IV insertion area guidelines

[patwil73]

Hello everyone,

I am looking for some guidelines on acceptable IV insertion spots and the dangers of using subprime areas - such as legs, shoulders, chest. Are their any places that are simply unacceptable to use and why? Finally if someone could point me to some best practice research that would be wonderful.

This case came up this weekend, where a patient had been poked around 7 times before I was called and I simply could not find an IV spot on her arms due to gross edema and cellulitis. Unfortunately she was dependent on levophed and upon arrival it had infiltrated into her wrist. The only spot I could find was the chest which had a great vein (surface) strong blood return, and flushing had the feel of fluid upstream from the insertion with no sign of infiltration. I wish I had someone who could put in a central line but no one was willing to do so.

I know it is not a good spot to place an IV, but the situation to me was a bit desperate and I truly could not see another spot (I tried in two others that both blew due to being spider fragile veins - and those were the only two I could see, which normally I would never have put an IV in except for the situation).

So if I could find some literature, perhaps we could revise our policy to push doctors to place central lines more often in cases where we lose IV's every 6hrs or where the only insertion site is a suboptimal space.

Thanks for any help you can provide

Pat

[IVRUS, BSN, RN]

Pat,

Standards for Infusion Therapy come from established organizations like Infusion Nurses Society(INS) and Oncology Nurses Society (ONS). As nurses, we've all seen the engorged, tortuous veins in our elderly patients. This occurs because of the incompetence of the valves as we age. Instead of the valves bringing the blood back to the heart, blood pools in the LE which increases the chances for DVT's. This, and the fact that superficial vessels and perforating vessels connecting to deeper vessels are more plentiful in the legs. This increases the chances of developing systemic complications from an otherwise local complication.

As far as the chest vessel is concerned, If you saw and palpated these vessels, it begs the question of WHY? Is this vessel present because of an obstruction in the larger vessels of the thorax? In addition, these vessels aren't supported by bone like the ones in the arm.

So, I suppose for a short time frame, and in an emergent situation, this cannulation may be needed, but get a longer term IV catheter in as soon as possible (A PICC or implanted port would be two great choices).

[patwil73]

Thank you so much for your reply.

I found a copy of Core Curriculum for Infusion Nursing at my hospital which does outline the veins that should be used in IV therapy - which are essentially the ones you see used most often. However it doesn't even mention the use of surface chest veins which leads me to ask - is there any research out there on the functionality and acceptability of their use?

To me it seems a lot like the scalp vein of an infant. It does lie over the bony ribs and sternum. It is not dependent so that should minimize the risk of blood pooling - particularly in a continuous infusion.

Now I am not arguing that we should jump right to this vein, but I am wondering if there has been any study done showing that it has a greater risk of complications and/or has it even been studied since it use is probably very rare?

Once again thank you for your time - and please know I am not arguing just to be argumentative, but I have this innate desire to know the reasoning behind things - instead of being told that you simply can't do it.

Pat

[IVRUS, BSN, RN]

Well Pat,

If you're trying to get me to give you a rationale for accepting this location as an "Okay" spot to place a line, you won't get that from me. As I mentioned before, I would worry since the vessels in the chest aren't normally seen and palpated, why is it there? And do I want to risk placing it there knowing that there could be an adverse situation with the other main vessels in the chest?

Though the ribs and sternum are in the chest, it IS NOT the same as the bones in the arm. If there was an issue with infiltration, or bleeding into the SQ tissue of the chest, could you control it? You would have a better job doing it if you had a PICC or Midline in as that area is compressible.

Sorry girlfriend, some things need to be seen and assessed in the light of knowing Anatomy and Physiology and appropriateness of care.

I would encourage you (if you work in a hospital) to grab your Vascular Surgeon and pose the same question to him or her. I would pray that they could offer insight, but then again, IV nurses can offer that as well.

[iluvivt, BSN, RN]

Yes..I agree these sites should only be used for a short term bridge solution until you can secure a more appopriate venous access. As always in nursing you look at the risk vs the benefit. The problem I have seen with this short term solution is that if I or our team members place in these locations we always follow-up in a timely manner and then usually get an order for a PICC. When other RNs place them they get left in place until they are no longer functional and sometimes I have seen some nasty infiltrates....if you were going to administer levophed into that vein..if it extravasated in that unconventional location.the potential for tissue injury is there..actually in any site...it may be difficult to explain why you did not secure another type of VAD ASAP.... I would have told the MD...Sorry we can not get access....you will need to put in a central line since levphed can cause tissue injury if it extravasates....Yes you do have to get pushy... ...be careful to document what and why you did it and your attempts to secure something more appopriate