IV insertion area guidelines

[patwil73]

Hello everyone - I posted this in the IV/Infusion group but it doesn't seem to get much traffic so I though I would repost here and see if I could get a few more views.

Original Post Follows:

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

__________________________________________________________________________________________________

I did get one response to look at the Infusion Nurses Society - but their website does not provide the guidelines (although you can buy the book from them). I found a copy of Core Curriculum for Infusion Nursing which outlines what veins should be used (and although it provides rationals for their use, it does not talk about the use of chest veins).

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.

So any answers out there as to why we should never use chest veins?

Thanks in advance

Pat

[traumarns]

somebody on levophed should have had a central line. was this in the er, when you dont have time to start the drip while waiting for the doc to put one in. or was this pt in the icu already?

if in the icu she SHOULD have had a central line.

in the ed, we go where we can, while the docs are putting in a cordis, cut down, central, anything.

did anybody try an EJ?

[patwil73]

This was in ICU where unfortunately we do not have a written policy on having central lines with specific drugs - even though we know we should. No one in the hospital other than ED and Anesthesia is trained in EJ's (although I have asked to be) so I couldn't go there. Anesthesia was in surgery (this at night with only 1 on) and the hospitalist was not comfortable due to training to put in a central line.

What I would like is a policy that states if you get this drug (dopamine, levophed, etc) you must order a central line and have it placed prior to start (unless an absolute emergency). Also if it requires more than 2 pokes for 2 consecutive blood draws due to poor venous access or you lose an IV in under 24 hours due to poor venous access you get a central line. However, we are not there yet.

Do you know of any reason why one can't use a surface chest vein? Any literature out there that says they can't be used?

Thanks for your reply

Pat

[BluegrassRN]

I can't answer your question, but I would like to point out that in our hospital, if we can't get a peripheral, time is of the essence, and there is no one or no time to insert a central line, we can call the ED and they will come up an put in an IO. In a code or rapid response call, if we don't have access, our protocols state we can put in an IO.

I've done it in theory--in ACLS. The nurses in the ED say it is so easy. The new standard for our county EMS is that if they have an emergency--ie trauma, code, that sort of thing--they don't even dink with IV access, they go straight for the bone. If they need access in a less emergent situation, can't wait to hit the ED, and have stuck twice without success, they go for the bone. If they need access and don't think they will be able to get it (poor veins, etc), they can go for the bone first try. Our ACLS instructor felt that we would be seeing more of these up on the floor, too, within a couple of years. We now have the equipment for it in all our code carts, and anyone who has been ACLS certified can put one in. I haven't seen it done of the floor yet, but I know we've done it in some codes in the ICU.

So that might be something to write into your protocols. When there isn't another option, no one can hit anything, there isn't anyone to try for an EJ, there isn't time or staff for a central line--you should be able to put it in the bone.

[RNKPCE]

We aren't allowed to put IV's anywhere but the arms and hands. Becareful using a chest vein. We had someone with a mediport, it wasn't accessed properly and they got a large infiltration of dopamine in their chest requiring plastic surgery. It is harder to notice infiltration in that area.

[PICNICRN, BSN, RN]

I think we are a little different in the Pediatric population in that we use feet, scalp, legs, groin, ect all the time- and I prefer the saph to any upper extrem vein in most cases. I've even seen one placed in the abdomen until central access was obtained.

I think your main concern should be what the heck is an ICU pt on Levo doing without a central line for God's sake?? Not only for access, but wouldn't they want a CVP on the person?? Many of the pressors are not so good to give peripherally- dopa can really cause some damage- and is recommended for central access only.

In a pinch, I guess you did the only thing you could do. The only other place I could think is an EJ or Fem- I don't know how your facility feels about that.

Personally, I find it appalling that any patient is stuck multiple times for IV access- it is totally unnecessary! Someone needs to place a Central Line in these folks.

[PICNICRN, BSN, RN]

I couldn't find anything about not using a chest vein either. In our world, if you have a good blood return and it flushes well- use it!

I'd imagine that some might think that you might not be able to see if it would infiltrate. But trust me- if you have an ICU nurse with a chest vein as the only access on a pt on Levo...... they will be watching that IV like a hawk! ohhh... and if I were that nurse assigned to that pt- I'd be making darn sure my pt got a central line!

You did all you could do!