You are absolutely right..it is not an ideal world. One time recently we were desperate for a line..so I assessed both arms with the US for a good vein...nothing there..elderly very dry lady....so I thought I might try something......I found a very small vein in her lower FA....... only suitable for a 24 gauge..accessed that vein.......she had a bolus ordered so I ran that open for a bit..then checked near the ACF again..and there was my target.......a full vein and I nabbed it with a 20 1-3/ 4 inch introcan.
Yes.... I did not mean to confuse you about the infiltration/extravasation issue. I believe you were indeed in an artery with some fairly classic symptoms. It was in a short time and since arteries are much thicker (as you know) I do not think based upon what you said your medication was administered into the tissue. The problem you need to be aware of is potential damage or sclerosis to the artery. and h spasming .which could impair blood supply to the tissue which it supplies blood to. Some medications when inadvertently administered into an artery can be so damaging that this can happen. A case in point was a lawsuit several years ago in which a radial artery was accessed and then Phenergan was administered . The blood supply to the patients arm was so impaired the patient actually lost half of their arm due to the gangrene. This was one of the cases that brought to the forefront just how damaging Phenergan is to the vessels. There were many many Phenergan lawsuits.
So its the damage to the vessel..that can lead to tissue damage or necrosis. Damaged vessels try to repair themselves and this can lead to emboli which further can impair circulation. So your assessment will include monitoring of the tissue distal to where the artery was inadvertently accessed and used. This can happen in a patient's arm because there is jut one main artery supplying blood to the arm in most patients. Anesthesia once told me they are trained to be careful not to access an artery in this area because of this.
The good news is ..the PIV was not in place too long and was no exposed to medication terribly long. I believe you said you did give some hypertonic dextrose though,that is not the greatest. But stay calm..unfortunately I have seen arterial lines..thought to be venous used for several days and the patient did just fine after I removed them.
If this was ever to happen again the nurse needs to teach the patient what to immediately report to the RN and doctor so action can be taken right away and document it carefully. This is critical should the patient be discharged. In recent contrast extravasation lawsuits several outpatients successfully won their cases because they were never instructed on what they should do if they noticed tissue blanching.had increased pain..etc at the extravasation site.
Last edit by iluvivt on Jul 4, '12
Jul 4, '12 by brainkandy87Quote from iluvivtI agree fully. I love having US to gain access, but they are definitely a short term solution. Ideally, you start an 18g in the basilic and then, if a PICC will be necessary, the guidewire can simply be inserted through the 18g and the Seldinger technique accomplished with an already existing line.Agree ,it's not uncommon to see the artery on top of the vein or to see an extra artery with US. Yes... you can use bedside US as one way to check your placement but you did a good assessment and had all the clues you needed to make the best decision and pull the line. I am not a great fan of US assisted PIVs though I do perform the procedure when needed. In a recent studies they have been found to have a high failure rate when compared to PIVs started in a traditional manner,with failure rates as high as 50% in 24 hrs. I have found this to be true. I have also found that the nurses have a much more difficult time assessing the sites and the infiltrations I see are much larger and caught later in the process of infiltrating. They do have a place in certain circumstances when specific and prudent guidelines are followed especially as a bridge line until a more suitable VAD can be placed if venous access still needed.
Jul 4, '12 by iluvivtYou are absolutely right..it is not an ideal world. One time recently we were desperate for a line..so I assessed both arms with the US for a good vein...nothing there..elderly very dry lady....so I thought I might try something......I found a very small vein in her lower FA....... only suitable for a 24 gauge..accessed that vein.......she had a bolus ordered so I ran that open for a bit..then checked near the ACF again..and there was my target.......a full vein and I nabbed it with a 20 1-3/ 4 inch introcan.