Do RN's insert EJ's at your hospital

Published

Hello all. We are working with the PICC placement nurses to develop a competency for EJ insertions. I wonder what size catheters, length included, taht you have seen used for this. Does anybody have a link to good policies for this procedure?

At our hospital, RNs can place peripherals only in the BLEs. Having said that, it is a very large teaching hospital with no shortage of MDs, NPs, PAs, etc.

In ICU we only place 18g or 20g. If someone comes up from the OR or ED with a 16g, we are very happy :D especially if it's in the forearm and not the AC! Some transfers from the floor will have a 22g in place, or sometimes in a patient with difficult access who needs 2 peripherals (and everyone in ICU needs 2) a nurse from the IV team will use a 22g. That's it.

Up Vote Up Vote ×
In the beginning i threw 18's in everybody! In the words of my preceptor, "no need to be mean and inflict unnecessary pain. We can give blood with a 22 of we had to." 20 is my go to for reg peripheral unless my PT is unstable, then the 18's.

This is very wrong. A 22g IV has like 1/4th the flow rate of an 18g. You also cannot use a 22g for powered injection for certain CT scan protocols. I mean sure, if the patient is entirely stable, and not preop, and not going to need a CT scan, a 22 is fine. But any patient that could possibly go to the OR, anyone who might suddenly become sick, deserves at least 1 large iv. Doing the right thing for the patient sometimes involves sticking them with a great big IV. The worst thing in the world is when the patient is crashing, and you realize that the patient came up from the ED with only a 24g iv in the finger.

1
Up Vote Up Vote ×
Specializes in Vascular Access.
This is very wrong. A 22g IV has like 1/4th the flow rate of an 18g. You also cannot use a 22g for powered injection for certain CT scan protocols. I mean sure, if the patient is entirely stable, and not preop, and not going to need a CT scan, a 22 is fine. But any patient that could possibly go to the OR, anyone who might suddenly become sick, deserves at least 1 large iv. Doing the right thing for the patient sometimes involves sticking them with a great big IV. The worst thing in the world is when the patient is crashing, and you realize that the patient came up from the ED with only a 24g iv in the finger.

How is what this poster said wrong? Most 18 gauge IV catheters do have better flow rates than 22 gauges, but a 22 g can handle approx. 2000mls/hr whereas an 18 g can handle over 6 liters an hour. Sure, that is three times the amount, but even 2L hr, is a lot of fluids. A 24 g in the finger, if that is all they could get in the ER, means it is limited to only isotonic infusions without additives.. so, yes, that is not the best choice for a sick patient. However, one should always be thinking of the patient and vein preservation too... Why throw in a large 18 g, just because you can? Standards say to always choose the smallest gauge and length for the prescribed therapy.

Up Vote Up Vote ×
Specializes in critical care, ER,ICU, CVSURG, CCU.
Just to be clear (since so many different abbreviations are tossed about on these pages) ... EJ = External Jugular?

In 15 years, I've never seen an RN put in a central line.

i have inserted cebtral lines 4o+yrs.

Up Vote Up Vote ×
Specializes in critical care.
Hello all. We are working with the PICC placement nurses to develop a competency for EJ insertions. I wonder what size catheters, length included, taht you have seen used for this. Does anybody have a link to good policies for this procedure?

I've had one patient come up with a peripheral IV catheter in an EJ. She charted it as a central line. Apparently the patient was a terrible stick. Anyway, that's the closest I've ever seen to a nurse placing a central line. The intensivists, ED docs, cardiologists and surgeons do ours. I'm sure the hospitalists can in an emergency, but as a rule of thumb, they don't. Primarily it's just the surgeons and intensivists.

Up Vote Up Vote ×

Usually I see EJ's coming in from the field or put in by the anesthesiologist because they couldn't get a central line.

Our PICC nurses will put peripheral lines in the usual places (arms, hands, feet/ankles) and a few unusual places (axillary, boob, upper thighs).

Up Vote Up Vote ×
Specializes in Pediatric Critical Care.
Most 18 gauge IV catheters do have better flow rates than 22 gauges, but a 22 g can handle approx. 2000mls/hr whereas an 18 g can handle over 6 liters an hour. Sure, that is three times the amount, but even 2L hr, is a lot of fluids.

...

Why throw in a large 18 g, just because you can? Standards say to always choose the smallest gauge and length for the prescribed therapy.

I totally agree. Sure, some patients need rapid fluid resuscitation to the tune of 6L per hour. But certainly not the majority. Obviously don't choose the massive hemorrhage patient for your 22g IV.

Also, the flow rate difference is not quite as big as I find is sometimes assumed. Part of this is because larger gauge catheters also tend to be longer, and the added length increases flow resistance. Here is some data on one common catheter type for reference, if anyone is interested: https://www.bd.com/infusion/products/ivcatheters/iagbc/videos/pdfs/iagbc_wp3.pdf

Up Vote Up Vote ×
Specializes in Emergency Department.

It's been a while since I've done an EJ, but my go-to with that site is an 18g but if I don't have any 18's in hand, I'll reach for a 16 before I'll reach for a 20. The reason for that is really simple. Longer catheters are more likely to stay in the vein if the head is turned. Most of the 20g catheters are too short for comfort. The EJ is a pretty large vein so it'll tolerate the larger bore IV catheters.

The other reason I'll reach for the larger catheter is that if my patient's other peripheral veins are so collapsed that all I've got left is the EJ, the patient is going to need a significant amount of fluid and/or blood. From my point of view, if you're already set up for a peripheral line and you don't have an IO within reach, going for an EJ is as simple as reaching for a long 18g or a 16g cath and mentally deciding to go for it. If I had an older-style cath that I could put a syringe on the back of, that would be even better for confirmation of entry into the vein. The EJ is also a low pressure vessel so you might not get a flash.

The ED where I'm at now very rarely does EJ lines. They're more likely to reach for an IO than go ahead and do an EJ.

Up Vote Up Vote ×

Where I work, nurses are allowed to place external jugular IV lines. We treat them like we treat all other peripheral lines, so they have a 3-4 day span of life. I was taught to always put a large gauge into the EJ. OTOH all the patients we have are liable to code, so we try not to go smaller than 18G. If we cannot establish a good IV peripheral access on a high risk patient, we will bug our doctors until they put in a central line.

Up Vote Up Vote ×

Only doctors at my facility. I wouldn't feel comfortable with that. I have used the lower extremities before - we get MD order for that. Rare, usually a last ditch effort before a line.

On the note of gauges, I aim for a 20 because you never know. I always feel for veins, avoid just looking. I'll inspect around for 5-10 minutes to avoid the wrist & AC if I have time.

Up Vote Up Vote ×

ER and ICU nurses are allowed to insert EJ's in my hospital, without any order from an MD. Usually 18-16 gauge, most of the time during an RRT, code situation.

Up Vote Up Vote ×

Never heard or witnessed anyone using 12 gauge for an EJ I can envision a thrombophlebitis within a few hours!!!!

Up Vote Up Vote ×
+ Join the Discussion