IV size

I have never seen IO used in a code or for routine use in adults. IO is used more in pedis for certain things but I can't tell you whether they use it much in pedi or not. IO is a big infection concern - think osteomyelitis and lots of tx costs for any infection. If it is some sort of trauma/code and IV access can't be obtained any other way, the docs may consider a cut down to the femoral vein. But in a code, mostly they'll just use the ETT for meds as a last resort unless some med student or new resident needs a procedure and is allowed to do a cut down.

IV size and placement has to be individualized. You need to be looking at the reason for IV line placement, whether IVF are continuous or intermittent, what meds/fluids are going to run through it, what the condition of the patient is.

If I am in the hospital for a non-emergent reason and you put an 18 in my AC - we're gonna have problems. I can't do ADLs with an 18 in the AC and you will be going nuts having to come turn off the beeping IV pump all day because I am not going to keep my arm completely straight for 24 or more hours.

There are no hard and fast rules, this is individualized for safety as well as comfort for the pt.

i hope you're not in the ER for 24 hrs!

in the most recent ACLS they put the IO route just after the IV route and before the ETT; med absorption through a tube is unpredictable.

is the risk for osteomyelitis w/ IO access greater than phlebitis w/ IV? and what is the infection rate for a cut down? that seems overly invasive and time consuming as opposed to IO access.

also, i understand the critical thinking aspect of IV selection but it seems you have more options w/ an 18 vs. 20. all of this assumes an emergent and not urgent situation.

anywhoo, thanks for responding.

Actually IO's are being used in all patient populations and for more than just trauma. For the most part they are used only for patients in extremis where attempts at peripheral lines have failed or rapid access is necessary. Another use is by EMS when faced with a prolonged extrication and an unstable/potentially unstable patient. They will use the humerous which is usually easily accessed. With the advent of the EZ-IO the need for femoral cannulization in an emergency situation has been minimized. In all actuality fem lines take too long to insert and have way more risk of complication than IO's. Do you really want a med student attempting one in the middle of a code? The statement that the use of IO's comes with a big concern for infection has been proven false. The risk of osteo is miniscule when the IO is inserted in a properly prepared site. The benefit of having a functional line in an emergency far outweighs what risk there is. I addition using the ETT as a route for medication administration is falling out of favor because of the inconsistent absorption rate and doubtful efficacy of this route. IO is the preferred route over ETT and femoral lines in emergencies. Anyone who tells you differently is misinformed. IO's usually come in 18 and 16 gauge sizes. They can be left in place up to 24 hours but are usually removed as soon as more permanent access can be established. They can be used in patients from neonates (>3kg) to the little old lady from the nursing home. Just remember that it hurts when you pressurize the marrow compartment so a little Lido is a kind thing to remember. Google "EZ-IO" there's a great video from the company showing the insertion of one on an alert, voluntary patient. He says the pain on insertion is no worse than a PIV.

As for PIV sizes it all depends on a host of circumstances. What is the IV for, how big is the vein, general circulatory status of the patient, etc. In the ER it's usually an 18 or 20 because blood specimens are usually obtained at the same time and we give lots of fluid boluses. the only CT I'm aware of that requires a specific size is a Chest CT for PE. My facility requires a minimum of a 20 because the dye is injected so quickly and the scan is also done very rapidly. If the dye does not infuse rapidly the picture is non-diagnostic. Never heard of a head CT requiring anything special. Hope this helps.

in the ICU we prefer 18's anywhere BUT the AC.....where central lines aren't available of course. i've only seen IO used once in an elderly septic patient. the line was removed as soon as she hit the ICU and we placed a central line. fem lines are still a better choice over an IO ......easy, no brainer insertion and takes just seconds to put in. while i can see the use of IO in trauma's in the field where accessibility is questionable, in a hospital setting i'd take a fem line over an IO any day!

Here's a link for IV flow rates for one type of BD IV catheter: http://www.bd.com/infusion/pdfs/d16131.pdf

I'm in the ED, and I usually put 18g IV's in everyone that I can (its good for IV contrast, fluid boluses, and drawing blood of the IV start). I rarely use the AC (I can't remember last time I did, although I do have patients from time to time that will request me to place it there), and I rarely use the hand. I will use a smaller catheter if I am going to be infusing irritating meds (to help dilute the medication more and lessen venous irritation). I've used 16g IV's and I once placed a 14g IV (I reserve these for trauma or other serious conditions).

I believe that ACLS is promoting the use of I/O after 2 failed IV attempts. If I am recalling correctly, adult I/O needles are 16g. Placing an I/O is extremely fast if you're using a drill and it buys time for a central line.

fem lines are still a better choice over an IO ......easy, no brainer insertion and takes just seconds to put in. while i can see the use of IO in trauma's in the field where accessibility is questionable, in a hospital setting i'd take a fem line over an IO any day!

IO's take less than 5 seconds to insert. I've never seen a fem line placed in that amount of time. While I appreciate your opinion I'm afraid that your information may not be up to date. We, however, may be comparing apples to oranges. Obviously an IO is not the route of choice for patients in the ICU but that was never their intent. They are intended for short term emergency use until a more long-term route can be established. In an emergency whether in hospital or out the IO route has become the route of choice over fem lines and it is not limited to trauma patients only. There have been many studies done that have supported the theory that IO's are superior to fem lines in emergency/urgent situations. Most progressive ER's are now using some form of mechanical IO insertion device and I dare say most if not all air and surface transport teams do as well. The advantages of IO's (over fem lines) has been well studied and documented. To state otherwise would be a reflection more of personal opinion than actual fact. I would wager a bet that unless you are working in an extremely small hospital you will see IO placement more and more as they become accepted standard management.

Regarding Intra Osseous access....

I can cite Bryan Bledsoe that "there is no emprical evidence" to support their usage.

I would challenge anyone to show/cite sound evidence/research that IO devices reduce overall mortality and improve final outcomes....

Also consider that currently the theory of "permissive hypotension" in trauma is being explored, and we may not be in such a rush in the near future for massive fluid volume resuscitations - which means I/O's go back on the shelf and all those Level 1 infusers become good lab coat hooks.

actually io's are being used in all patient populations and for more than just trauma. for the most part they are used only for patients in extremis where attempts at peripheral lines have failed or rapid access is necessary. another use is by ems when faced with a prolonged extrication and an unstable/potentially unstable patient. they will use the humerous which is usually easily accessed. with the advent of the ez-io the need for femoral cannulization in an emergency situation has been minimized. in all actuality fem lines take too long to insert and have way more risk of complication than io's. do you really want a med student attempting one in the middle of a code? the statement that the use of io's comes with a big concern for infection has been proven false. the risk of osteo is miniscule when the io is inserted in a properly prepared site. the benefit of having a functional line in an emergency far outweighs what risk there is. i addition using the ett as a route for medication administration is falling out of favor because of the inconsistent absorption rate and doubtful efficacy of this route. io is the preferred route over ett and femoral lines in emergencies. anyone who tells you differently is misinformed. io's usually come in 18 and 16 gauge sizes. they can be left in place up to 24 hours but are usually removed as soon as more permanent access can be established. they can be used in patients from neonates (>3kg) to the little old lady from the nursing home. just remember that it hurts when you pressurize the marrow compartment so a little lido is a kind thing to remember. google "ez-io" there's a great video from the company showing the insertion of one on an alert, voluntary patient. he says the pain on insertion is no worse than a piv.

as for piv sizes it all depends on a host of circumstances. what is the iv for, how big is the vein, general circulatory status of the patient, etc. in the er it's usually an 18 or 20 because blood specimens are usually obtained at the same time and we give lots of fluid boluses. the only ct i'm aware of that requires a specific size is a chest ct for pe. my facility requires a minimum of a 20 because the dye is injected so quickly and the scan is also done very rapidly. if the dye does not infuse rapidly the picture is non-diagnostic. never heard of a head ct requiring anything special. hope this helps.

well said- full of great info!

we use ios in codes adult/pedi if an iv is not readily in place. they stay in place until the pt stabilizes enough to get a 'good' peripheral or better yet, a central site because chances are these types of patients have beaucoup drips running that often don't mix well together.

what is the consensus regarding IV size and placement? go big within reason, 18g in the AC, or small and distal 20g below the AC?

Traumas patient's obviously get 18s and 16s.

If it's a patient with a potential hot MI or an acute stroke, I try and insert double lumen (Like the TwinCath from Arrow) catheters if possible, because more likely than not these patients are going to be getting multiple non-compatible drugs at the same time. It's a little hard to insert these because the catheter itself is rather long and you don't always find good, long veins to insert them into :) But hey, if you can...

i know some CT contrast can't go into a 20 (head CT? do to the slower speed?)

Our facility has "requirements" when it comes to chest CTs. Preferably an 18g but at the very least a 20g - in the Right AC (apparently due to blood flow and distribution).

cheers,

Thanks for your comment mwboswell, and hope you dont mind if I add my :

From Bryan Bledsoe himself: "I think the IOs are a good tool ... I think the IOs should be on the ambulances, but only as the ultimate last resort (akin to a surgical airway or chest decompression tool)..." http://forums.firehouse.com/showthread.php?t=78122&page=4

In my opinion, its hard to gauge whether or not I/O's significantly improve mortality rates. Patients receiving I/O's are usually victims of severe trauma and/or have significant circulatory collapse and have a higher rate of mortality regardless (furthermore, IV cannulation in these patients was impossible, leading staff to resort to I/O placement). Yeah, research is now documenting the rate of survival with I/O access, but patients that are receiving I/O's are sicker to begin with and are not clinically equivalent to any comparison group.

On the other hand, research has shown that medication absorption via I/O is comparable to IV absorption (with some minor differences for some meds). It is this research that validates the use of I/O's for patients requiring lifesaving medications/fluids when IV placement is unsuccessful.

I think the risks of I/O's could be reduced by having a good securing device. There's been a few times that I've seen patients arrive in the ED with an I/O that isn't secured or covered. Sure, infection at that point doesnt matter if they don't have a heartbeat. But if it is your only means of circulatory access, you better darn well secure it! As far as I'm aware, there isn't a commercially available securing device for I/O's (but I'm sure we could develop one and make some real cash!).

I would also take a fem line over an I/O - but if you don't have a fem line, what can you do? Personally, I see the use of an I/O as a temporary means to administer meds and fluids until a central or peripheral line can be placed. I've never sent a patient to ICU with only an I/O...but, I have had ICU nurses refuse to pull the I/O despite the fact that I had placed an 18g and 20g PIV in the "stabalized" patient (I/O was placed in the field, and the previous RN could not get a PIV; a central line had been unsuccessful, and the subclavian attempt had caused a pneumo resulting in a chest tube - and buying the patient a ticket to ICU).

i didn't see this in the search results.

what is the consensus regarding IV size and placement? go big within reason, 18g in the AC, or small and distal 20g below the AC?

what is the flow difference between these two? time for a liter to flow through a 16, vs. 18 vs. a 20? i know some CT contrast can't go into a 20 (head CT? do to the slower speed?)

during a recent ACLS class the instructor noted the increased speed and accuracy of dropping (drilling) in an IO vs. an IV and alluded to trauma situations going to the IO route over IV. how long can an IO remain in place? and what gauge are they? big i assume.

dan

I'm a huge fan of 20s, just because most veins that I've seen can tolerate them fine. If you've got big huge veins or you need a PE study (radiology requires at least an 18), then u get an 18. I've seen 18s in hands, but I've never put one in a hand myself. Never seen an IO placed. Just learned about them in ACLS.

With all due respect I believe you are clouding the issue. IO's are never intended to be used for "massive fluid volume resuscitations" and certainly not with a rapid infuser. Using an incorrect application to support your apparent dislike for the IO route is at best disingenuous and at worse misleading. Nobody is putting forth that the IO route is perfect but it is, however, an easy, effective and rapid manner to gain access in a patient who needs IMMEDIATE intervention until such time that a definitive route, be it peripheral or central, can be obtained.

Furthermore, nobody has made any claims that IO's have any influence over the morbidity/mortality of trauma or cardiovascular collapse patients. As kmoonshine pointed out the patient's who get IOs are the ones who are statistically in the "crapper" if you pardon my expression. Do you honestly think they had a better chance with NO ACCESS at all. These are the patients that you can't get anything in; not peripherally not centrally. So the fact that they showed no improvement in M&M is statistically insignificant. But at least every attempt was made.

In addition, while I have a great deal of respect for Dr. Bledsoe, especially regarding his views on HEMS, to cite him (from a forum no less) soley as support for your position is extremely weak. He is expressing an opinion only and with no statistics posted to support his views. Not only that but the opinion is being taken out of context and I encourage everyone to read the entire post, especially the comments following his that do cite studies supporting the use of IOs in EMERGENT situations. And that is from where I think the disagreement is stemming. We aren't talking IOs as appropriate to use in every situation which the "anti IO" faction seems to be misconstruing. IO acess is an appropriate and effective tool for use in a patient who needs immediate intervention and where rapid peripheral access has been unsuccessful. Yes a CVC of some sort is preferable for further care and no an IO is not a replacement for one.