Abdominal IV

[dmurph615]

Recently in our Emergency Department we had a patient going to the ICU who is a frequent flyer, substance abuser, with very difficult veins. Multiple attempts at a peripheral IV were attempted in the hands, forearms, antecubitals, feet, and legs, until we came across a very straight, juicy, superficial vein in the abdomen. The catheter was placed just like in any other site, blood return, easy flush, etc. A supervisor walked by and saw this and now I am getting detailed from my department because she says this is an "inappropriate site" for an IV. When I asked "Why?" She stated because she's never seen one there before. Now my colleagues say they have seen this before, and the ED Physician backed me as well, but I was wondering if anybody else has done this or seen it done? And if there is any literature supporting or opposing this as an appropriate IV site. Any information would be greatly appreciated.

And FYI, the site held up through 2L of Normal Saline and some much needed meds until the patient pulled it out.

[IVRUS, BSN, RN]

True nrsang97... Just because one hasn't seen it before, doesn't mean that it can't be done, as we ALL are in a perpetual learning state, however, I said, this nurse's hesitency has merit and wasn't silly. There is a difference.

I know that placement of a peripheral IV catheter with U.S. is not always available, but in an emergency, like this, a MD placed Central line would have been best.

[nrsang97, BSN, RN]

I think the general concesus is that a central line or IO would be best, but the ER didn't place one.

[PMFB-RN, RN]

There is a reason why this is not done.... Your supervisor's hesitency is NOT SILLY, but actually has merit.

*** In this case the supervisors stated reasons were that she hadn't seen it before. Hardly a valid argument.

As a clinician, one must take into account the possibility of what an infiltrate, or in the case that you're administering a vesicant, an exravasation can do to this area. Many nurses have seen the awful outcomes which occur when a nasty drug has caused the tissues surrounding the vein to necrose and die. What will this do to the Abd? Or, will your patient need a Mastectomy when it's given in the vein that's arising out of the breast tissue.

How are you going to defend your stance in a court of law?

*** Oh this is easy. Of course we must take the possibility of infiltrating a vesicant. I assumes that was so basic and obvious and to not need mentioning. The answer is very simple, don't administer vesicants through such IVs. Most patients who need an IV don't need vesicants. An IO may not be justified from drawing lands and administering some IV meds and fluids, but certainly would for pressors or other vesicants. Seems silly to me to place an IO for fluids and IVP meds.

Do you not have a nurse trained in Ultrasound in your facility? They can locate a vein to use, in most cases.

*** In my hospital the RTT RNs have an ultrasound for finding veins.

[IVRUS, BSN, RN]

PMFB-RN,

"Most people who need IV therapy don't need vesicants"... Really? So your patient who needs a K-ridder, or Vancomycin, or IV Phenegran - which are all common IV meds.. Don't have to worry, cuz' they aren't frequently given?

I disagree. But then, we can agree to disagree.

There is a REASON why the supervisor may not have seen an IV catheter put in the breast or the Abd and it probably has to do with the fact that in MOST cases, those vessels aren't visable to begin with, much less palpable. So, that brings me back to my point... Why do they have this Aberrant vessel? And should it be cannulated?

Utilizing my expertise, I say NO.

And one can never ASSUME that something goes without saying. because when you do, someone does it! Making the admonition important.

[martymoose, BSN, RN]

what about anesthesiologists? ours seem to get them in when we cant( in an emergency/urgency , of course...) Granted, that will be one expensive access.

the pt didnt have like EJ access?

[twinkletoes53]

I worked in an NICU for 30 years, and I know that if we could not get an IV in a baby that needed one, we would stick an abdominal vein. This was not a routine occurrence; rather a decision that was made, usually by an experienced NICU nurse, when it was the middle of the night, and the infant desperately needed the IV for fluids and antibiotics. Surprisingly, these IVs would last. No need for an armboard; and we carefully monitored and taped the site. We did have PICC lines placed in the infant as soon as possible, but sometimes an abdominal vein was the best vein we could see.

Another unusual place that I've had to place an IV was in an infant's axilla. If the baby was small enough, the veins were easy to locate. And I've had an axillary IV last for as long as 3-4 days in a baby.

[canoehead, BSN, RN]

I with the "if they need it then you get it wherever you can" crowd. BUT I would notify the MD afterwards and get their blessing to use the site in writing. If you're lucky the patient will grow better veins after a couple litres of fluid. I would be cautious about defending myself to the nursing supervisor without an order. Hospital policies can be very specific about where we can place IV's, and some management types are very literal and unimaginative once they spot something they disapprove of.

Anytime you do something that is not commonly done you are putting yourself at risk, even if you're right. So when you place that IV watch it like a hawk, and continue to document the lack of alternative access, and that you notified everyone that is writing IV orders where the site is located. If you gotta give a vesicant, document the blood flow, and easy flushing, and that the pt is (hopefully) aware enough to notify you if it starts to hurt. And document the people you called to get better access, like anesthesia, ICU, and what happened.

[CaitlynRNBSN]

a vein is a vein is a vein. Maybe not IDEAL spot for an IV, but it's a spot..and its a vein, and you got medications in it you needed. You were doing the best you could given the situation. It's better than the patient NOT getting his IV. What if this patient needed Narcan and you had that beautiful juicy vein and never put it in because "its never been done before." Well...it's a vein. Stick it in, give the medications you need. Maybe think about MML or PICC line later down the road but in an emergency you do what you can.

[KatieMI, BSN, MSN, RN]

I do not think that an abdominal IV would be inappropriate for drawing blood. But infusion there can be a different story. Anterior abdominal wall veins belong to cava inferior and hepatic portal outflow system (that's why they become widened and make "caput medusae" around the umbilicus in case of portal hypertension). It is impossible to figure out clinically, without contrast Xray or something like that, where the particular vein drains, and if it goes into portal system, then everything that is infusing in there goes straight into the liver. Effects of even D5NS or LR will become unpredictable then, because of liver's biochemical activities.

Years ago ( in another country) we were taught about shooting drugs in the thickness of the tongue muscle (an inch from the tip of the chin, at midline and straight up 1 - 1.5 inch) if nothing else was available. The rationale was that the place has a mass of small veins and so absorbing will be quick. I did it several times, in emergencies, and the action of the drugs was often unpredictable, with tendency to be much weaker than expected. Later on, I found out that the veins supplying tongue base mostly bypass systemic circulation and blood from them joins the esophageal plexus and then goes into portal vein and into liver. This was probably the reason why the meds didn't work, and I'm afraid that using abdominal wall veins for infusion may cause the same problem.

[dmurph615]

Keep in mind, at my facility IOs are not permitted (I know, ridiculous), and EJs can only be performed by Physicians (which this patient didn't have very good EJs), so the Physician was okay with this location. But the Nursing Supervisor decided to take matters into her own hands. There is no policy against it in my facility, and the entire team of ER Physicians feel as though it was appropriate. I've always been taught a peripheral IV is much more desirable than a central line...

[dmurph615]

I agree, our facility does not permit IOs (ridiculous I know) and EJs can only be placed by a Physician. This Physician looked at the EJs but the patient was moving his neck back and forth so much it wouldn't have lasted a minute. The abdominal IV worked great...

[dmurph615]

I think the general concesus is that a central line or IO would be best, but the ER didn't place one.

Correct, except IOs are not permitted, and I can't start a central line, so I did what needed to be done to get fluids and meds in, then let the ICU figure it out from there.