Forearm First!

[LibraNurse27, BSN, RN]

Hi all! Just curious about some advice I got today. We have an excellent resource team who do procedures, moderate sedation, PICCs. We also call them for difficult IV starts when they have time. They are super nice and taught me how to start IVs with the ultrasound. Some of them didn't specify first choice of site and often starts IVs in the larger veins in the upper arms.

One of the other resource RNs advised me never to use the hand due to proximity to nerves, pain, and easy to infiltrate. She also advised against the A/C. She said start with the forearm and avoid the upper arm to preserve these veins in case the patient needs a PICC. If it blows or infiltrates none of the veins below it can be used. She said only use upper arm (especially right arm) if there are no other options or it is an emergency and easier to look quickly for a large vein. If an upper arm veins blows or infiltrates, does it heal? Could it still be used later for a PICC? Do upper arm veins more easily develop clots? Now I am so scared to do an upper arm IV, and a lot of our patients are super hard sticks, after multiple days of IVs and blood draws the hands and forearms are beat up...

[MunoRN, RN]

As you've discovered, there are widely varying views on this.

The Infusion Nurses Society (INS) recommends against using the hand, wrist, AC, and the 4 to 5 inches proximal to the wrist, which only leaves the few inches distal to the AC and the upper arm, which is a bit silly in real-life practical terms.

In reality there are too many patient-specific factors to consider to make broad and sweeping rules. As examples, a patient with multiple incompatible infusions that should not be stopped but still requires lab draws while those infusions are infusing should be left with at least one lab draw site well-distal of the infusions, ie the hand. Patient behaviors, reliability of vasculature, etc should also all be taken into account.

New PIVs or PICCs shouldn't be placed distal to a recently infiltrated or even discontinued site, but yes the sites do heal and lines can then be placed distally, the amount of time it takes to heal is not specifically defined.

In the end though, ideal is just that, we generally aren't going to deny a patient infusion therapy when doing so could cause harm or death just because the site isn't 'ideal'.

["nursy", RN]

Agree with MunoRN. But the patients you describe of having multiple IVs and sticks, and forearms are getting beat up, maybe they should be getting PICCs?

Also, having been an infusion specialist for 20 years, I wasn't crazy about hard and fast rules. For example, a lot of ER oriented nurses would like to stick 18 gauge caths into everyone, bigger sizes, faster infusions for emergencies, blood etc. INS guidelines state SMALLEST size possible that will get the job done. It used to be that you couldn't transfuse with anything smaller than a 20 gauge, and a lot of nurses still believe that, even though it currently is not true. So would I put an 18 gauge into the hand of an alert, mobile patient? No. Would I put a 22 gauge into the hand of a comatose patient getting a KVO? Sure. So basically, a lot of it is common sense. I wouldn't be "scared" of doing upper arm IV's. The only down side is losing a potential PICC site, so it's just something to keep in mind.

[LibraNurse27, BSN, RN]

Thank you both, very informative! Yes we often have patients who we would like to do PICCs on due to the frequent labs and IVs but the doctors don’t like to do them just because a patient is a hard stick, they say patient has to meet criteria for long term infusions. Sometimes I feel so bad for the people that don’t need long term infusion but are there for a week or so and have been stuck so much. We did just get some extended dwell peripheral IVs that we can draw labs from so that’s cool! Infusion nurses are great

[brownbook]

When your patient needs an IV put the IV in any vein within reason, and hopefully common sense ?, that looks, feels, reasonably doable for you at your level of skill and confidence.

New grads learning IV skills with an I'm so scared, and lots of cannots and should nots is a recipe for IV disaster.

The number of times I've seen expert IV nurses and anesthesiologist put IVS in sites I had been told not to use would fill a book. (Well....a slim pamphlet, there aren't that many choices ?).

As "nursy" RN said a patient with multiple sticks and beat up forearms needs a PICC.

I've seen IVS in fingers that last long enough to get the patient through a short procedure. And can possibly last long enough to hydrate the patient so a larger size IV can be inserted in a more secure site.

[MunoRN, RN]

2 hours ago, LibraNurse27 said:

Thank you both, very informative! Yes we often have patients who we would like to do PICCs on due to the frequent labs and IVs but the doctors don’t like to do them just because a patient is a hard stick, they say patient has to meet criteria for long term infusions. Sometimes I feel so bad for the people that don’t need long term infusion but are there for a week or so and have been stuck so much. We did just get some extended dwell peripheral IVs that we can draw labs from so that’s cool! Infusion nurses are great

The need for frequent labwork and unreliable ability to obtain these labs is a commonly recognized indication for a PICC or central line since the delay in these labs can cause patient harm. If doctors feel that a clear risk of harm resulting from delayed or unobtainable lab results always outweighs the relatively smaller risks of better access probably shouldn't be practicing.

[Guest219794]

All of these rules are great when you have plenty of time and an ultrasound. For the rest of us, the IV is going where we find it.

This might include fingers, feet, anterior shoulder, chest........

I am good at IVs. I work with a couple people who are great at IVs. Still, we sometimes scramble. It would be great if I could summon the vascular access team, but we don't have one.

[Lipoma, BSN, RN]

I put IVs in wherever I have access...

If the AC is juicy.. That's where I'm going... If the hand is juicy, that's where I'm going.

Hx if IV drug abuse and the finger is the only access I can achieve.... That's where I'm going.

[Nurse SMS, MSN, RN]

I always started with forearms. Not as painful, bigger veins than the hand and far more stable and comfortable for the patient. I loved it when I could get an upper arm but that was less common. I never put it in the AC unless I had no choice. Didn't love doing hands but did plenty of them.

[zoidberg, BSN, RN]

When i train someone on US guided PIV... stick in this order

forarm

cephalic vein(on top of bicep, not near major arteries or nerves)

basilic

brachial

Do NOT stick the brachial veins until you are experienced enough to know you can find and avoid the brachial artery and nerve.

you will probably do lots of basilic and brachial IVs as patients have been stuck over and over. If you are skilled, a good PIV can last several days or even a week or more. This is often enough time to get to discharge without a PICC. of course, if they have an indication for a central line, advocate for one.

[YumCookies, BSN, RN]

Depends. In general, I prefer the forearm and will look there first.

In the ED setting: If I need a large bore, labs, and something quick, I like the AC (unless I can find a juicy forearm one). I will go right for the AC if I suspect the patient may need a CTA further down the line. Sometimes, patients come in so dry and dehydrated that the only option they have is the AC!

For difficult sticks where I am lucky to get any gauge: I like the hands and wrist, even fingers in desperate circumstances. Yes, it gets valve-y in there, is inconvenient for the patient, and increases risk of infiltration. However, there is little adipose tissue in the hands therefore making the veins a little easier to see and palpate.