IVs in the breast

IVRUS, BSN, RN · Nov 10, 2015

Psst... A central line is going to take just as long if not longer than a PICC.

A PICC is a central line. Normally, a PICC can be placed in 1.5-2 hours. This time frame covers the thorough chart review and the line placement in a cooperative adult. A non-tunnelled, percutaneously placed central line can be inserted by an MD in 15 minutes if they are well accomplished.

applewhitern, BSN, RN · Nov 16, 2015

We have had quite a few placed in the breast, and I have not seen any problems with them. We would never do an intra-osseous for simple IV antibiotics, and being a small hospital, we don't have access to u/s guided, PICC teams, etc. Each nurse places their own IV here. Like I said, I haven't witnessed any problems with a breast IV. They are just like any peripherally placed one. They are placed mainly on the sides or top, anyway; never around the areola.

Lev, MSN, RN, NP · Nov 16, 2015

I just remembered, the lady I started the breast IV on actually suggested it since we could not find a vein. In reference to member IV's, never started an IV, but have had patient at methadone clinic draw blood for the RPR for me from his member. We had tried fingerstick but no go so he offered, it worked.

Wow he must have really wanted his methadone!

dudette10, MSN, RN · Nov 16, 2015

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.

Bluntly speaking, the infusion nursing standards are so "perfect world" that they can often be unrealistic and don't take into account risk vs benefit. "If a patient needs a vesicant medication, ultimately they need a central line." Really? Potassium, vanc, and contrast agents have vesicant properties, but I'm not about to hold up everything to get a central placed for those. Centrals are not without their risks, and in my opinion, have a higher risk than benefit of potential vesicants. Just maintain your PIVs well, people!

And not every chemo agent is a vesicant. I've had four infusions of Cytoxan and Taxotere through PIVs. Two infusions actually went through the same vein, and I can still see the vein. One infusion went through a vein on my right arm, and I am endlessly fascinated by the fact that I can see where my body created a new vein that is essentially a detour around where it collapsed post-infusion.

blondy2061h, MSN, RN · Nov 16, 2015

I had D50 peripherally and got thrombophlebitis afterward.

Anna Flaxis, BSN, RN · Nov 16, 2015

Bluntly speaking, the infusion nursing standards are so "perfect world" that they can often be unrealistic and don't take into account risk vs benefit. "If a patient needs a vesicant medication, ultimately they need a central line." Really? Potassium, vanc, and contrast agents have vesicant properties, but I'm not about to hold up everything to get a central placed for those.

Yes, really.

Potassium is a vesicant at concentrations greater than 2mEq/mL. Have you ever given KCl at that concentration?

Vancomycin intended for peripheral use is generally mixed at a lower concentration and given over a longer period of time than for a central line, so that it is considered an irritant when given peripherally.

Intravenous contrast material, when extravasated, rarely causes serious complications. Plus, most institutions have protocols in place for the size and location of PIVs to be used for contrast injection.

I understand the concept of risk vs. benefit. Every medication, every treatment, has an element of risk, which is why we educate our patients about these risks.

Still, would I give a vesicant medication through a 24g. in the chest wall? Nope.

VANurse2010 · Nov 17, 2015

A PICC is a central line. Normally, a PICC can be placed in 1.5-2 hours. This time frame covers the thorough chart review and the line placement in a cooperative adult. A non-tunnelled, percutaneously placed central line can be inserted by an MD in 15 minutes if they are well accomplished.

I've never seen a PICC take anywhere close to 1.5 to 2 hours, and rarely seen a standard CVC take "only" 15 minutes. And I think we're all aware that PICCs are central lines, hence what the "CC' in PICC stands for.

VANurse2010 · Nov 17, 2015

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

Whether one agrees with this practice or not, I don't think anyone in this thread was advocating power injecting contrast or running chemo through a flimsy IV, breast or otherwise.

IVRUS, BSN, RN · Nov 17, 2015

Van, You, yourself posted this:

Psst... A central line is going to take just as long if not longer than a PICC

So... It appears that you are saying here that a central line is different than a PICC. Your words, not mine, and therefore my comment. It is funny that you copy and pasted and choose to comment on two Infusion Specialists posts. Hmmm...

And, If your read my post, I said that from initial chart assessment to completion of the line placement.. So yes, my time frames are correct.

takkatak · Nov 17, 2015

I have placed one out of desperation. Pt had rhabdo and needed IVF. ED and ICU nurses tried to place access to no avail. No PICC line at night. A 22g in the chest held up well at least until the patient was able to get PICC line during the day.

VANurse2010 · Nov 18, 2015

Van, You, yourself posted this:
Psst... A central line is going to take just as long if not longer than a PICC
So... It appears that you are saying here that a central line is different than a PICC. Your words, not mine, and therefore my comment. It is funny that you copy and pasted and choose to comment on two Infusion Specialists posts. Hmmm...
And, If your read my post, I said that from initial chart assessment to completion of the line placement.. So yes, my time frames are correct.

I think it has been clear from the context of this thread that when we're talking "central line" we're referring to a CVC in the IJ or subclavian, not a PICC. I think everyone here understands the distinction - you don't need to be an infusion nurse to understand this common parlance.

I do not believe your time frames are correct. I've seen the PICC procedure take place in far less than 1.5-2 hours on multiple occasions.

IVRUS, BSN, RN · Nov 23, 2015

I think it has been clear from the context of this thread that when we're talking "central line" we're referring to a CVC in the IJ or subclavian, not a PICC. I think everyone here understands the distinction - you don't need to be an infusion nurse to understand this common parlance.
I do not believe your time frames are correct. I've seen the PICC procedure take place in far less than 1.5-2 hours on multiple occasions.

I think that you would be truly amazed at how many nurses do not understand the differences in IV catheters. I am really glad that you do seem to get it. Also, if you've seen PICC's placed in shorter time frames, I'm okay with that as long as steps weren't omitted and patient outcomes remain high.