Ok, something came up today that got me to wondering... is there a rationale for using a smaller angiocath than possible when starting an IV on a patient?
I mean, back in my Paramedic days, we didn't start anything smaller than a 16 antecubital and tried really hard to get an 18 in even for hands if we at all could, because we had no clue what kind of fluids the patient would end up needing, and I was taught that blood products needed at least an 18. Ok, so I've since been educated that blood products *can* use a 20, but an 18 is preferable. And I'm not calling for 14 and 16 in regular use.
But.
Last night the nurse knew my pt needed a unit of PBRC and it would be coming on my shift. The existing IV (an 18) she said was leaking, so she put a 20 in so I'd have it for the PBRC. As a new nurse, I asked around (supervisor, other ICU nurse on duty) and the consensus was that if I could get an 18 in, that would be preferable. Pt had decent veins and I had no trouble starting an 18. (I'm in an LTAC ICU)
So, it got me to thinking... the only nurses I have seen routinely use 18's are ICU and ER/Trauma nurses. Everyone else seems married to 20's and 22's. Is there a rationale for using less than an 18 if you can get an 18 in and assuming there's no expectation of administering blood? (I fully recognize there are lots of patients that you're lucky to get a 22 in, and those aren't the ones I'm talking about.) Or is it that the larger angiocaths scare a lot of nurses for some reason?
I've tried to search my references and even Google for it, and haven't found much of any help. All I've really found is that 20 is the minimum for blood, and 18 is preferred.
"I always put an 18 in! They might need me to squeeze blood in fast!" Being prepared is good, but at some point, think about the actual patient that's in front of you at the moment. Why on earth would you put an 18 in the AC of patient that only needs IV antibiotics? Did you REALLY think they were going to need to be bolused with four liters in under an hour for some cellulitis? And it needed to be done so fast you couldn't look for a better vein than their AC?
Yeah, what Wooh said. I try to avoid the ac if possible and 20g is my go to catheter. I also try to get a 22 into a fat vein if pressors are or might be ordered.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
Back in the old days there was more incentive to place larger than needed IVs. What happens in the patient takes a turn for the worse and has no BP and we can't get a bigger one in then? Was the question we had to ask ourselves. However now that we can obtain a "for sure" access in an emergency with IO there is little reason to place large IVs when not indicated for the current condition.
Some nurses never got the message. This is a case of EBP taking too long to make it to the bedside.
Thanks to everyone for the excellent information. This was a subject that really wasn't covered in nursing school, so I hadn't heard a lot of the rationale presented here. I had a very experienced ICU nurse at work tell me that the larger bore irritates the veins less, so I suspect the advice has varied over the years. Most of my population have PICC's or midlines so it rarely becomes an issue. The question arose because a patient of mine was definintely going to get PBRC's and the nurse on the offgoing shift had to replace the IV and told me she'd given me a #20 *because* my pt was getting PBRC's. I had zero difficulty getting a #18 and I am by no means the vein whisperer, so it piqued my curiosity.
BTW, when I was a medic the AC was our "go-to" site by training, and having been a patient a number of times since then as well as acquiring my own experience as a medic, I developed a distinct preference for the forearm veins. I don't like hands because they're frequently positional and fragile. I don't like AC's because it can cause problems for needing a distal later, and AC's are horribly positional in my experience. There are a number of beautiful sites in the forearm for most patients.
I believe I'll still prefer a #18 (if possible, I know lots of patients have problematic veins) when I have reason to think (or know for certain) I'll be giving blood products, but I am coming to reconsider the #18 as my go-to cath. Thanks!!
PSU_213, our CT machines require a 20 or larger in the AC. It has nothing to do with the tech at my hospital. They simply are not allowed to do a CT without a 20g A/C; something about the pressure/machine itself.
We will use a 20 for blood. If we use a 22, we have to get a doctor's order to use it. At my old hospital, a huge teaching facility, they didn't care what size we used. They always said a red-blood cell is only 4 microns, so it didn't matter.
Thanks to everyone for the excellent information. This was a subject that really wasn't covered in nursing school, so I hadn't heard a lot of the rationale presented here. I had a very experienced ICU nurse at work tell me that the larger bore irritates the veins less, so I suspect the advice has varied over the years. Most of my population have PICC's or midlines so it rarely becomes an issue. The question arose because a patient of mine was definintely going to get PBRC's and the nurse on the offgoing shift had to replace the IV and told me she'd given me a #20 *because* my pt was getting PBRC's. I had zero difficulty getting a #18 and I am by no means the vein whisperer, so it piqued my curiosity.
BTW, when I was a medic the AC was our "go-to" site by training, and having been a patient a number of times since then as well as acquiring my own experience as a medic, I developed a distinct preference for the forearm veins. I don't like hands because they're frequently positional and fragile. I don't like AC's because it can cause problems for needing a distal later, and AC's are horribly positional in my experience. There are a number of beautiful sites in the forearm for most patients.
I believe I'll still prefer a #18 (if possible, I know lots of patients have problematic veins) when I have reason to think (or know for certain) I'll be giving blood products, but I am coming to reconsider the #18 as my go-to cath. Thanks!!
Sounds like your a new grad , so your going to make a few mistakes and that's okay. Heave knows i made some choices as a new grad that now I wouldn't .......... but what REALLY REALLY bothers me about your post is that you had a 20 gauge already in that is more than acceptable for blood and you for no reason other than your preference changed it to an 18 gauge . I hope you can see why that is inappropriate? That is doing and unnecessary invasive act on a patient. and policy and evidenced based practice should guide your practice , not your own preference. I would look at the infusion nursing statement as a very serious indication of what my practice should be.
ps. also i did a search to try and find where it said 18 gauge is the preferred gauge and i'm wondering if you are thinking about when "Giving blood" (as opposed to receiving" ?
I have used a 22 for blood before with no problem whatsoever. An 18 is overkill and is def. NOT needed if a 20 or even a 22 (in less than ideal circumstances) is already in place.
I work in the ER, and I mostly stick to 20s, unless it's a trauma or I think they may need blood. I reserve 22s for kiddos, and the occasional super hard stick with teeny veins.
And if they already have a 20 in and need blood...not going to stick them again. More work for me, more sticking the pt, lose-lose situation, imo! As a funny aside, when I was in practicum, my preceptor trained me to use 18s whenever possible because they may need a CT with contrast, and that dye can't go in a smaller than an 18....still no idea where that came from, I send pts to CT with contrast all the time with just a 20, never been an issue.
And if they already have a 20 in and need blood...not going to stick them again. More work for me, more sticking the pt, lose-lose situation, imo! As a funny aside, when I was in practicum, my preceptor trained me to use 18s whenever possible because they may need a CT with contrast, and that dye can't go in a smaller than an 18....still no idea where that came from, I send pts to CT with contrast all the time with just a 20, never been an issue.
Simple - your preceptor didn't know what she was talking about, or the folks in CT who advised her didn't know what they were talking about.
wooh, BSN, RN
1 Article; 4,383 Posts
"I always put an 18 in! They might need me to squeeze blood in fast!" Being prepared is good, but at some point, think about the actual patient that's in front of you at the moment. Why on earth would you put an 18 in the AC of patient that only needs IV antibiotics? Did you REALLY think they were going to need to be bolused with four liters in under an hour for some cellulitis? And it needed to be done so fast you couldn't look for a better vein than their AC?