Alternative sites for peripheral IV access

[MacDSlim]

Hello, everyone!

I was hoping to get your opinions, experiences, and any known dangers or contraindications to gaining IV access in not so common spots.

Namely legs, feet, and chest wall (axillary vein).

In my experience, if they can't find a suitable vein or fail on the arm/hand they move on to EJ/central. I can't seem to wrap my head around why. No one really has any solid reasons as to the avoidance of alternative sites.

[ChryssyD]

Having spent years working with chronically ill children, I've put IVs in all sorts of weird places--in: fingers, bottom of the foot, behind the knee, the thigh, the chest...

Basically, with kids, if I can see it and stick a line in it, it's all good. But in big people, there are other considerations. I have used foot veins for hydration and blood administration in older patients who had no available upper extremity access, with a doctor's order. As far as chest area veins, if they're accessible, I don't know of any studies that show they are more prone to DVTs than other sites, but I am not an expert. It comes down to risk assessment vs convenience, I think. If a nurse can safely place a peripheral line, the MD doesn't have to order or insert a more complex alternative. But it seems that generally, the more unusual the IV, the more likely the complications, so extreme peripheral IV placement should be a last resort if central line placement is somehow contraindicated or seriously inconvenient. PICC lines, though, done correctly, are a good option for many patients.

[applewhitern, BSN, RN]

In any hospital I have worked at, we had to have a doctor's order to use the lower extremities on adults. We were always told it was because of the possibility of blood clots, phlebitis, infection, etc. I guess the rationale is that it is better to lose a hand or arm, rather than a foot or leg. (Of course, we were always free to use the lower extremities on pediatric patients.)

[NurseLife88, ADN, RN]

I work peds and float NICU. Our most commonly used alternative sites are feet, legs, and scalps. But these alternative sites are mainly used in only peds and NICU. Other parts of my hospital generally go EJ when access is difficult.

[canoehead, BSN, RN]

I'm in the ER, so if I can get the IV but it's in a weird spot, I go ahead. I notify the doc before using it. Usually if we hydrate for a couple hours there are alternative sites available. I've never done a peripheral IV in the trunk, but would in a crisis. I have done feet and fingers, and if an adult patient is well enough I'll tell them to call with any swelling, and splint it well.

[Ellie G]

So called "alternative sites" can cause lots of problems. The INS does not recommend these sites. My experience is as an IV/PICC nurse. If I were making recommendations, I would suggest a midline if it wasn't feasible to do a PICC or other central line. We've all seen the infiltrations from hell when a normal site is used. Try having those in your neck or foot. Depending on the drug used and the amount infiltrated you can have either a minor or a major problem, but you will have a problem. I had someone come up from the ER septic with vancomycin infusing in a 24g in the thumb. That is some shoddy nursing care.

[Ellie G]

I have seen IV's done in many alternative sites. EJ's can come with their own risks and patients get very freaked out about them, I have had to convince many patients to get an EJ. Central lines also can carry a lot of risks and aren't sometimes necessary.

Truly the reason for the IV access is an important factor here. In the pt types TraumaRUS spoke about an alternative site would be acceptable depending on what you can find. People that are hard to get lines on anyway because of the different diseases they have, keep in mind those people are also high risk for infections, every time you access them as well will cause scaring over time leaving that site no longer usable over time. So if you can get a good patent line in a more alternative less used spot than that would be the better option. Same with pt's with terrible veins from IV drug use, or sickle cell patients.

I think the biggest thing is people aren't comfortable trying to gain access in alternative sites and inexperience. No one wants to miss their IV's and have to keep sticking the patient. I have found this lack of confidence in doing IV's ends up causing more sticks. I am usually the go to IV person in my ER's because I am not afraid to go to alternative sites and I know I am really good at placing IV's. I display that confidence and am very honest so my patients feel comfortable with me when I explain why we are going to try in a different spot.

I mean most people have an amazing vein on the back of their arm that can be deeper and hard to see (but don't get me started on those that have to see the veins and never FEEL) but can easily get a 16guage in (if needed) and it will work amazingly and not get in the way of normal body mechanics, but I have found so many people that have never done one there. They can be awkward to place because I have to get in various yoga positions but they are excellent veins and go unnoticed so usually not as damaged.

HOWEVER, if it's an emergent situation and there is no time to try multiple alternative sites than all that goes out the door and pt is getting a central line of EJ, More times than not though there is a little time to try and gain good access before busting out the big guns.

I am a guitarist with calluses on my fingers and for that reason I often can't feel a vein but I guarantee you that I am still going to get the vast majority of veins anyway. I can see even the smallest shade of blue on people. If needed I would use the vein finder. I do agree with you about the vein on the back of the arm, especially in men

[Ellie G]

Intravenous nurses society webpage will have that information for you. There are reasons for avoidance of alternative sites and there are some drugs that can cause major problems in one of those sites.

[Ellie G]

I work peds and float NICU. Our most commonly used alternative sites are feet, legs, and scalps. But these alternative sites are mainly used in only peds and NICU. Other parts of my hospital generally go EJ when access is difficult.

EJ brings with it its own problems. An infiltration can compress vascular structures in the neck. We didn't keep them in med-surg with an EJ because they really need close monitoring. In ICU it was a stop-gap for a central line.

[canoehead, BSN, RN]

So called "alternative sites" can cause lots of problems. The INS does not recommend these sites. My experience is as an IV/PICC nurse. If I were making recommendations, I would suggest a midline if it wasn't feasible to do a PICC or other central line. We've all seen the infiltrations from hell when a normal site is used. Try having those in your neck or foot. Depending on the drug used and the amount infiltrated you can have either a minor or a major problem, but you will have a problem. I had someone come up from the ER septic with vancomycin infusing in a 24g in the thumb. That is some shoddy nursing care.

Well, if that's all they could get, and the patient needed the Vanco, there wasn't a lot of choice. I'd notify the doc about the crappy access, give that first dose, and start making calls to get a better site, but I wouldn't hold the antibiotic.

Possibly after a few hours of hydration, there will be lots of sites to choose from. Or if we hold the antibiotic he'll get a lot worse in two hours. You have to weight the alternatives.

[Ellie G]

Exactly but I have seen many times that this doesn't happen. I totally agree that you wouldn't hold the antibiotic. That's just common sense and perhaps I didn't make myself clear. I wasn't saying don't guve the antibiotic until you have better access. What I'm saying is that we get a better line done ASAP. I've been in code situations with a 22 in the shoulder and having to start levophed with a 22 in a crappy site. Being more proactive about IV access lessens these things happening

[Queen Maeve]

I am not a nurse. However, I have a friend who came to the US as a refugee from Sarajevo during the Bosnian War. She was hit by a bomb when she was 19 years old and both her arms were amputated almost to the shoulder. Obviously, they cannot insert an IV in her arms, because she doesn't have any. I asked her how her condition is accommodated, and she said they always draw blood from and insert an IV in her feet. On one occasion they used her scalp for the IV, but she was so uncomfortable with this that it was never done that way again. I'm sure there are other severely disabled people who require similar accommodations.

I personally have a severe phobia about IVs. I cannot tolerate them in my arms. This is not negotiable. I need cervical fusion surgery right now, and my current surgeon is resisting accommodating my phobia. He has in fact come close to refusing to perform the surgery because of this, but I am holding firm and being assertive. If he persists, I will find another surgeon.

[MunoRN, RN]

I am not a nurse. However, I have a friend who came to the US as a refugee from Sarajevo during the Bosnian War. She was hit by a bomb when she was 19 years old and both her arms were amputated almost to the shoulder. Obviously, they cannot insert an IV in her arms, because she doesn't have any. I asked her how her condition is accommodated, and she said they always draw blood from and insert an IV in her feet. On one occasion they used her scalp for the IV, but she was so uncomfortable with this that it was never done that way again. I'm sure there are other severely disabled people who require similar accommodations.

I personally have a severe phobia about IVs. I cannot tolerate them in my arms. This is not negotiable. I need cervical fusion surgery right now, and my current surgeon is resisting accommodating my phobia. He has in fact come close to refusing to perform the surgery because of this, but I am holding firm and being assertive. If he persists, I will find another surgeon.

I don't know that you'll be able to find any surgeon willing to perform spinal surgery without IV access.