IVs in the breast

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Does anyone have any evidence based information on IV access in the breast? I've seen some catheters placed in the breast by nurses in the ED and I'm trying to find Best Practice/Evidence for this.

IOs are not painful. The pop is a little disconcerting, but it really hurts about as much or less than an IV. I let a friend do one on me in school. The flush can be painful though. There is one drug that I know of that is contraindicated for IO use--d50. I am not 100% sure but I think it is because it can have necrotic effects when used IO....similar to what would happen if it were administered to a non patent PIV site.

I don't know of a specific contraindication to giving D50 intraosseous to the adult patient, but if you are concerned about risks, you could run D10, which is just as effective as D50, and is not a vesicant.

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NO NO and No,Never do this, there is no research to support this practice and it is not recognized by any professional organization. With that being the case should any adverse outcome occur and the patient suffer any damages you as the nurse would not have a leg to stand on legally,even if you had an MD order! Why risk harm to the patient and your ability to earn an income..just do not do it. They will get a Vascular Access Specialist on the stand and they will drag out the INS standards and other industry standards and you will be toast!

If you need access desperately you need to place an IO,then work on getting another type of access. IO can be placed within minutes! Any port in a storm is not true because when the storm subsides and there is an extravasation of Calcium or Dopamine and the patient loses their breast and is disfigured you will be sorry

I'm not necessarily disagreeing, but I've noticed that several infusion nurses on this forum seem to confuse INS standards with a legal standard of care. They are not exactly congruent.

Has any PIV access really been seriously studied that it could be called "evidence-based?"

Is going from no PIV access straight to an IO evidence-based?

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Hmmm, I didn't get the sense that iluvivt was equating standards of care to legal standards, but rather, was illustrating how a failure to follow a standard of care could get a person into legal trouble. I'm not a legal scholar, but it seems to me that following standards of care is prudent, since in a malpractice suit, this is what the plaintiff must establish and prove was breached.

The case of infusing D50 is an excellent example, for instance if all you could get was a chest wall vein to infuse hypertonic dextrose which extravasated and resulted in the loss of the breast tissue. It would be quite easy for the plaintiff to establish that there were options available, such as IO or even IM/SQ glucagon.

In the case of sepsis where aggressive fluid resuscitation is standard of care, a small bore catheter in the chest wall would be indefensible.

If the person isn't sick enough to warrant intravenous access, medications can be given by other routes. If the patient is sick enough that they do need access, there are plenty of other options besides a chest wall vein.

If the physician insists on IV access through a chest wall vein, I will invite them to initiate the access themselves and I will document accordingly. However, this doesn't make much sense when an EJ would provide better access.

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Hmmm, I didn't get the sense that iluvivt was equating standards of care to legal standards, but rather, was illustrating how a failure to follow a standard of care could get a person into legal trouble. I'm not a legal scholar, but it seems to me that following standards of care is prudent, since in a malpractice suit, this is what the plaintiff must establish and prove was breached.

The case of infusing D50 is an excellent example, for instance if all you could get was a chest wall vein to infuse hypertonic dextrose which extravasated and resulted in the loss of the breast tissue. It would be quite easy for the plaintiff to establish that there were options available, such as IO or even IM/SQ glucagon.

In the case of sepsis where aggressive fluid resuscitation is standard of care, a small bore catheter in the chest wall would be indefensible.

If the person isn't sick enough to warrant intravenous access, medications can be given by other routes. If the patient is sick enough that they do need access, there are plenty of other options besides a chest wall vein.

If the physician insists on IV access through a chest wall vein, I will invite them to initiate the access themselves and I will document accordingly. However, this doesn't make much sense when an EJ would provide better access.

I think perhaps you had a different take on it, but part of my interpretation is based on several posts by several different infusion nurses. Suffice it to say, if INS standards were actual legal standards of care, then one would see that reflected in nurse practice acts and facility policies at major hospitals - and that is certainly not the case.

I don't think anyone here is suggesting that a breast IV is appropriate for fluid resuscitation in sepsis.

There are other options, but that doesn't mean that accessing them is an option - particularly in smaller community hospitals. A lot of this discussion is academic speculation. In reality, anyone with shoddy enough access to get a breast IV is going to end up with a CVC if they're admitted.

Have you ever seen an EJ extravasate? I have, and seen someone killed by it, that is why *I* will never run vesicants or pressors through those.

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No, you are quite right, if the patient needs a vesicant medication, ultimately they need a central line. I was thinking in terms of crystalloids and non-vesicant meds when I wrote that (about EJs).

I agree, there does seem to be a difference in perception. I'm not feeling like we're being told that INS standards are legal guidelines. I do think it wise though, and this is what I am inferring from the referenced post, to follow standards of practice, and whenever you deviate, to have a rock solid, defensible rationale.

"It was all I could get", in this instance, is not defensible.

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No, you are quite right, if the patient needs a vesicant medication, ultimately they need a central line. I was thinking in terms of crystalloids and non-vesicant meds when I wrote that (about EJs).

I agree, there does seem to be a difference in perception. I'm not feeling like we're being told that INS standards are legal guidelines. I do think it wise though, and this is what I am inferring from the referenced post, to follow standards of practice, and whenever you deviate, to have a rock solid, defensible rationale.

"It was all I could get", in this instance, is not defensible.

I guess my point is "it was all I could get" may actually be true in some facilities at some times.

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I work in a facility where at times, there is the temptation to practice like that. We don't have a lot of resources, and not all of our providers are comfortable inserting central lines. Until recently, RNs were not allowed by facility policy to insert IOs, and some of the physicians are more reluctant to drill than others. I've advocated for training RNs in ultrasound guided PIV placement, only to be told no. A couple of our providers know how to do this, but you can't count on being on shift with one of them when you need it. So I get what you're saying. I really do.

Still, I encourage following standards of practice.

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Specializes in Pediatric Critical Care.
I've advocated for training RNs in ultrasound guided PIV placement, only to be told no.

Frustrating. I cant think of any reason except money not to allow this. :(

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Specializes in Pediatric Critical Care.
I work in a facility where at times, there is the temptation to practice like that. We don't have a lot of resources, and not all of our providers are comfortable inserting central lines.

I worked for a while at a facility where the doctors were hesitant to insert central lines (probably because they hadn't done so in years). We had a patient (an infant) that needed pressors, and the doc told me that since I wasn't comfortable running them through the PIV that I had placed in the babys hand, that he would place a 22g or 20g angiocath in the groin for me to run them through. Uh.....no, that is still not a central line doctor. If you want to run pressors through that, you'll have to do it yourself. I told him that if he couldn't or wouldn't get me central access on this baby, then he needed to transfer them to a facility that was willing and able to do it.

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Specializes in Infusion Nursing, Home Health Infusion.

I know the difference between the standard of care (SOC) in a nursing situation and a legal standard. The SOC is the nursing intervention that would be performed by a prudent nurse in a similar situation. How is that standard derived you might ask. Well many moons ago I did know until I was given the job of writing policies and procedures with very little guidance. So in order to do a great job I had to find out all about this. Nowadays most are scientifically based (evidenced based) or practice based (standards recommended by clinical experts and quality improvement initiatives).

In a court of law, "learned treatises" are looked to in order to help the court decide if a SOC in a particular situation was violated to cause the harm. The "learned treatises" in the IV world come from a variety of sources with one being the INS standards of practice. Others would be the recommendations coming from the ONS,APIC,AVA,ANA,ASPEN,CDC,TJC and others. Other legal cases may also be used as well as manufacturer's IFUS for any products used.

So all I am stating is that they will use these documents to make their case against you. If you place a PIV in a breast and then you give a power injection of ionic contrast through it and it extravasates and causes permanent harm then you can bet an expert witness would state that is against standard XYZ to place a PIV in that location.

If you administer vesicant chemotherapy in a VAD and DO NOT document a blood return and it extravasates and causes harm both INS and ONS standards will state you did not follow the standard of care. They will use these documents against you to make their case

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Specializes in ER.
And BTW if they can't find a site on an arm for a PIV, how do you suppose they could get a PICC in?!!! If your answer is ultrasound then they best method would be to use the ultrasound and place a peripheral line i that way! It takes a good physician about 20 seconds to find the IJ or the landmarks for a subclavian, not much searching, compared to trying to find a vein for PICC access on a patient with poor peripheral vasculature!

Annie

Annie

Isn't it standard procedure to use the ultrasound for PICC line placement?

Isn't it standard procedure for hospitals to require training with the ultrasound for PIV placement? At least it is for ours.

Our physicians are supposed to be using the ultrasound for central line placements too.

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Specializes in MCH,NICU,NNsy,Educ,Village Nursing.
YOWCH!

Isn't that the truth!!!

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