I had a patient yesterday who was hypoglycemic. Previously, I'd placed her IV in that diagonal vein in the AC that I've used 100x... Or so I thought. She had an episode of hypoglycemia and had to get D25%. I started slow pushing it, but she complained of warmth and feeling flushed, and her arm was looking flushed. I had probably given 2 cc at that point. So I diluted it in 100 cc NS and hung the infusion over 20 min. She had another episode of her distal arm getting flushed and mottled, though it remained warm with sensation, a strong pulse and no edema. I slowed the infusion more, her arm started to go back to normal. The whole time, the line flushed and drew without pain or complications. Later, the oncoming nurse said he thought the line was pulsatile!!! I totally trust him, but I never noticed a pulse, there was no back flow without me pulling back, and the blood I drew was dark red. I even let it free-flow for a second and it didn't spurt. The tech who d/c'd it said it didn't bleed when taken out. Does it sound like it was arterial?! I am so upset to think I might have put DEXTROSE of all things into an arterial line!!! I have called the floor she's admitted to 3times and the nurses say her arm is fine and she's not complaining. Last time I checked on her was 16 hrs after this whole mess. How soon would tissue damage show itself though!? I can't think about anything else until I know she's going to be OK!!!
IVRUS is correct in that tissue damage from a vesicant may not be apparent for several weeks. An extravastion and infiltration are not terms that can be used interchangebly. It does sound like you had an arterial placement based upon your explanation of the tissue flushing and blanching. If you were near the basilic vein it is not that difficult to hit the artery instead . We have a little saying here about PIVs it's "when in doubt take it out" and I would have definately questioned it based upon your excellent observations. You should not base your decision to leave the line in place on the fact that you were able to easily instill and the patient was not having any pain b/c that does not exclude an arterial placement. Many times they do not have pain and may not even pulsate easily. I know of several cases in which an arterial line was inadvertently used as a venous line for several days..and yes the pump continued to pump the IVF. I noticed on the most recent one I happened to catch..just such a case...but I could tell b/c when I checked for a blood return..it was just way too brisk.
There is slight possibility that the patient may have had a small arteriovenous fistula. I remember one time I accessed the accessory cephalic vein on this patient....it was very large,soft,and on the surface..I felt it..it was a vein..but after I accessed it ...it was behaving just like an artery..very strange.....I took it out b/c I suspected and AV fistula...does not happen very often..but I have started thousands upon thousands of IVs.
Contrary to popular belief the ACF veins are not desirable for routine IV therapy for a variety or reasons...inadvertant arterial cannulation,very positional, at an area of flexion,should be preserved as blood drawing veins, IVs should be started optimally from the hand up (preserves available proximal veins for use). I know the ED likes to use them and I deal with it....and they are usually easy to hit,but if the patient beomes an admit....we just have to change them anyway b/c the pump beeping drives the patient crazy. I do use them for power injection if I have to..but then I have them d/ced after that and resite it in a better location.
Last edit by iluvivt on Jul 3, '12
: Reason: spelling