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| No. 20 | 
Jul 05, 2004, 02:10 AM
When I used to be a preceptor for Paramedic students, I always taught them that a successful stick is most often the result of picking the right vein. Veins that you can see pretty well are usually thin and superficial. It's the veins that you can't see that usually provide the best sites. I am personally a big fan of the posterior aspect of the forearm. You usually cannot see those, but they are well-anchored.
My preferred back-up site for fluid resuscitation is the saphenous vein. Certainly not practical for long-term use but they will usually hold a 14 guage catheter.
As for catheter size, I always use an 18 or larger unless one cannot be successfully placed. Anything smaller is simply worthless in a patient who might need fluid replacement or blood products. Giving blood through a 22 guage catheter is one of the most assinine things I have ever heard. If they are losing blood, they could very well be losing it just as fast as you are giving it. And if you want to be stuck doing vitals every fifteen minutes for several hours, you can have it.
A 22 guage might be fine for a drip on the floor or in ICU. However, from the standpoint of emergent care, it is very appropriate to try at least an 18.
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Jul 05, 2004, 02:48 AM
agree w/ above poster about the size of the catheter. I almost always use an 18g on adults, sometimes 20g. I'll go w/ a 22g only if I have no other choice. the one time you start a small IV on pt because you're trying to be nice, is the pt that crashes on you or goes to surgery and needs blood. I'll use a 16g or 14g w/ bad GI bleeds and traumas. If you're concerned about the increased discomfort of the larger bore IVs (and you have time), first infiltrate bicarbonated lidocaine into the site.
| | No. 22 |
Jul 05, 2004, 02:52 AM
I was taught upon my arrival to our SICU, that we do not put in anything smaller than an 18, there is nothing smaller even stocked routinely. i cant see any reason to even try to get by with some measly 22. if the pt only can support a little 22, then the pt may need a CL, at least in the ICU. Why waste 4 hrs to infuse 1L fluid bolus when the pt needs that liter in 10-15 min. 22's are for premies
| | No. 23 |
Jul 05, 2004, 03:02 AM
thanks a lot for sharing that technique. i'm learning a lot and i'm enjoying...  | | No. 24 |
Jul 05, 2004, 08:37 AM
Originally Posted by TraumaInTheSlot what if your patient drops their pressure? can u fluid resuscitate through a 22g? itll take at least an hour or two to get the liter of ns in.
if you draw blood through a 22g, it will hemolyze frequently.
i know, id rather have the large bore in me, until they had a diagnosis on whats wrong with me. always prepare for the worse when there is a vague complaint like cp or abd pain that can be one of a million things.
blood through a 22g? are you kidding? ive seen it done, but always after lying that the transfusion takes 4 hours when it actually took 5.
i respectfully disagree. ivs get phlebitic because they are in bad spots and the catheter moves in and out. id rather have a phlebitic patient than a dead one. 18g is not that big
I guess its all in the technique. I draw blood through 22's numerous times in one day and I have not had a hemolized specimen in over a year. If the patient is in danger of bleeding out, then we use larger bore (18's at the largest), and usually 2 of them.
I can give blood through a 22 in about 3 hours. I can also give D50 through one, without problems. IMHO if anyone puts a #18 or larger IV in me because I came in with abdominal pain, I would throw a fit!!!
All I am saying is, the trend (at least in our area) is away from the huge IV cannulas. Its worth checking out. Our hospital spent a lot of money on the study.
IBigger is not always better.
| | No. 25 |
Jul 05, 2004, 08:48 AM
Originally Posted by PA-C in Texas
As for catheter size, I always use an 18 or larger unless one cannot be successfully placed. Anything smaller is simply worthless in a patient who might need fluid replacement or blood products. Giving blood through a 22 guage catheter is one of the most assinine things I have ever heard. If they are losing blood, they could very well be losing it just as fast as you are giving it. And if you want to be stuck doing vitals every fifteen minutes for several hours, you can have it.
A 22 guage might be fine for a drip on the floor or in ICU. However, from the standpoint of emergent care, it is very appropriate to try at least an 18.
Please dont generalize. "Giving blood through a 22 guage catheter is one of the most assinine things I have ever heard." How often do your paramedic students hang blood in the field? If you are going to hang blood to run over a period of less than 4 hours, you can do it through a 22. If you are going to pressure a bag in, obviously you would need a bigger catheter.
I think the lesson here is to determine the need. Not everyone needs a huge IV.
| | No. 26 |
Jul 06, 2004, 03:41 AM
[quote=nursbee04]A friend in nsg school had trouble remembering where her veins were once she had rubbed the site down with the alc pad, so our clinical instructor taught her to pick her vein, pick out where she is going to insert the IV and take the end of a skinny ball point pen (not the marking end) and make an indentation at the site (not enough to hurt the pt...), then clean. The indentation will stay long enough for you to stick. Good trick for beginners.
I clean the site with the alcohol pad then leave it on the site. Once you're ready to stick it remove the pad, let dry for a few secs and go. | | No. 27 |
Jul 06, 2004, 08:14 PM
Originally Posted by TraumaInTheSlot oh, and if a heroin addict says "thats not a good vein" , they are right.
i agree... even with some patients like the sicklers, you should believe them when they say "that's not a good vein, try this one.."
| | No. 28 |
Jul 06, 2004, 08:54 PM
ALWAYS listen to postitve advice like, "They usually have good luck with the one in my left hand." Take advise like, "They always have to call anesthesia to start me," with a grain of salt. I've been successful with a lot of "anesthesia starts."
I like to stick just above a bifurcation (sp?) because it provides a bit of an anatomical anchor.
Look and FEEL...don't just look...it's amazing what you can feel, but not see.
Don't tie your tourniquet too tight on patients with big ropes...you'll risk blowing the vein.
When you don't succeed the first time, try sometime different the second time...change arms, try a smaller cath, move the tourniquet higher or lower...
BTW...I learned on 18s and 16s...can't imagine using anything smaller for a patient who needs blood or a bolus or D50...
| | No. 29 |
Jul 09, 2004, 08:59 AM
I think the lesson here is that you need to guard against what you don't know. When someone walks into the ED, you don't know what is going on with them until you perform a physical exam and review the appropriate diagnostics. That generalized ABD pain could very well be an atypical presentation of a dissecting aortic aneurysm. Then how are you going to get a large bore cath when they have ruptured and are clamped down so that their antecubital fossa veins have magically disappeared? Are you going to be frantically calling for someone to come start a femoral while the patient crashes through the basement? Taking reasonable steps to prepare for the unexpected is just something that is appropriate when you don't know.
It might be appropriate for smaller guage catheters to be started in non-emergent settings where a patient's condition has been better defined.
Someone mentioned using a bifurcation as a natural anchor. I like to go in right below the bifurction and hit the vein where it splits rather than going on top of the vein. You might have to advance the needle slightly further to get through some valves, but its a pretty sure bet.
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