Vent: "I should warn you, I'm a tough stick..."

~Mi Vida Loca~RN, ASN, RN · Nov 4, 2011

Nah I just realize not everything is black and white. Their are always extenuating circumstances or reasons this or that might not work. My first response was to a poster that stated how other units always start them in the AC but in his ED they didn't. I posted in response to that that in my experience it's always been the opposite. My neighbor the guy on the IV team and I were talking about it one time when he had to come redo yet another IV. He also stated that he wished the ED nurses would use other veins first outside of a true emergency where they need quick and easy access. This came from a person I have never seen miss an IV and does thousands of them. He also worked 10 years in the ED. So this was the opinion of someone that did work in the ED.

As far as not knowing before hand what they looked like, well usually we get this thing called report that says why the patient was brought in and what they were given. If they had a bolus and so on. Many many times I had a patient come up buff caped with nothing given. The IV was placed just in case and they had good veins on the arms. I know this because I ended up having the move it from the IV getting compromised from the patient moving to much and bending their arm to much and even had the site tear around it once. My personal opinion is I try not to use that site as a first go. You can use 18 and 20 Gage's usually on other areas of the arm that are easier to maintain if the patient is staying and you can bolus a large amount through these.

I seriously don't understand this mentality that people have when someone else has a difference of opinion. It's like their can only be one right way and everyone must agree. It's absurd. Everyone has their preferences they all have their Pet Peeves.

Music in My Heart · Nov 4, 2011

Exactly!! :) It's amazing how you'll see veins that didn't seem to exist earlier after a patient gets a couple liters ....
For some CT studies, like PE studies, we are required to put something large-ish (preferably 18g) in the AC. It seems like everyone's d-dimer is always elevated, ugh (highly sensitive, non-specific, and highly ANNOYING lab test, LOL). In my current facility, it has to be in the right AC -- that's the radiologist's requirement, and this is the only facility where I've encountered that (right side only). Anyone else have that requirement?

I'd love to see the doc's evidence for that mandate. We do IV contrast CTs all the time and the radiology techs don't have a problem with a 20 low on the forearm, or even - in a pinch - a 22 that's really solid. The idea that it has to be an 18 in the AC seems to be a wive's tale without solid basis in evidence or fact.

As to the topic: I love it when they say what a tough stick they are... I get to puff up and strut a little after I get 'er in without any trouble... or at least give myself an excuse to bust out the vascular ultrasound for practice.

And some folks are just tough, tough sticks (and make me long for an IO drill).

~Mi Vida Loca~RN, ASN, RN · Nov 4, 2011

This is the post I first responded too. Look at that, someone that was or is in the ED that didn't like using AC first. :rolleyes: of course some times you have to. Nothing is ever black or white.

"One the sources of this problem is the fixation many practitioners outside the ED have for starting IVs in the AC. When I did my internship in the ED before I graduated from nursing school, I very quickly learned to look all over the arm for veins - usually, if someone has crappy ACs, they'll have nice hands or forearms. The only time I insist on an AC is if I think the pt will be going for a PE study (or if the doc has added one on and I don't already have that kind of line). The only time outside of a PE study that I insist on 20g or better is for blood administration or high-volume fluid resuscitation. If I had a dollar for each time those two "rules" got me a line on a patient who was supposedly a hard stick, I wouldn't be retired yet - but my student loans would be much smaller :-D."

~Mi Vida Loca~RN, ASN, RN · Nov 4, 2011

I'd love to see the doc's evidence for that mandate. We do IV contrast CTs all the time and the radiology techs don't have a problem with a 20 low on the forearm, or even - in a pinch - a 22 that's really solid. The idea that it has to be an 18 in the AC seems to be a wive's tale without solid basis in evidence or fact.
As to the topic: I love it when they say what a tough stick they are... I get to puff up and strut a little after I get 'er in without any trouble... or at least give myself an excuse to bust out the vascular ultrasound for practice.
And some folks are just tough, tough sticks (and make me long for an IO drill).

We could use the forearm as well and a 20. I sent many people down that way without problem.

In our New Grad IV classes we were told a 22 90% of the time will be just fine as well.

That also said rarely do you truly need an 18 and that in most cases 20's work just fine for large volumes.

Altra, BSN, RN · Nov 4, 2011

Exactly!! :) It's amazing how you'll see veins that didn't seem to exist earlier after a patient gets a couple liters ....
For some CT studies, like PE studies, we are required to put something large-ish (preferably 18g) in the AC. It seems like everyone's d-dimer is always elevated, ugh (highly sensitive, non-specific, and highly ANNOYING lab test, LOL). In my current facility, it has to be in the right AC -- that's the radiologist's requirement, and this is the only facility where I've encountered that (right side only). Anyone else have that requirement?

Fortunately, we're getting away from using the d-dimer, for exactly that reason.

And yes, I've worked in a hospital where radiology had very specific requirements for IV site and guage, for a number of different studies which use contrast.

Altra, BSN, RN · Nov 4, 2011

We could use the forearm as well and a 20. I sent many people down that way without problem.
In our New Grad IV classes we were told a 22 90% of the time will be just fine as well.
That also said rarely do you truly need an 18 and that in most cases 20's work just fine for large volumes.

It will be interesting to see if working in the ED changes your preference for 22#s.

~Mi Vida Loca~RN, ASN, RN · Nov 4, 2011

I never stated I had a preference for 22's. I only stated what we were told the newest evidence based practice has shown. My preference is actually a 20 since we were told that is a safe bet usually for adolescence and up, and on the really little ones I will use a 22 or 24 although I try to avoid a 24 if I can. But sometimes when you have a baby that is all you can use or you are having to use such a small vein, as was the vein on the 2 year olds foot was.

Editorial Team / Moderator · Nov 4, 2011

Can we all agree that patient presentation and needs will drive gauge and site? Pretty please?

TinyRNgrl · Nov 5, 2011

I am with Lunah on this one. :smokin:

Editorial Team / Moderator · Nov 5, 2011

I am with Lunah on this one.

Yay for the shorties! (I assume you're short/tiny/small. LOL)

wooh, BSN, RN · Nov 5, 2011

I have actually never done an IV in an AC. Never attempted there.

I can't get an AC. CANNOT. Something about the angle. Even when I was the go-to person, the one that could get it in the dehydrated COPD little lady's pinky, I wouldn't be able to get an AC on a 20 year old weight lifter.

wooh, BSN, RN · Nov 5, 2011

Can we all agree that patient presentation and needs will drive gauge and site? Pretty please?

CRAZY TALK!!!!!