IV Gauge for CT

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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??

Specializes in Emergency.

18G is what is desired in my hospital, but they take what they get because there have been a few times we could only get a 22G. 18G is my go to guy, occasionally a 20G and rarely a 22G. The only time I use 24G is on peds

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Specializes in Emergency/Trauma/Critical Care Nursing.
We are required to have 18G in a great vein (AC or better) for R/O PE (which I assume was the reason for the chest CT). This rule is so ingrained that even if you have a 20 in the AC they will not take it and require a central if no 18 can be established. Typically we do deep brachial with Ultrasound guidance as a last resort. This is due to the pressure necessary for CT angio of head/neck/chest as it must reach the organs at the same time as the scan. For abd ct and gauge will do.

Our go to IV size is 18 or greater. Only time we use a smaller guage is if we just can't get an 18.

Personally, I think that policy is :down:, i absolutely HATE HATE HATE deep brachial ultrasound guided IVs, i will ONLY let people attempt to put one in my pt (i had no desire to take the training course for it lol), if all other measures have failed and the MD isn't available to place a central line reasonably soon. I've seen SOOOO many of them infiltrate so easily, but it isn't as easily detected until the pts arm is all swollen and cold. i had one pt when i was a new nurse, getting blood transfused via U/S guided line, kept checking the pt, denied any pain/discomfort, it seemed to be infusing appropriately, until the transfusion was almost complete and the pts entire arm was now purplish black, cold to the touch, with an arm full of that unit of PRBCs she obviously needed, filling up everything in her arm BUT her veins.. i was so mortified, pt was freaked out.. you can't trust those crappy lines :cool:

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Specializes in ER.

how about asking the tech. They know what they need... all Radiologists have different preferences, but as I just encountered this argument myself... I had only a #22 and it was INSANELY difficult to get. They did it, but wanted a 20. They did a test bolus to see if the contrast could get to where it needed to get as quickly as a 20 could, and it did.

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Specializes in ER.
Hostility? Seriously? If you really believe that, you better report my posts and let the mods decide for themselves.

you guys are gonna get slapped by the moderators!!! :doh:

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Specializes in ER.
An EJ is never recommended for power injection due for the potential for an extravasation in this area which would be be devastating. b/c of the large vessels and nerves in this area. There is a huge manual on contrast injection and current recommendations for acceptable sites. There own organization states that a large forearm vein or AC vein is acceptable. I have had this discussion way too many times with the techs. I place a good 20 gauge as a minimum and I always place an 18 for a chest CT.t.hey just get better pictures that way and it gives them more flexibility with the rate of power injection. 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. Thee 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

had a resident offer to start an EJ for CTA to r/o PE.... he's pretty on the ball and insisted it was OK to use for contrast, but I would hesitate to have had him start one for that purpose without asking the tech first.

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Specializes in ER.
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.

another *issing match within this thread.

Very entertaining. :up:

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Specializes in ER.
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

why would having an 18 or 20 in the left antecubital not be as good as the right???

perhaps that was a typo... but if not, I'm dying to read the rationale.... since we'd ALL be doing it wrong. Every day.

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Specializes in ER.
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.

"we go for the right arm as most doctors are right-handed "

well since many are left-handed, why not just err on the side of caution and be pc and start one on both sides, so we can please all people all of the time. :yeah: that's soooo ridiculous! how about start a line where you find a vein and have that doc stand wherever there's a free spot of tile.

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Specializes in Med/Surg, ICU, ER, Peds ER-CPEN.
why would having an 18 or 20 in the left antecubital not be as good as the right???

perhaps that was a typo... but if not, I'm dying to read the rationale.... since we'd ALL be doing it wrong. Every day.

read back a few pages, I explained our policy already :)

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Specializes in ER.
read back a few pages, I explained our policy already :)

read your post back there....well that is interesting.

Stinks for you guys having a old scanner! Not great if you don't have that option, though - say a left arm injury or no veins, etc etc blah blah.... but I'm sure the CT tech works it out if there's no other option, as most do.

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Specializes in 1 PACU,11 ICU, 9 ER.
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.

"...sorry, it's the nurses not the md's business if there is an extra iv"

i would like to see you go to your state bon with that line of thinking; they'll pull your license so fast your head would spin.

begging your pardon we do not wait for the pt to see an md to get 'an order' before we place an iv. as an rn with plenty of experience i can assess whether an iv is needed or not and if it is not, oh well, it gets pulled upon dc.

in our facility it is preferrred to have an 18g in the ac but they will take at least a 20g above the wrist.

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Specializes in ED, CTSurg, IVTeam, Oncology.
Begging your pardon we do not wait for the pt to see an MD to get 'an order' before we place an IV. As an RN with plenty of experience I can assess whether an IV is needed or not and if it is not, oh well, it gets pulled upon DC.

In our facility it is preferrred to have an 18G in the AC but they will take at least a 20G above the wrist.

Pardon me, but...

I think you're only reading a part of the discussion. I wasn't talking about whether or not to place the IV without having a MD's written order in an emergency, as just about all ED's having medically sanctioned standing policies (ie. an institutionally prepared set of anticipatory medical orders to be used by nurses in cases of emergencies).

What the argument revolved around was, that after the MD's exam, when the doctor specifically directed an IV to be removed, then THAT is in and of itself, a medical judgement, AND thus constituted a medical order that must then be followed by nurses. Again, standing orders used in hospital policies are only to facilitate medical convenience, and do not rise to the legal level that it allows nurses to overrule or supercede a primary doctor's medical judgement. This is because regular nurses, as a matter of legality, do not ever have medical judgment as they are not medical doctors. I suggest that if any nurse has doubt, check with their institution risk management and ask specifically, when a doctor orders an IV removed, and in the nurses judgment the IV should stay; who is in the legal right.

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