[Seemoni]

Wow, I wouldn't say that attempting an 18g is a waste of time at all. I have been in the ER for almost 6 months now and 18's are my mainstay. They're pretty much all I start. I feel a bit defeated if all I can get is a 20g. I know that for most part a 20g is perfectly fine for things short of fluid resuscitation. However, being able to stick an 18g in just about anyone is really helpful, cause usually when you actually need one the pressure is on and it becomes that much more difficult. If it's a habit, there's no big deal about it. Just keep practicing with it and use the larger one if you can. After a few weeks of 18's only you'll have no problem at all, then try 16's when you can because those actually do feel pretty different, you have to get a certain "popping" sensation with them and advance with the needle a lot further cause the bevel is so large you can start advancing into the vein wall if you're not careful. Actually make sure you're doing that with your 18s. After you get a flash, don't thread immediately. Your bevel tip may be beneath the vessel wall but the entire needle may not have gone into it and you don't want to advance without being all the way in or you're just tearing/blowing the vein then. Get the flash, slowly advance a bit more, than thread. Voila.

[ozinurse]

I would imagine the use of 18g cannula on everyone is a generalisation.

I think the size of the cannula inserted needs some discression. It is not necessary to insert large bore cannulas in stable patients only requiring maintence fluids or intermittent antibiotics.

However, I am in agreement that caution should be made, and insertion of a larger cannula when the patient is or potentially unstable, and/or requiring fast fluids or blood administration. The nature of emergency department, is that patient diagnosis is often unclear and an 18g cannula in these patients is appropriate.

It is admittedly a lot more annoying to see inappropriately small cannulas insert into sick people. I have heard the excuse, that it is all they could get in. Maybe they should have gotten someone who was capable of stick the correct size in to do the job.

[ZippyGBR]

Originally Posted by ozinurse

I would imagine the use of 18g cannula on everyone is a generalisation.

I think the size of the cannula inserted needs some discression. It is not necessary to insert large bore cannulas in stable patients only requiring maintence fluids or intermittent antibiotics.

However, I am in agreement that caution should be made, and insertion of a larger cannula when the patient is or potentially unstable, and/or requiring fast fluids or blood administration. The nature of emergency department, is that patient diagnosis is often unclear and an 18g cannula in these patients is appropriate.

It is admittedly a lot more annoying to see inappropriately small cannulas insert into sick people. I have heard the excuse, that it is all they could get in. Maybe they should have gotten someone who was capable of stick the correct size in to do the job.

if you are going in an ACF because you can't get a hand or forearm vein then bigger is better if this might end up being the 'lifeline'

too many people won't use forearm veins - these are often the best option unless the patient has 'big' hands -as a cannula i nthe dorsum of the patient's hand will irritate and run the risk of getting knocked out a lot easier

[LilgirlRN]

When I worked nights I would get called allover the hospital to gain IV access for a patient. To me, 18's aren't always the answer, put in what you can get in until you pump them up with some fluids. I've put 18's in thumbs, in shoulders, AC's but when putting in something that big I numb the patient first. Some people say that the bleb from the lidocaine obstructs their view of the vein, to me it's psychological. If I know I'm not hurting the patient I feel better about wiggling the needle around.

[ozinurse]

I am a huge fan of local anaesthetic.

There are several articles that suggest the use of lignocaine decreases the pain of cannulation (and abg's (Lightowler and Elliot (1997 and Giner et al 1996)) by half. (Robinson et al 2007, Murphy and Carley 2000 and Harris 2001) and also if used correctly, that it doesn't effect the success rate (Murphy and Carley 2000).

I use it when inserting 20-16g cannula, and have had an excellent patient response. Despite working in a 'best practice' driven environment it is still difficult to get people to use local. The (false) perception that it makes it more difficult is one of the reasons it isn't taken on.

As an advocate for the patients well being, simple measures to ensure that the patients hospital managament is as un-unpleasant as possibleis (I believe) it is important. Just because they have come to the emergency department, doesn't mean that we have a right to inflict unnecassary pain on them. We often think that they should just grit there teeth, or show some gumption, but from my experience, cannulas hurt.

The same principles would also pertain to other pain inducing procedures, such as NG insertion. Female catheterisation (Chung et al 2007). If your department doesn't already have analgesia incorporated into these procedures, it is worthwhile at least having standing orders so that you have the option.

Chung C, Chu M, Paoloni R, O'Brien M and Demel T 2007, Comparison of lignocaine and water-based lubricating gells for female urethral catheterisation: a randomised controlled trial, Emergency Management Australasia, 19, pp. 315-319.

Giner J, Casan P, Belda J, Gonzales M, Miralda R and Sanchis J 1996, Pain during arterial puncture, The American College of Chest Physicians, vol. 110, no. 6.

Harris T, Cameron P and Ugoni A 2001, The use of pre-cannulation local anaesthetic and factors effecting pain perception in the emergency department setting, Emergency Medicine Journal, 18, pp. 175-177.

Murphy R and Carley M 2000, Prior injection with local anaesthetic and the pain and success of intravenous cannulation, Emergency Medicine Journal, 17, pp. 406-408.

Lightowler, J and Elliot, M 1997, Local anaesthetic infiltration prior to arterial puncture for blood gas analysis: a survey of current practice and a randomised double blind placebo controlled trial, Journal of the Royal College of Physicians of London, vol. 31, no. 6, pp. 645-646

Robinson P, Carr S, Pearson S and Frampton C 2007, Lignocaine is a better analgesic than either ethyl chloride or nitrouse oxide for peripheral intravenous cannulation, Emergency Management Australasia, 19, pp. 427-432.

[iluvivt]

since you are able to get a 20 gauge in you should be able to get an 18 gauge with some minor changes in your practice. First the 18 gauge catheter over needle device should be considered. When you look at the device you will notice the needle and bevel are usually a bit longer and once you hit the vein you must thread it a bit further than say a 22 or 20 gauge......and yes even 1/8 inch or so can make a difference. The next thing is to select a vein that will accommodate an 18 gauge...you can also apply a warm pack for a few minutes (if pt condition can tolerate the wait). another trick is just place what you can get and start the IV fluids and in a few hours the veins will look much better. Other tricks ..use two tourniquets.....bp cuff pumped to slightly below pts diastolic ...also remember the flow rate difference between a 20 gauge and an 18 gauge is not that significant also try the deeper veins that you can feel. remember that if you can not see it or feel it do not go for it