I have devised an effective technique for placing large-bore intravenous catheters in patients considered to be “hard sticks.” The idea occurred to me after a morning of performing Bier blocks for upper extremity procedures.

After placing a tourniquet on the upper arm, the provider introduces a small-bore (20- to 24-gauge) catheter into the dorsal hand or volar wrist. Without removing the tourniquet, a volume of crystalloid (I have used 60 ml normal saline, but the volume could vary according to the circumstances) is injected via  the catheter. The saline will distend the arm veins to the point where a large-bore catheter can be placed easily.

I recently applied this technique in the case of a patient with a known placenta accreta who was scheduled to undergo cesarean delivery. She seemed to have poor peripheral venous access, so I distended the veins in her right arm by injecting saline via  a 20-gauge catheter in the back of her hand. I had no trouble placing an 18-gauge catheter in her “intern's vein.” I was then able to change the catheter via  Seldinger technique to an 8.5-French Rapid Infusion Catheter (Arrow International, Inc., Reading, PA). The patient was thus spared the risks associated with central venous catheter placement.

York Hospital, York, Pennsylvania. j.i.stein@worldnet.att.net