep to feel easily.

So you see, there are plenty of options - I know it is easy to say, but do try not to worry about it too much.

Take care,

Em H

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Thank you so much your such a detailed reply. I am just a little worried as they have such trouble getting lines in at the moment and I am only 30. I will ask GP/cons about using the feet for blood tests as it might give my wrists and hands a rest. It often takes them many attempts to get blood and put venflons into my arms/wrists/hands but they usually find something eventually. I just worry that the day might come where my veins are all completely knackered.

Thanks for the advice