Alternative sites for peripheral IV access

sallyrnrrt, ADN, RN · Apr 24, 2017

In my almost 45years, mostly critical care, I have seen one IV access to a lady' breast veins.......but for me personally in acute situations if I can not nail a pephral, I go IJ external jugular......sub clavicle and my least favorite femoral vein........

Trauma Columnist · Apr 24, 2017

My pts are all on dialysis so IV access is always problematic. If not diabetic, feet is fine, in kids, feet is fine. For some sickle cell pts or those with other access issues, yes, I've seen anterior chest wall also.

I've never done an IJ (internal jugular) but have done EJ (external jugular) frequently in the ER.

MacDSlim · Apr 24, 2017

If not diabetic, feet is fine, .

Mind explaining?

**NICU Guy, BSN, RN** · Apr 24, 2017

I have seen an IV put in a shoulder in the ER. This was suggested by the patient. He said that he is a hard stick and that was an easy place for them to get access.

Newborns, we use hands, feet and scalp.

~Mi Vida Loca~RN, ASN, RN · Apr 24, 2017

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.

AnnieOaklyRN, BSN, RN, EMT-P · Apr 24, 2017

Hi,

I work as an IV nurse and we use arms (upper arms included) and feet, but only if absolutely necessary and with a doctor's order. I will not do a foot IV on an elderly person, someone with PVD, or a diabetic. I would NEVER put an IV in someones chest wall, especially a female because if they end up with a bad infection or infiltrate that could mean the loss of breast tissue and could be disfiguring! Not worth it when here are alternatives. We can usually find one in the arm with ultrasound. If we cannot we will consult with the physician and they can opt for some other access, either a PICC, midline, or EJ.

In emergency I recommend an IO if there are no contraindications.

Annie

Zyprexa · Apr 24, 2017

My hospital's policy when I worked medical was no IVs in legs/feet due to the risk of DVT. Alternatives I've seen are EJ (external jugular) and IJ (internal jugular). The one time I saw a IV in the leg, it was during my med-surg clinical at a different hospital. The patient had contraindications to IVs for both arms, and came from a skilled LTC unit where apparently she has had this IV in her leg for months. When I saw it, it was infected and had completely infiltrated as nurses had been using it without assessing it first. IV therapy had to remove it, but the patient refused a PICC or any type of central line. So that is my experience.

That Guy, BSN, RN, EMT-B · Apr 24, 2017

A great doc once told me when it comes to lines "If you can see it, stick it". We get what we can and then we move to a better one down the road, whether that be ultrasound, central line whatever.

Now thats not to say I don't love drilling people if the need arises

mmc51264, BSN, MSN, RN · Apr 24, 2017

We have the occasional EJ and in rare instances feet-but like others have said, not in a diabetic.

~Mi Vida Loca~RN, ASN, RN · Apr 24, 2017

A great doc once told me when it comes to lines "If you can see it, stick it". We get what we can and then we move to a better one down the road, whether that be ultrasound, central line whatever.
Now thats not to say I don't love drilling people if the need arises

That doc is an idiot, how many docs are sticking in PIV's?? You don't stick a vein just because you can see it. That's how you get all these nurses sticking these superficial veins that immediately blow and leave giant bruises!

Reminds me of a vein I have on my forearm you can see but it is a terrible vein, it's superficial but visible, and yet they always insist on "trying" because some nurse thinks they have the super power to make it work and every single time the same result happens and I end up black and blue.

MikeyT-c-IV · Apr 26, 2017

I could give an entire lecture on IV access. But for the sake of time I will just say a couple of things.

I think in urgent/emergent situations alternate sites are acceptable. When the crisis is over then appropriate access should be obtained.

I am a HUGE supporter of ultrasound guidance for IV access. During the course of my 8 years using ultrasound I have literally NEVER not obtained IV access in the arms with the exception of one patient that I had to place a jugular. I do realize that not every facility has the luxury or access to an ultrasound for PIV placement but I think this is something that should be and would be worth the investment. Not only for patient care but for the nurses trying to place the vascular access. Honestly I can place and ultrasound guided PIV much faster than by traditional palpation/visualization.

There are a ton of resources to research your question. The Infusion Nurses Society and The Association for Vascular Access has some great information on this topic. Also there are facebook pages (if you're in to that thing) that are groups just for vascular access nurses that discuss topics such as this. All very informative.

There is a ton of EBP and studies on this topic. Happy researching!