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.
"In an emergency a 22 ga cathlon anywhere in the patient is better than five 18 ga cathlons in the sharps container."
I personally prefer 18 ga cathlons for most patients but if they are only getting a dose of antibiotic, don't need fluid bolus, and don't need lab studies, I go with the 22 ga.
In our facility which is a teaching facility any one who comes in with chest pain gets a chest CT, they need and 18 gauge in the AC. Anyone who comes in with abd pain gets a CT abd which requres at least a 20 gauge in the AC preferably an 18 guage (this is hospital policy) Everyone else it does not matter, if I know it is only a short period like rehydration I will use the AC only because I do not run into valves like I do with hand and arm veins that I cannot float IV's through. For the Surgical patients the MD's prefer IV's in the hands and arms not the AC's. Trauma patients they want the biggest IV gauge you can get and that is usually in the AC. Seizure patients they want IV in anywhere but the hand (you don't give dilantin in hand IV's). Septic patients and code patients also need large IV's for fluid and vasopresors but not in the small veins (true critical patients will get central lines but not in the beginning). Obese patients,junkies, long tome alcoholics and elderly patients you just do your best they have horrible veins no matter what and if you find a vien it is usually tortuous.
To avoid getting off topic, my answer to the original question:
Within the EDs I've worked, the expectation is for all ED patients to have an 18g or larger. If unable to obtain access with an 18g, or if an 18g is not realistic (which pretty much only translates into having a pediatric patient with veins that are not compatible with an 18g IV), then something smaller is used. When starting an IV on a patient that is remotely ill and they have large veins, I may insert a 16g. 14's and 16's on acute MI, trauma, overdose, CVA, arrests, etc.
On a monthly basis, I might insert 3-5 20g IV's, and maybe one or two smaller IVs if I have an infant/child.
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?
To avoid getting off topic, my answer to the original question:
Within the EDs I've worked, the expectation is for all ED patients to have an 18g or larger. If unable to obtain access with an 18g, or if an 18g is not realistic (which pretty much only translates into having a pediatric patient with veins that are not compatible with an 18g IV), then something smaller is used. When starting an IV on a patient that is remotely ill and they have large veins, I may insert a 16g. 14's and 16's on acute MI, trauma, overdose, CVA, arrests, etc.
On a monthly basis, I might insert 3-5 20g IV's, and maybe one or two smaller IVs if I have an infant/child.
Wow, I need you to come talk to some of my fellow coworkers! I put a 16g + 18g in a symptomatic borderline hypotensive GI bleed, and my unit educator called me "cruel" - her exact quotes were "they can run blood through a 20g, even a 22g, so that would have been big enough." EMS was unable to obtain IV access, but I got both IV's on the first attempt (and no digging). The patient even said "Gee, I didn't feel that at all..."
I really should start using trauma lines more. I had a motorcycle crash pt who was rear-ended by an SUV going 35mph. Helmet was on, but the patient's head was actually pinned under the SUV. When the patient came in, we had 2 nurses and a tech in the room. The tech was going to put in the IV while we were looking the patient over, and I told the tech to put in at least a 16g; I even put a 16g and 14g at the bedside. I was peeved when I saw he only placed an 18g - because again, "a 16g is cruel." Well, after finding out the pt had T8-T12 compression fractures and a speen lac, the 16g would have been appropriate - at least that's my own opinion.
You could be putting in a 22g and digging around trying to find a vein, and that causes more pain that a clean 14g PIV placement.
BTW, I could have used someone like you today on my pediatric pt - couldn't even get a 24g in the poor kid!
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
... "Anyone" huh - where's our pt advocacy for saving some of that radiation????? Have we gotten that lax in not being able to "rule out" some people without the gift of radiation????
....
In our facility which is a teaching facility any one who comes in with chest pain gets a chest CT, ...
In pts that I figure will most likely get some fluids and meds and then go home, I'll usually put a 20g. Anyone else I will always try to get an 18, and quite often I'll go for a 16. It never hurts to have that big IV. And speaking from experience, I fractured my back this summer and got bilat 18g IVs...seriously, if you are sick or hurt enough to be in the ER in the first place, they don't hurt enough to even phase you. Just my . :)
Specializes in Spinal Cord injuries, Emergency+EMS.
18 or 20 depending onpatient size preferably in a forearm vein unless you've got huge hands when a 20 in a metacarpal vein might just work out
save the ACFs for crashing emergencies when you want a 14 or 16 or for taking blood samples with a needle and the establishments choice of blood taking paraphenalia
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.
We just used an IO on a code the other night. pt was extremely obese, and it was to difficult to get a central line. The Dr put a IO in a matter of seconds, and poof you now have a line.
my unit educator called me "cruel" - her exact quotes were "they can run blood through a 20g, even a 22g, so that would have been big enough."
LOL. That's funny, because the nurse educator in the first ED I worked in told us that "anything smaller than an 18g is unacceptable, so anyone who needs to brush up on their IV skills needs to start now!" And, the director of the ED supported that statement. Cruel or not, I guess my first thought is, "You are here for an EMERGENCY visit. I will treat you as if you are having an emergency." I would prefer someone be "cruel" and possibly save my life, than try to be "nice" and be scrambling at the last minute to get a large bore IV in me while someone is doing compressions. Yes, that sounds extreme, and maybe unrealistic in most cases, but a stick is a stick, small or large they don't tickle, so I don't see what the big deal is!
... "Anyone" huh - where's our pt advocacy for saving some of that radiation????? Have we gotten that lax in not being able to "rule out" some people without the gift of radiation????
....
I agree that patients need to be spared from radiation when at all possible, but do you currently work in the ED? I know that where I work, people demand an explanation for the slightest ache, and anymore, are flat out requesting a CT "just to be sure." If they aren't, the docs are generally forced to CT just to further rule out any possible obscure diagnosis. (It's all about getting those positive Press Ganeys! )
And... if they don't get a CT, the docs are chewed out by administration for not pleasing the patients. I don't know that patient advocacy has anything to do with it. We discharged a woman with the recurrent "abdominal pain" diagnosis (aka med-seeking) who has had >20 CT's this year. The doc was hesitant to scan her, and wrote out very specific discharge instructions re: the # of scans she's had, and the damage that radiation can do, and educated her as well. Still, she wanted to be scanned because "something has to be wrong." Who is getting lax? Maybe you are in the wrong profession -- should be educating emergency physicians re: treating and diagnosing their patients. :)
Specializes in Spinal Cord injuries, Emergency+EMS.
In our facility which is a teaching facility any one who comes in with chest pain gets a chest CT, they need and 18 gauge in the AC. Anyone who comes in with abd pain gets a CT abd
is there no medical radiation control legislation in the USA ?
as for abdo CTs what happened to USS or dignostic laproscopy as lower impact diagnostic intervntions
In the ED I work in 18g is standard. We deal with a lot of IV drug users that blow out veins and skin pop and in them we get whatever we can in. I'll be nice sometimes and do 20g if they're not really needing much, but I typically default and grab an 18g. 16g if they're a GI bleed or trauma. For those that keep saying that you could end up missing the vein and wasting time you could have used to start a smaller line I think its just a matter of getting comfortable with larger caths. I used to only do 20g's at the last ED I worked with and at first had an awful time getting 18g's into people. But after a week or two of pushing myself to try the 18's I'm pretty competent and just as fast. If there's a vein that I can put a 20 in I can 90% of the time get an 18 in as well. And now 16 are easier for me too so that when that massively bleeding patient comes in its no sweat to get a line in them. Practice makes perfect.
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Rickbos
31 Posts
An old ER nurse once told me:
"In an emergency a 22 ga cathlon anywhere in the patient is better than five 18 ga cathlons in the sharps container."
I personally prefer 18 ga cathlons for most patients but if they are only getting a dose of antibiotic, don't need fluid bolus, and don't need lab studies, I go with the 22 ga.