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.

[CP2013]

Boy some of you are really making us infusion specialists cringe! I do understand using what you can get in an emergency situation, but please do bear in mind that in a court of law (defending yourself because you infused D50 into an abdominal vein on an adult and it infiltrated, for example), "That was the only vein I could get" will not stand up as a rationale.[/quote']

My question then becomes in a court of law in the death of a patient, would it be alright to say that "I couldn't find a vein?"

Would that then defer fault to the physician for not placing a central?

In a small community hospital where there is no IO and the ED doc is not willing to place the central, how do you proceed when needing to infuse fluids and antibiotics say for sepsis for example?

I ask because I have watched ED nurses search for 15 minutes for veins in the arm or leg and if they don't find anything, they have to call the PICC team who is on call, wait for them to arrive and begin, and then you have to wait for X-ray to confirm placement and an MD order for why you are using it now instead of waiting 8 hours or one crap policy for the floor.

[Esme12, ASN, BSN, RN]

Sure there are many medications I have given this way especially in homecare. The medication and/or IV fluids still must have that listed as an acceptable route of administration. In addition ,what I see all the time is that as long as the patient has an IV access it is used for anything and everything. This is why I only place midlines in very specific circumstances that I can guarantee that it will only be used for what it has been placed for. So if someone comes along and administers some Calcium Chloride through that and it extravasates that would not be considered hypodermoclysis. Also the IVF were not started out that way so if it did infiltrate or extravasate it would then be considered a complication of IV therapy and not ok well now the patient is receiving hypodermoclysis.

Its a bad idea and if it must be done to save a life......OK I get it.... but as soon as possible change it to a site that meets the patients needs.

right...I agree and no calcium chloride can't and shouldn't be given through a line like this and no it shouldn't be for long term. Yes the MD should drag thir behind in ad get a line. Not all facilities have IV nurses to place a PICC. I can place PICCS and a facility where I moonlighted as a supervisor placed them ONLY in radiology by the radiologist....talk about seeking revenue.

Yes if the IV infiltrates it is a complication of IV therapy and hypodermoslysis is essentially for hydration. ANY IV site out of the "norm" is temporary....there are times hydration will allow other viable site to develop/appear.

I am just saying that in the original post the supervisor said they had never seen IV's in the abdomen. While it isn't the BEST solution it could be a temporary one . The risks are great and it need to be monitored closely. There are many facilities that don't have IV teams, nurses who can do PICCS and flat out lazy MD's.

[edmia, BSN, RN]

I understand your dilemma OP, but in this situation I would have advocated for the doc to place a central line. If the guy needed access that badly and was heading to ICU, a central line is needed. What if he crapped out and needed pressors? Abdominal IV infusion? I don't think so.

With things like this, I always think about sitting in front of a jury and answering questions. If it won't make sense then, I look for safer options.

I think you need to accept that this was not the best call. I'm not saying it was totally crazy, but there were other options to explore.

This is a great case to advocate for IO access capability at your ER. It is awesome and underutilized.

Sent from my iPhone using allnurses.com

[Anna Flaxis, BSN, RN]

I disagree. If the patient has a sugar of 20, and is unresponsive, you get what you can get, and save their life.

One word. Glucagon.

[Anna Flaxis, BSN, RN]

My question then becomes in a court of law in the death of a patient, would it be alright to say that "I couldn't find a vein?"

Would that then defer fault to the physician for not placing a central?

This is a huge hypothetical, and I can't really give you an answer because there are so many variables in a legal case and I am not an attorney.

My best guess is that they would ask about a foot site, an EJ, an IO, or central access and why those things weren't done.

[Anna Flaxis, BSN, RN]

To the OP and everyone else, I'm not saying you can't ever do this. No, it is not an ideal access and if done, a better access should have been placed ASAP.

I think the supervisor's rationale was faulty. Just because you've never seen it before doesn't mean it's inappropriate. I was just pointing out some other reasons why it could be considered an inappropriate site based on best practice.

[dmurph615]

Here's an interesting article:

The American Journal of Emergency Medicine "A new site for venous access: superficial veins of portal collateral circulation"

And another:

Thoracic or Abdominal Wall Veins Are Acceptable Sites for Intravenous Access -- This was actually a study performed by two doctors at St. Louis University in St. Louis, MO.

And to add to the story. The line was dc'd once he received some fluids (approx 2 hours), after he got some hydration his veins easier to access. Also, just keep in mind that this facility is behind the times, no IOs, no vein vinders, no ultra sound, no anesthesiologist or PICC Line nurse (not at night anyways), and the EJ had been ruled out due to the patient shaking his head back and forth too much. And there is no policy prohibiting this. No one ever said this was "ideal," however, under the circumstance, it worked! And the patient's condition improved in part bc of this IV. And in the end, isn't the patient outcome what's most important?

Thanks for all the input and suggestions, I do think this is something that needs to be studied more, because apparently in the cases it has been looked at there has been some success. My goal is to push for IOs and EJs for my department, since we are in the 21st Century...

[Anna Flaxis, BSN, RN]

Hey, I'm not saying you shouldn't have done it, and I am glad your patient's condition improved as a result. What got me uptight were some of the comments in this thread that I feel are a bit....cavalier about site selection.

I hope you're successful in making some improvements in your departments venous access policies.