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.
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.[/quote']
Was it at my hospital?? Our CT department insists that the patient must have an 18 in the AC or higher. An 18 in the forearm won't do, nor will a 20 in the AC. It absolutely drives me bonkers.
*** What sort of accidents? The worst I can think of is the IO gets knocked or pulled out and that is no big deal.
We don't wait for a code to place an IO or two. I find having an IO placed hurts less than an bigger IV in the back of the hand (yes from experience).
I believe a hub got snapped off of the needle, and a couple cases of dislodgment with infiltration into the calf. I don't think these even happened at my facility but I work for a large health system with region wide policies. Like I said though, we don't go IO until IV fails, partly because it is not at nursing discretion (in my place of work) to start an IO. By the time a doc shows up we probably have a good IV, or several, and going IO when you have good access *is* unnecessarily invasive. Of course, in Peds or if we have tried twice with no success on an adult we will use the IO.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
I believe a hub got snapped off of the needle, and a couple cases of dislodgment with infiltration into the calf. I don't think these even happened at my facility but I work for a large health system with region wide policies. Like I said though, we don't go IO until IV fails, partly because it is not at nursing discretion (in my place of work) to start an IO. By the time a doc shows up we probably have a good IV, or several, and going IO when you have good access *is* unnecessarily invasive. Of course, in Peds or if we have tried twice with no success on an adult we will use the IO.
*** None of those seems like it would happen often enough, or is a big enough deal to make each IO patient a one to one. The worst part of such an absurd policy is that it will make staff reluctant to place one when needed. I know it's policy in a large system and has nothing to do with you.
I am amazed that IO placement is not at nurse's discretion.
*** None of those seems like it would happen often enough, or is a big enough deal to make each IO patient a one to one. The worst part of such an absurd policy is that it will make staff reluctant to place one when needed. I know it's policy in a large system and has nothing to do with you.
I am amazed that IO placement is not at nurse's discretion.
It is only recently that it has been in our scope to place them, and most of our nursing staff is still not checked off to do them, different rules in different places. I'm sure some day we will get there. I don't think our docs are reluctant to place them, they tend to order what they want and let us figure out how we are going to do it .
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
It is only recently that it has been in our scope to place them, and most of our nursing staff is still not checked off to do them, different rules in different places. I'm sure some day we will get there. I don't think our docs are reluctant to place them, they tend to order what they want and let us figure out how we are going to do it .
*** You may like to know that in the system I work for every physician who has learned to place IO and is checked off to do it learned from an RN. In my hospital any ICU or ER RN, as well as the rapid response RNs (I am one of them) can place an IO at their own discretion and anyone, including physicians, who wants to learn to place and manage IOs must take (and pass) a class taught by one of the five full time RRT RNs. Usually it's only interns and residents who take the class, our attendings being perfectly happy to let the nurses place the IO as we do all the other vascular access devices, except Swans (placed by CRNAs or MDAs), subclavian and femoral 3 lumen caths. RNs place IJ 3 lumen caths, PICCs and art lines in my hospital.
Knowing that they can get an RN to place a PICC, IJ 3 lumen, IV or IO means that it is very rare that a physician will place a different kind of line.
*** You may like to know that in the system I work for every physician who has learned to place IO and is checked off to do it learned from an RN. In my hospital any ICU or ER RN, as well as the rapid response RNs (I am one of them) can place an IO at their own discretion and anyone, including physicians, who wants to learn to place and manage IOs must take (and pass) a class taught by one of the five full time RRT RNs. Usually it's only interns and residents who take the class, our attendings being perfectly happy to let the nurses place the IO as we do all the other vascular access devices, except Swans (placed by CRNAs or MDAs), subclavian and femoral 3 lumen caths. RNs place IJ 3 lumen caths, PICCs and art lines in my hospital.
Knowing that they can get an RN to place a PICC, IJ 3 lumen, IV or IO means that it is very rare that a physician will place a different kind of line.
Yes, things are different here in the frozen north (unless you work outpost in the real frozen north, their scope is huge). Our practice act does allow for RNs to do advanced vascular access, but the places I have worked (large urban hospitals) staff RNs are not responsible or trained in central line insertion. We also don't run codes without a physician (there is always a physician present) as I remember you doing from another post. I am not on the inpt code team (run by ICU nurses) so their practice may be different from mine, as is that of a rural nurse in a small hospital who may be the only staff member in the hospital at a given time.
I can, however, reliably get a large bore IV into a teeny LOL with no pulse in 20 seconds flat, so that is what I do. I imagine in the future we will continue to expand in our scope, someday I may do some or all of the above, but not this week:).
Personally, I usually go with a 20 ga for multiple reasons. ... In addition, we give lots of abx, especially vancomycin ...
All the more reason to use a SMALLER cath:
For vesicents you want quick hemo-dilution and the smaller the gauge the better More blood flow around the catheter creates more hemo-dilution. Larger bores can sometimes occlude some blood flow.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
Yes, things are different here in the frozen north (unless you work outpost in the real frozen north, their scope is huge). Our practice act does allow for RNs to do advanced vascular access, but the places I have worked (large urban hospitals) staff RNs are not responsible or trained in central line insertion. We also don't run codes without a physician (there is always a physician present) as I remember you doing from another post. I am not on the inpt code team (run by ICU nurses) so their practice may be different from mine, as is that of a rural nurse in a small hospital who may be the only staff member in the hospital at a given time.
*** LOL! I live in the frozen north. Unless you are talking about Alaska, and I think you are.
I can, however, reliably get a large bore IV into a teeny LOL with no pulse in 20 seconds flat, so that is what I do. I imagine in the future we will continue to expand in our scope, someday I may do some or all of the above, but not this week:).
*** You must be a great asset to your hospital. I hope they treat you and the other nurses well.
This is a great thread. I really learned a lot. I do work in an ICU, so my thought has always been 18s if possible, if not I'm married to 20s. Only use 22s in desperation. Granted, I do have a lot of GI bleeders and septic patients, but I am definitely going to run my vanco and peripheral amino through smaller gauges now.
Specializes in Orthopedic, LTC, STR, Med-Surg, Tele.
Agree with Altra, you can give red cells through smaller IVs than a 20, as it was explained to me by the same nurse as above: "yah think the cells can squeeze through our teeny tiny capillaries but are going to automatically lyse at the sight of a 22?!?" (I love this coworker btw).
Yes! We have a couple of new grads at the floor who get skittish about putting PRBCs through a 20 or 22. I will have to remember this.
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PMFB-RN, RN
5,351 Posts
*** What sort of accidents? The worst I can think of is the IO gets knocked or pulled out and that is no big deal.
We don't wait for a code to place an IO or two. I find having an IO placed hurts less than an bigger IV in the back of the hand (yes from experience).