IV Gauge for CT

[EDrunnerRN]

In the ER today I had a 20 y/o "chest pain." Of course the pt received the full cardiac workup as well as a CT of the chest. Prior to taking my pt to CT the MD asked me what size IV I put in the patient and I replied 20 G. In my opinion, I felt this size IV was sufficient. However, the MD, who is newly off residency, snapped back and said I want an 18 G in this patient. I proceded to question why and he said that he could (not sure why he said he bc it is the radiologist who does this) could read the scan better. I had my doubts but let the fight rest because for one I had no time for this and two I knew it would get me no where, fast. He put in an order for the 20 G to be DC'd and an 18 G LAC placed. I spoke to a few seasoned nurses as well as rad tech's who have never heard that the size 20 or 18 G made a difference on the scan. Anyone knowledgeable in this area??

[CCL RN, RN]

Wow. Quite a ******* match.

Extravastion of an EJ is not acceptable. It is the last option to place an EJ for a CT. A decision made in, tops, 15 minutes of arrival time.

I've worked here 5 years and have never, ever had an EJ blow. Nor have I seen any.

I'm simply stating what our hospital policy is on catheter size for CT. That was the question.

18G in the AC or above (both in the body and in G) if it's a CT for anything chest and up.

This is a code/trauma protocol.

A larger catheter size makes the risk of extravastion much lower.

Just the facts.

And thank you for the inservice on what an angiography is.

Relax, dude.

You're welcome. A CTA is different, *quite different* than a regular CT chest.

To be fair, I was quoting YOU.

Routine tests, I absolutely agree. Not worth it to risk extravasation.

I don't agree with never. Sometimes the risk outweighs the benefit. And those are the types of cases I see everyday.

You've worked for 5 years and never had an extravasation, yet you see the cases everyday where an EJ admin of 90 ml of contrast outweighs the risk of extravasation. Huh?

To place a central line, which truly endangers a patients life, because your facility refuses to accept a 20 gauge is pathetic. To risk extravasation of an EJ, placed only for one test, is even worse. And if you have a trauma pt who needed emergent access, you and I both know it would be femoral, and not EJ. And they wouldn't be going for a CTA either. It would be a reg CT chest or CT angio.

I cant imagine a CT that requires a more precise measurement than a CTA, but then again, you knew that, right? And somehow, somehow,they get done everyday just fine with a 20g FA IV.

[TXTraumaRN]

I have worked in 3 different Level 1 trauma centers and a 20 g has been sufficient at all of them. Placement is another thing. One hospital it didn't matter if the IV was located in a forearm or AC, whereas where I work now, it has to be in AC or as close as possible. The argument of 18g vs 20g is a moot point when you take into consideration that the Luer lock caps we place on our IVs turn an 18g into a 20g. It sounds to me like it's a case of a newly minted ED physician who still believes in doing things "exactly" by the book.

[DeadHeadRN, BSN, RN]

I really wish there was a more cut-and-dry way to decide "This patient may have have a PE, or may have a mass or a subdural bleed in their brain", but by the way ER doctors order it doesn't seem like it. They radiate patients like water.

What about a D-Dimer?

[DeadHeadRN, BSN, RN]

I beg your pardon, but an invasive procedure such as an IV insertion absolutely requires a doctor's order. If the doctor says to D/C it, it is a medical, and not a nursing judgment.

At my facility, I do not need an order for an IVL.

[Lunah, MSN, RN]

What about a D-Dimer?

Sometimes even a d-dimer isn't a great indicator -- there are many things that can elevate a d-dimer. It's one of those tests with high sensitivity, but low specificity. If our doc suspects a PE, they just order the CT angio and skip the d-dimer.

[Mrs.0]

You're welcome. A CTA is different, *quite different* than a regular CT chest.

To be fair, I was quoting YOU.

You've worked for 5 years and never had an extravasation, yet you see the cases everyday where an EJ admin of 90 ml of contrast outweighs the risk of extravasation. Huh?

To place a central line, which truly endangers a patients life, because your facility refuses to accept a 20 gauge is pathetic. To risk extravasation of an EJ, placed only for one test, is even worse. And if you have a trauma pt who needed emergent access, you and I both know it would be femoral, and not EJ. And they wouldn't be going for a CTA either. It would be a reg CT chest or CT angio.

I cant imagine a CT that requires a more precise measurement than a CTA, but then again, you knew that, right? And somehow, somehow,they get done everyday just fine with a 20g FA IV.

Thanks. I'll let my trauma coordinator know about your concern. Jesus.

[murphyle, BSN, RN]

Its just silly not to use a power PICC or port or other CVC that is capable of power injection. both ionic and non-ionic contrast are vesicants and can cause severe tissue damage upon extravasation. There have been many many lawsuits b/c of this and the first question I would ask is why the power injectable VAD WAS NOT USED. If anyone wants to know more about the contrast manual I can share more

I'd be interested to have a look at that manual, if you don't mind. I've had different technologists tell me different "mandates," "policies" and "licensure restrictions" on multiple forms of imaging, both at my own hospital and at other hospitals within my healthcare system. (The no-power-VADs thing immediately comes to mind, but we've also had go-rounds with administration and timing of PO contrast, BUN/creatinine guidelines for IV contrast, and so forth.) I'd like to know how much of that is actual fact/policy/law and how much is lore and tradition.

Thanks in advance! :up:

[CCL RN, RN]

Thanks. I'll let my trauma coordinator know about your concern. Jesus.

Glad I could help!

[ZooMommyRN, ADN, RN]

we aim for a 20 in RAC or as close to the AC as possible, an 18 or a 20 in LAC would be useless for our facility

[lpnstudentin2010, LPN]

we aim for a 20 in RAC or as close to the AC as possible, an 18 or a 20 in LAC would be useless for our facility

I am guessing rac is right ac and lac is left ac. why would an IV in the left be useless?

[DebanamRN, MSN, RN]

With Acute MI, we go for the right arm as most doctors are right-handed and stand on the patient's left side. This gives better access to the iv for the team. If the patient has crappy veins, then any side will do. I go with a 20 in the AC for chest pain, sob, any time I think the pt may need a CTA or blood transfusion. If the AC is no good, a 20 above the wrist also works. And as Lunah said, some of our docs don't even bother with a dimer, just go to CTA, or if they can't do that for whatever reason, a v/q scan.

PS. If that young doctor did that to me we would have had a brawl. This is not about him, this is about the patient.

[ZooMommyRN, ADN, RN]

I am guessing rac is right ac and lac is left ac. why would an IV in the left be useless?

Because our dino of a machine can't capture the image properly if the CTA contrast is injected into the left, when the right is used the "flash" that is captured shows PE. Left not enough is left by the time it circulates and PE can be missed. Some of the higher slice machines can capture them, we just aren't so lucky