Anticoagulant Preventing CVC Insert?

[betterinthesun]

I apologize for the grammatically incorrect title I was just trying to find something that would fit in the subject line. I have been a nurse for years but have only been in an ICU for a few months. We commonly have emergent or semi-emergent CVC insertions on my floor. Many times already I have seen it being done because it was necessary even if the patient has recently gotten anticoagulants (I'm mostly thinking of subcut heparin and lovenox here) as long as PT/INR, PTT, etc aren't unusual. But recently I was told a patient can not have one placed because subcut anticoagulant within 12 hours. The patient had no bleeding and coag studies were not concerning values. The patient was very acutely ill and needed pressors (only had peripheral IVs). There is no policy for this at my facility its supposed to be by physician decision.

Does your facility have a policy on this? What do you see most commonly practiced? Thanks

[IVRUS, BSN, RN]

Crazy, crazy drug books that are telling nurses to use a big catheter and in an area of flexion.... This is a super bad idea! First of all, the IV catheter should be the smallest to accommodate the ordered therapy and NOT in an area of flexion!

[Nurseboy1]

Working with cardiac patients, I routinely place central lines on patients that have received loading doses of plavix, aspirin, brilenta, or are on infusions of heparin, integrilin or aggrastat. I even place them on patients who have received thrombolytics for STEMI prior to cath. For me site selection is key, IJ or Femoral, somewhere I can compress the vein if necessary. I avoid subclavian veins in these patients.

[traumanightsRN, NP]

Crazy, crazy drug books that are telling nurses to use a big catheter and in an area of flexion.... This is a super bad idea! First of all, the IV catheter should be the smallest to accommodate the ordered therapy and NOT in an area of flexion!

Incorrect. You do not give a peripheral vasopressor in a small IV and yes you do give it through a big vein regardless of where that vein is, whether it's in the AC or an EJ. That's why central lines are put in....they are in big veins. I have seen what happens when you give levo through a 22ga PIV in a forearm vein that extravasated. Patient had to get a skin graft from the damage. Also, unless a central line is put in as a PICC or as a subclavian line, they are put in points of flexion, i.e. IJ (neck) and femoral (groin). To prevent a patient from bending the arm you just put a freedom splint on their arm. Safety first.

[IVRUS, BSN, RN]

Incorrect. You do not give a peripheral vasopressor in a small IV and yes you do give it through a big vein regardless of where that vein is, whether it's in the AC or an EJ. That's why central lines are put in....they are in big veins. I have seen what happens when you give levo through a 22ga PIV in a forearm vein that extravasated. Patient had to get a skin graft from the damage. Also, unless a central line is put in as a PICC or as a subclavian line, they are put in points of flexion, i.e. IJ (neck) and femoral (groin). To prevent a patient from bending the arm you just put a freedom splint on their arm. Safety first.

Totally diagree.... Vasopressors should go centrally, we agree on that.. But If given into the peripheral vasculature, then why are you choosing a large bore IV catheter??? That makes NO SENSE! The goal is to prevent damage to the tunica imtima, so one should choose the largest blood vessel possible in the arm, to allow for hemodilution and adequate blood flow around the IV catheter. And by NOT placing the IV catheter into an area of flexion, you diminish the damage to the smooth tunica intima. This damage due to the larger size starts the process of phlebitis/infiltration/extravasation.

PICC should be put in with US thus they are NOT in an area of flexion. Safety should be a consideration, yes, but knowledge about the IV catheters as well as the medication that will be infusing into it HAS TO BE your major consideration. So, in an emergency, and with a vesicant, place a short term peripheral, of the smallest size possible to adequately administer the ordered drug, then get a central line in asap.

[traumanightsRN, NP]

We're just going to have to agree to disagree lol.

[Mully]

Totally diagree.... Vasopressors should go centrally, we agree on that.. But If given into the peripheral vasculature, then why are you choosing a large bore IV catheter??? That makes NO SENSE! The goal is to prevent damage to the tunica imtima, so one should choose the largest blood vessel possible in the arm, to allow for hemodilution and adequate blood flow around the IV catheter. And by NOT placing the IV catheter into an area of flexion, you diminish the damage to the smooth tunica intima. This damage due to the larger size starts the process of phlebitis/infiltration/extravasation.

PICC should be put in with US thus they are NOT in an area of flexion. Safety should be a consideration, yes, but knowledge about the IV catheters as well as the medication that will be infusing into it HAS TO BE your major consideration. So, in an emergency, and with a vesicant, place a short term peripheral, of the smallest size possible to adequately administer the ordered drug, then get a central line in asap.

Where have you gotten this information about small IV sizes being better for pressor administration? Do you have any research or manufacturer's guidelines? You seem pretty adamant.

[IVRUS, BSN, RN]

If you are giving ANY medication into the peripheral vasculature, you want the smallest gauge IV catheter possible to decrease damage to the vein and allow for the best hemodilution of that drug, or best blood flow around that IV catheter itself. Larger IV catheters in a peripheral vein does MORE damage to that vein and increases the chances of phlebitis and extravasation. One never has the blood flow in your arms that is there in the central venous system. INS guidelines call for this, as do many other infusion experts.

[OhioCCRN, MSN, NP]

Re: catheter size :I think It depends on the patient

There is no hard/fast rule that will work with all patients

I'm my practice #22 are as useless as a nasal cannula in a code.

[kayern]

I think consideration needs to be given to the risks v. benefits. Wait because of the SQ for DVT prop v pressers to sustain life.........in my opinion = no brainer! I work in a cardiac care facilitity EVERYONE is on some kind of anticoagulation. If its really necessary there are many ways around waiting 12 hours, vit K, FFP, think outside the box