Placing PIV in stroke affected arm (Evidence Based research)

brownbook · Mar 15, 2019

I tried really hard to find my old post. I had the same question you did. I can only remember that generally, maybe, kind of, it was not a huge issue. I think I found some vague information. I didn't get any responses to my post.

I work out patient surgery where we start IV's all day long. I mentioned it to our chief anesthesiologist, the "snippets of information that says not to place them in a stroke affected arm" she had never heard of it.

I guess, assume, it is not a huge issue or it would be more common knowledge.

IVRUS, BSN, RN · Mar 15, 2019

In order to get appropriate venous return to the heart, it requires the use of the muscle pump action in the arm. If one is flaccid, that is impaired. Thrombosis and venous stagnation are two concerns. So, no, this is not an arm you want to place an IV catheter into.

brownbook · Mar 15, 2019

2 hours ago, IVRUS said:
In order to get appropriate venous return to the heart, it requires the use of the muscle pump action in the arm. If one is flaccid, that is impaired. Thrombosis and venous stagnation are two concerns. So, no, this is not an arm you want to place an IV catheter into.

This certainly makes common sense. But I don't think the answer is never use an affected arm. I know your did not say never.

Assess the mobility of the affected arm, one that is completely flaccid, don't use. Some degree of movement, check the radial pulse, blanch return, etc. should be okay.

There are and will be cases when a stroke affected arm is the only option, (outside of a foot, IJ, central line, etc.) so assessing the affected arm makes sense.

Tracykg · Mar 16, 2019

Thank you for your replies. I know the reasons for not placing an IV (or other vascular access device) in a stroke affected arm, and that sometimes they are placed out of necessity. I have looked at the INS Standards of Practice , and I have seen other discussion boards/posts where experts in the field (Lynn Hadaway, for one) discuss the muscle pump action, decreased sensation, etc. However, I am looking for an evidence-based research article(s) on why this is not considered best practice. I have an evidence-based research project for our unit that requires solid, evidence-based research studies for our PICO question. So if anyone knows of something specific, I would love to know the source! Thank you.

IVRUS, BSN, RN · Mar 17, 2019

I don't know why you need a research article if a complications is known to have a direct correlation to the cause. I guess that someone figured this out a long, long time ago, but how would having their research change your practice? If you know that Alopecia can be the result of someone who constantly pulls their hair out, do you need an article to verify this?

offlabel · Mar 17, 2019

On 3/15/2019 at 7:12 AM, IVRUS said:
In order to get appropriate venous return to the heart, it requires the use of the muscle pump action in the arm. If one is flaccid, that is impaired. Thrombosis and venous stagnation are two concerns. So, no, this is not an arm you want to place an IV catheter into.

So don't place a peripheral IV in someone that is intubated, sedated and paralyzed? If the best vein and site for what is needed is in a limb affected by a stroke, then it should be used without hesitation.

offlabel · Mar 17, 2019

On 3/16/2019 at 11:02 AM, Tracykg said:
Thank you for your replies. I know the reasons for not placing an IV (or other vascular access device) in a stroke affected arm, and that sometimes they are placed out of necessity. I have looked at the INS Standards of Practice , and I have seen other discussion boards/posts where experts in the field (Lynn Hadaway, for one) discuss the muscle pump action, decreased sensation, etc. However, I am looking for an evidence-based research article(s) on why this is not considered best practice. I have an evidence-based research project for our unit that requires solid, evidence-based research studies for our PICO question. So if anyone knows of something specific, I would love to know the source! Thank you.

I suppose you could search as easily as anyone else. But You're not going to find anything meaningful if you find anything at all.

Tracykg · Mar 17, 2019

21 hours ago, IVRUS said:
I don't know why you need a research article if a complications is known to have a direct correlation to the cause. I guess that someone figured this out a long, long time ago, but how would having their research change your practice? If you know that Alopecia can be the result of someone who constantly pulls their hair out, do you need an article to verify this?

Because I have a project that requires such. Also, there seems to be a difference of opinion among nurses as to whether this is an acceptable practice. Evidence-based research changes practice, even if it might not be the practice that I engage in.

2 hours ago, offlabel said:
I suppose you could search as easily as anyone else. But You're not going to find anything meaningful if you find anything at all.

Yes, I could. And I have. And I continue to do so. Either there is evidence-based research to back the practice or there isn't. So far I am only finding opinions.

offlabel · Mar 18, 2019

1 hour ago, Tracykg said:
Because I have a project that requires such. Also, there seems to be a difference of opinion among nurses as to whether this is an acceptable practice. Evidence-based research changes practice, even if it might not be the practice that I engage in.
Yes, I could. And I have. And I continue to do so. Either there is evidence-based research to back the practice or there isn't. So far I am only finding opinions.

So...As you become more experienced you'll find that, for the vast majority of our practices, no one has ever decided to establish a scientific basis for doing or not doing something. We get the impression that this is not so with the tsunami of papers that are published, but a stark minority have any validity or meaning.

The vast majority of what we do is based on reason, need and many years of experience.

You might call that "opinion."

Need proof? Ask someone more experienced than you to give an example of a practice that fell out of favor for seemingly good reasons that then, over time, came back into use when the utility was "re-discovered".

You'll never find what your looking for in a published paper on this topic. But search away....

JKL33 · Mar 18, 2019

offlabel, the ones who need this ^ information are the instructors who seem to believe that one should not make the mistake of saying the sky is blue unless a nurse has published a research article saying so in the last 5 years.

?

JKL33 · Mar 18, 2019

On 3/16/2019 at 1:02 PM, Tracykg said:
However, I am looking for an evidence-based research article(s) on why this is not considered best practice. I have an evidence-based research project for our unit that requires solid, evidence-based research studies for our PICO question. So if anyone knows of something specific, I would love to know the source! Thank you.

It seems like you will have to utilize evidence-based articles that address the supporting ideas. For example, papers about general situations that increase risk of VTE (e.g. decreased mobility); papers about increased risk of VTE following CVA; papers that describe the skeletal muscle pump.

Theoretically you can make a case for one thing or another based on known/supporting research even if no one has specifically answered your particular PICO question. This is an interesting question; it would be better (IMVHO) to address it in a realistic way and come to a best conclusion based on supporting information rather than trying to prove something without available research or doing the actual research.

Where should a short-term peripheral IV be placed in a quadriplegic? Sometimes you have to accept common sense. If there is an alternate site, that is preferable. If not, limit risk factors as much as possible, increase surveillance, etc.