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.
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....
No head CT I know of uses contrast. The only stuff requiring contrast for the head/brain is MRI (Gadolinium for example).
We do CT Angios of the head all the time. It's usually up to neuro/neuro-surg to make that decision.
All I'm alluding to as far as the Bledsoe reference is that he notes that there has been no evidence supporting improved outcomes with I/O use... It's like EMS backboards, we're just using them (I/O's) without science proving them to make a difference.
We don't need evidence to prove that they don't help - we need evidence to show they do. You don't attempt to prove the negative, when the positive aspects haven't been proved yet.
That's all I'm saying is that it's something that's being marketed to us healthcare providers as the "golden" option. I'm just advocating for public research to be done before something is touted as the "standard of care" in "x-y-z" scenario. (Please refer to Steroid use in Spinal cord injuries for another "sacred cow").
Thanks for your comments - I love the dialogue.
I don't think anyone is touting them as a "golden" option. But they are just that... an option.
I, too, would like to see some research on the IO supporting them as improving morbidity/mortality. However, I don't believe there is any research showing that a large bore PIV, Fem line, IJ, EJ or any of the other means of veinous access improve morbidity/mortality in the patient population that would require IO access, either. Research on M/M outcomes in only patients with IO access would not prove/disprove the superiority of other means of veinous access in this patient population.
I here you on the Solu-Medrol for spinal injuries. Although, we do it all the time. Interesting case a couple of weeks ago... a middle-aged woman involved in a MVC came in, had decreased sensation below the chest and almost no movement of her lower extremities. When asked to move her feet, at best we would see a toe "twitch". Turned out she had a C6 on C7 subluxation. Steroids were started even before we went to CT. When we saw the CT all of our stomachs dropped. C6 was basically in front of C7. Hard to explain without a picture. Anyways... ortho came down and did a closed c-spine reduction. Within about 30 minutes she was able to move her feet. About 1 hour after the reduction, we took her to MRI to image her cord. Neuro check showed she was able to move both legs. I took her straight to NICU after the MRI. I followed up with ortho (they seem to spend most of their time in our EC) about 4-5 days later and they told me she was in rehab... Walking!!! Was it the rapid c-spine reduction that minimized her loss or was it the Solu-Medrol reducing secondary injury? Who knows? If it was my neck, I'd take "good in theory" any day!
While I can understand wanting to use larger bors catheters for trauma and surgical patients, in practical application, it's much less traumatic to the patient, quicker, and you have a higher success rate with 20 guage than with 16 or even 18 guage caths. They (20 guage) work just as well and can take the higher pressures for IV contrast, plus you can give blood through them essentially as well as 18 guages. If the pt. needs large bore, a central line might be a better choice. Now, this is all predicated on the size of the pt's veins to begin with. If they have large veins, then a larger catheter can be placed easily (although if their veins are that engorged with blood, do they really need a large bore angio?).
In practice, I use 20 guage catheters on alomst everyone with no problems.....trauma patients excluded. TRUE trauma patients should have large bore, but depending on the type of trauma, they may or may not need large volumes of fluids. But as previously stated, a central line would be preferable.
While I can understand wanting to use larger bors catheters for trauma and surgical patients, in practical application, it's much less traumatic to the patient, quicker, and you have a higher success rate with 20 guage than with 16 or even 18 guage caths. They (20 guage) work just as well and can take the higher pressures for IV contrast, plus you can give blood through them essentially as well as 18 guages. If the pt. needs large bore, a central line might be a better choice. Now, this is all predicated on the size of the pt's veins to begin with. If they have large veins, then a larger catheter can be placed easily (although if their veins are that engorged with blood, do they really need a large bore angio?).
In practice, I use 20 guage catheters on alomst everyone with no problems.....trauma patients excluded. TRUE trauma patients should have large bore, but depending on the type of trauma, they may or may not need large volumes of fluids. But as previously stated, a central line would be preferable.
Just my
May I respectfully disagree? I've found 18g caths to be less traumatic because they won't bend when placing the IV (especially in someone with tough skin). Granted, you must be skilled at IV insertion. If someone is an "in-and-out" patient, I go 20g (basic fluids, then home). If someone is sick (IVF, CT with contrast, admit), I opt for 18g if their vein can handle it. From my experience, 18g IV's decrease the possibility of hemolysis when you're drawing labs off the IV start.
I "cringe" when I see a patient arrive to the ED via medic with a 20g in their hand (yet, the patient has ropes that could easily take a 14g). My rule of thumb: no AC, no hand; go forearm, use appropriate cath size for situation (and an 18g is acceptable in almost all circumstances to draw labs, quickly deliver blood & IVF, give contrast, etc).
Also, from what I understand, "trauma lines" (14g and 16g) can infuse faster than central lines. A peripheral 16g can infuse approx. 205 mL/min, and a 14g peripheral can infuse approx. 330 mL/min. So, unless you're delivering pressors, 2 large-bore PIV tends to be the choice in any trauma. Forgive me if I'm wrong as I cannot find the max flow rate for central lines!
My theory in chest pains, cardiacs, possible cva, trauma, crappy vitals or other cases when you need a line without much delay is simple; Go big or go home, in other words, the 18 or larger in the AC where you can get the bigger IV in a large vein capable of handling whatever you throw at it. Granted, someone with ropes on their arms can get an 18 or 16 in any of those places, but if you can't see an obvious large vein in the first 30 seconds then the AC is always a sure bet.
If someone is a n/v or abd pain then 18 or smaller in forearm, hand is what I prefer. Usually just needs fluids and meds.
May I respectfully disagree? I've found 18g caths to be less traumatic because they won't bend when placing the IV (especially in someone with tough skin). Granted, you must be skilled at IV insertion. If someone is an "in-and-out" patient, I go 20g (basic fluids, then home). If someone is sick (IVF, CT with contrast, admit), I opt for 18g if their vein can handle it. From my experience, 18g IV's decrease the possibility of hemolysis when you're drawing labs off the IV start.
I "cringe" when I see a patient arrive to the ED via medic with a 20g in their hand (yet, the patient has ropes that could easily take a 14g). My rule of thumb: no AC, no hand; go forearm, use appropriate cath size for situation (and an 18g is acceptable in almost all circumstances to draw labs, quickly deliver blood & IVF, give contrast, etc).
Also, from what I understand, "trauma lines" (14g and 16g) can infuse faster than central lines. A peripheral 16g can infuse approx. 205 mL/min, and a 14g peripheral can infuse approx. 330 mL/min. So, unless you're delivering pressors, 2 large-bore PIV tends to be the choice in any trauma. Forgive me if I'm wrong as I cannot find the max flow rate for central lines!
You most CERTAINLY may disagree! That's the beauty of the forums. :)
As for bending, I've never, in 28 years, seen a 20 guage bend upon intorduction into a vein. The type of patients your ED sees has to be taken into account also. We see a LOT of elderly patients, so 18 guage's wouldn't fly as easily (smaller, less straight veins, etc.). As for CT's, our radiology dept. doesn't have a problem with 20's for any CT. They seem to work just fine for all of them. Now, hemolysis is another story. But I've had just as many draws hemolyze (per lab) with 16's and 18's as with 20's. It's all in the technique I guess. :)
I DO know from firsthand experience that a 20 guage is MUCH less painful (traumatic) than an 18 guage (and I have great veins.....called ropes!).
I looked for flow rates before and couldn't find specific volumes, but again, it would depend on the size of the catheter (18 guage double lumen vs. triple lumen, etc.). But they're finding more and more that there are fewer trauma patients who actually need large volume replacement (i.e. not in open thoracic of head injuries unless profoundly hypotensive.......
One other thing to consider is the amount of time you have to spend starting the IV. Now, I know much of this is repitition, but still.........you have a better chance of starting a 20 guage on the first shot than an 18 (again, depending on the size of the veins, age of the pt., etc.).
I'm thinking much of it comes down to personal preference. I've used 20 guage's for years with little problems and have heard all of these arguements over and over again. And in the end, the 20 guage cath has continued to work (policies have changed, restrictions loosened, etc.). Just my
When choosing a size I try and think of what the pt needs the IV for now and down the road. Do they need lots of fluids or blood products which require a large gauge or do they just need an access? Sometimes I smaller is better because small access is better than no access. Then as the others suggested you can get a central line. Regarding flow rates, that stuff is usually printed right on the IV catheter wrapper.
Specializes in Internal Medicine, IV Therapy, Emergency.
The only time I go A/C (any size) is when the pt is crashing and it's the easiest access or there is nothing else periprheral.
One can usually track the basilic vein (in "averge veins") far down enough as to not occlude a pump due to arm flexion. I believe that a tweny is a good all-purpose size unless it is a pt. with a bleed, then I will try 18, usually foolowed by a second site for Panto.
Then you have the option of more rapid fluid infusion as well as the ability to switch around .
Another option (in really good veins) is a double lumen 18/20.
CT usually prefers 18g, as they can control infusion rates if less pressure is required but they can get by with less, rest assured, so go with your gut on size/location. After all, everyone's sense of "feel" and needle handling is different.
In pt's going to O.R. anesthetists usually prefer lower, outer arm for ease of access when the pt. is positioned on the table, again allowing opportunity for an 18 or 20 guage vs. 20/22 in the hand.
My rule of theumb: the bigger the better-- just go slow and easy.
When choosing a size for the patient a lot of it depends on what is wrong with the patient. If it's truly a trauma case and we suspect internal bleeding and think that the pt. will need a blood transfusion then I want to put in an 18. FOr your NVD folks who present with neither tachycardia or low BP a 20 will be fine for them. But if they are hypovolemic shocky then I'll 18 them if I can. The big word here big IF. If soemone comes in with their volume depleted their veins arent going to be easy to find. And then there are folks like me, I just have no veins, never have. I was stuck 16 times once when I was 12 or so and had pyelonephritis. I think that what I do the most is to make the best of a bad situation, get in the biggest thing I can if I think the patient is really in trouble. Or I have to make do with what I can get at the time. If someone is very dry, may hve to start with a 22 until we can build up their reserve then give them something bigger if they really need it. I have taken patients to ICU with only a 22 in their thumb, the doc has a cow and wants it changed. The ICU nurses look, find nothing, call the nursing supervisor who then calls me because I have always been her go to person for starting IV's. I walk in look at the doc and hand him a central line tray.
I generally use 20g, preferably in the forearm, unless the patient is complaining of abd pain or chest pain. Then, I may try for an 18g in the AC, if their veins will tolerate it.
IOs are great for emergent pediatric and adult patients, but they are short-term, good only for 24 hours.
Specializes in Internal Medicine, IV Therapy, Emergency.
Yes, of course, each patient is different and at the end of the day that is what must be remembered--- just giving my general rule of thumb.
I work in my provinces only Level One Trauma Centre but central lines are really a final option for us, only used if the pt is truly crashing.
Otherwise, if our Dept can't get a line or two, we still have an IV Team to troubleshoot and then the next choice is to Interventional radiology for a PICC Line.
Carlitos
15 Posts
We do CT Angios of the head all the time. It's usually up to neuro/neuro-surg to make that decision.
I don't think anyone is touting them as a "golden" option. But they are just that... an option.
I, too, would like to see some research on the IO supporting them as improving morbidity/mortality. However, I don't believe there is any research showing that a large bore PIV, Fem line, IJ, EJ or any of the other means of veinous access improve morbidity/mortality in the patient population that would require IO access, either. Research on M/M outcomes in only patients with IO access would not prove/disprove the superiority of other means of veinous access in this patient population.
I here you on the Solu-Medrol for spinal injuries. Although, we do it all the time. Interesting case a couple of weeks ago... a middle-aged woman involved in a MVC came in, had decreased sensation below the chest and almost no movement of her lower extremities. When asked to move her feet, at best we would see a toe "twitch". Turned out she had a C6 on C7 subluxation. Steroids were started even before we went to CT. When we saw the CT all of our stomachs dropped. C6 was basically in front of C7. Hard to explain without a picture. Anyways... ortho came down and did a closed c-spine reduction. Within about 30 minutes she was able to move her feet. About 1 hour after the reduction, we took her to MRI to image her cord. Neuro check showed she was able to move both legs. I took her straight to NICU after the MRI. I followed up with ortho (they seem to spend most of their time in our EC) about 4-5 days later and they told me she was in rehab... Walking!!! Was it the rapid c-spine reduction that minimized her loss or was it the Solu-Medrol reducing secondary injury? Who knows? If it was my neck, I'd take "good in theory" any day!
'Los