Is this true?

Editorial Team / Admin · Nov 6, 2015

Google Scholar can bring up multiple articles. Here are 2:

Peripheral nerve injury from intravenous cannulation

[h=2]Neuroma of the Superficial Branch of the Radial Nerve After Intravenous Cannulation[/h]

MunoRN, RN · Nov 6, 2015

It's a stretch to say it's "no longer acceptable", that would suggest wide acceptance of some recommendations that at least so far are not well established. The Infusion Nursing Society does recommend that the hand and wrist should not be used, the AC should not be used, and that the 4-5 inches of the arm proximal to the wrist should not be used for IV sites, which only leaves a few inches above and below the AC as what it considers to be appropriate sites. While that's their recommendation, it hasn't come close to being accepted as the standard in practice.

Courtney Nurse Writer, BSN · Nov 7, 2015

Wow MunoRN. I didn't know this. That doesn't leave much else places for an IV to go!!!

IVRUS, BSN, RN · Nov 10, 2015

It's a stretch to say it's "no longer acceptable", that would suggest wide acceptance of some recommendations that at least so far are not well established. The Infusion Nursing Society does recommend that the hand and wrist should not be used, the AC should not be used, and that the 4-5 inches of the arm proximal to the wrist should not be used for IV sites, which only leaves a few inches above and below the AC as what it considers to be appropriate sites. While that's their recommendation, it hasn't come close to being accepted as the standard in practice.

Muno, Muno, Muno..... Why you have such an aversion to INS standards of practice, I'll never know!!! However, while INS Standards of Practice aren't mandatory, and aren't laws per se', they SHOULD be used to measure clinical practice both in and out of a court of law setting.

Hoosier_RN, MSN · Nov 10, 2015

Muno, Muno, Muno..... Why you have such an aversion to INS standards of practice, I'll never know!!! However, while INS Standards of Practice aren't mandatory, and aren't laws per se', they SHOULD be used to measure clinical practice both in and out of a court of law setting.

The couple of inches left that are acceptable to INS are not always attainable. Muno never stated an aversion, just the facts and the realities

IVRUS, BSN, RN · Nov 10, 2015

The couple of inches left that are acceptable to INS are not always attainable. Muno, never stated an aversion, just the facts and the realities

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CountryMomma, ASN, RN · Nov 10, 2015

I'll be sure to inform the ED that the AC is off limits, despite the pt's obvious need for a few liters of blood/fluid expander. I'm sure placing an 18ga in the 3" of inner medial forearm they approve will be a snap in an unresponsive, obese DKA pt.

I'm not a big fan of ACs in pts that aren't at risk of needing blood/bolus b/c they tend to occluded and just generally peev my pts off, but if that's what's available, its what I use.

We'll completely overlook the requirement for at least a 20ga AC for power jet contrast injections, yes?

IVRUS, BSN, RN · Nov 10, 2015

I'll be sure to inform the ED that the AC is off limits, despite the pt's obvious need for a few liters of blood/fluid expander. I'm sure placing an 18ga in the 3" of inner medial forearm they approve will be a snap in an unresponsive, obese DKA pt.
I'm not a big fan of ACs in pts that aren't at risk of needing blood/bolus b/c they tend to occluded and just generally peev my pts off, but if that's what's available, its what I use.
We'll completely overlook the requirement for at least a 20ga AC for power jet contrast injections, yes?

Emergency nursing has a completely different set of objectives... However, that is why once a line has been placed in the ER, or even in a non-traditional setting like a MVA site, the IV catheter should be REPLACED within the first 24 hours after placement. What good is it to scrub really well at the site, and be especially pristine in your steps, if your pt is dead?

And, yes, place a 20g for the CT scan if the patient does not have a power injectable Central line in.

Asystole RN · Nov 12, 2015

It's a stretch to say it's "no longer acceptable", that would suggest wide acceptance of some recommendations that at least so far are not well established. The Infusion Nursing Society does recommend that the hand and wrist should not be used, the AC should not be used, and that the 4-5 inches of the arm proximal to the wrist should not be used for IV sites, which only leaves a few inches above and below the AC as what it considers to be appropriate sites. While that's their recommendation, it hasn't come close to being accepted as the standard in practice.

I will post what the actual standard of practice is and no it is not a recommendation but published in the INS Standards of Practice, hence the name Standards of Practice. Granted, this is the standards set forth by a single organization but that organization is cited by most others in the formation their own standards.

When the nurse goes to court or the board over something IV related I can about promise that the INS Standards of Practice will be referred to. I know this from personal, professional experience with both.

33. SITE SELECTION

Standard

33.1 Site selection for all vascular access devices (VADs)

shall be established in organizational policies, procedures,

and/or practice guidelines.

33.2 The vasculature shall accommodate the gauge and

length of the catheter required for the prescribed therapy.

33.3 Site selection for vascular access shall include assessment

of the patient's condition; age; diagnosis; comorbidities;

condition of the vasculature at the insertion site and

proximal to the intended insertion site; condition of skin at

intended insertion site; history of previous venipunctures

and access devices; type and duration of infusion therapy;

and patient preference.

33.4 Prior to insertion of a peripherally inserted central

catheter (PICC), anatomical measurements shall be taken

to determine the length of the catheter required to ensure

full advancement of the catheter to the lower third of the

superior vena cava and the junction of the superior vena

cava and right atrium.

33.5 Placement of central vascular access devices

(CVADs) by nurses shall be established in organizational

policies, procedures, and/or practice guidelines and in

accordance with rules and regulations promulgated by the

state's Board of Nursing.

Practice Criteria

I. Peripheral Venous Access via Short

Peripheral Catheters

A. For adult patients, veins that should be considered

for peripheral cannulation are those found on

the dorsal and ventral surfaces of the upper extremities,

including the metacarpal, cephalic, basilic, and

median veins. Avoid the lateral surface of the wrist

for approximately 4-5 inches because of the potential

risk for nerve damage. For pediatric patients,

similar veins to consider are in the hand, forearm,

antecubital area, and upper arm below the axilla, as

well as the veins of the scalp, foot, and fingers in

infants and toddlers. For adult and pediatric

patients: avoid the ventral surface of the wrist due to

the pain on insertion and possible damage to the

radial nerve.1-5 (V)

B. Site selection should be initiated routinely in the distal

areas of the upper extremities; subsequent cannulation

should be made proximal to the previously

cannulated site.3 (V)

C. Site selection should be initiated routinely in the

nondominant arm. VAD sites should avoid areas of

flexion; areas of pain on palpation; veins that are

compromised (eg, bruised, infiltrated, phlebitic, sclerosed,

or corded); location of valves; and areas of

planned procedures. In infants and children, avoid

the hand or fingers, or the thumb/finger used for

sucking.2,3,6,7 (V)

D. Veins of the lower extremities should not be used

routinely in the adult population due to risk of

tissue damage, thrombophlebitis, and ulceration.2

(I A/P)

E. Veins in an upper extremity should be avoided on

the side of breast surgery with axillary node dissection,

after radiation therapy to that side, or with lymphedema,

or the affected extremity from a cerebrovascular

accident. For patients with chronic kidney

disease stage 4 or 5, avoid forearm and upperarm

veins suitable for placement of vascular

access.â€ A collaborative discussion with the patient

and the licensed independent practitioner (LIP)

should take place related to the benefits and risks of

using a vein in an affected extremity.3,6,8-12 (V)

F. Veins in the right arm of infants and children

should be avoided after procedures treating congenital

cardiac defects that may have decreased blood

flow to the subclavian artery.13 (V)

G. Cannulation of hemodialysis fistulas and grafts

for infusion therapy requires the order of a

nephrologist or LIP.3 (V)

H. The nurse should consider using visualization

technologies that aid in vein identification and

selection.3,14(V)

Asystole RN · Nov 12, 2015

I'll be sure to inform the ED that the AC is off limits, despite the pt's obvious need for a few liters of blood/fluid expander. I'm sure placing an 18ga in the 3" of inner medial forearm they approve will be a snap in an unresponsive, obese DKA pt.
I'm not a big fan of ACs in pts that aren't at risk of needing blood/bolus b/c they tend to occluded and just generally peev my pts off, but if that's what's available, its what I use.
We'll completely overlook the requirement for at least a 20ga AC for power jet contrast injections, yes?

Avoiding areas of flexion sounds reasonable to me.

What everyone is getting confused about is the Standards v. Practice Criteria. The standard is the Standard, the practice criteria is basically a guide of how to implement the Standard.

In this situation the standard is to assess for the best placement depending upon a multitude of factors. To guide you in what is appropriate...it is best to avoid putting a catheter in a known troubled location. The standard doesn't say no, it says to assess the situation.

Reasonable, no?

MikeyT-c-IV · Sep 12, 2016

There is a ton of evidence, now, that tells us which sites are appropriate and which sites are not. I don't care. Get your access and initiate whatever care is necessary. But PLEASE call me in the morning to access the most appropriate site / device for care. :)