Ultrasoudn Guided Peripheral IV

Rexie68 · Mar 7, 2010

Hello,

I find it interesting that RN's aren't allowed to start peripheral IV's in the brachial vein.....but MDs are. Most of the doctors I work with would much rather have an RN start the line than do it themselves, because we're most comfortable using the ultrasound. As a member of the IV team, there aren't any restrictions on us starting IV's in the brachial, basilic or cephalic veins. Often we'll use a 20 gauge 2 inch needle to start an IV in the upper arm when we can't get access in the lower arm. That's the longest peripheral IV needle we'll use...anything deeper needs a midline or a PICC. We've had many, many people who have less and less veins available and I'd hate to limit the IV team by ruling out the brachial, especially with ultrasound guidance. Good luck to you! :twocents:

iluvivt, BSN, RN · Mar 8, 2010

What we need to realize here is that brachial vein is near the brachial plexus and if you have an infiltrate and especially an extravasation in this area the patient can have a permanent disability and a permanent nerve injury. The catheters placed in these deep veins are inserted at a deeper angle and they are subject to much more motion and movement than a traditional PIV site Most IV experts have realized that these US guided PIVS are not always the answer to gaining access on a patient with limited veins.....They do have a much higher incidence of infiltration,extravastion, leaking and diminished dwell times. I would much rather use my bag of tricks and get a good IV site in the traditional way... than one that will infiltrate the next day. These infiltrations b/c they are deeper are much more difficult to detect..so by the time you see them the damage may already be done!!!! Also it is important to note that most extravastion injuries can not be fully evaluated for 1-2 weeks after the actual occurrence...you may not always to be able to tell right away the extent of the injury!!! We absolutely do not allow MDs or Rns to place in the brachial veins for routine IV therapy..rather we use the cephalic and the basilic vein,just above the ACF or access below the ACF. So you are NOT limiting yourself you are providing safe and prudent nursing care. When a midline is in place it as restrictions on the medications and IV fluids you can infuse...so you can ONLY infuse isotonic or near isotonic infusates and those with a ph between 6 and 9....WELL a PIV in in the brachial vein will have its tip in the same location as the midline. That is something to think abut

Rexie68 · Mar 8, 2010

Well, we shall agree to disagree. We certainly don't put IVs in the brachial unless we have too, but there are times that the basilic or cephalic aren't available for one reason or another, either above or below the ACF. It's certainly not our first or second choice...I was only stating that it is an option if necessary....especially if nothing in your "bag of tricks" works. Heck, sometimes there is NOTHING we can access even with the ultrasound. We currently have a patient whom we cannot use either arm to get an IV...from fingertips to shoulders and we can't put in an EJ PICC due to occlusions..and the doctors can't put in a central line in her IJ or subclavian and don't want to in the femoral due to high risk of infection.....so her IV is in her leg (since one foot infiltrated and we couldn't find a vein in the other). My point here is.....there is a time when you have to do things that you don't really like to do, but circumstances require you to do so. I would not like to see a blanket policy stating that you can never use the brachial vein, despite the risks involved. Just like most things in health care, it's not a black or white situation. :twocents:

Madam PICC · Mar 10, 2010

I am also working on a program to teach a select few on US PIV placement. I would like to know how is yours going. I was going to use the main problems associated with PIV placement. I am also going to use these select few as an early assement tool. We currently do not have an IV team, at your hospital who is going to do these PIV placement? :twocents:

Rexie68 · Mar 10, 2010

At the facility I work in, we have an IV team and all IV nurses are trained to use the ultrasound to insert peripheral IVs. It does take some time and practice to become comfortable using the equipment, but once you do so it's a lifesaver at times (sometimes literally!) Without an IV team, I'm not sure how you'll decide who to train, but perhaps a few nurses from each floor who are already competent inserting peripheral IVs and willing to learn. Good luck to you!

Madam PICC · Mar 11, 2010

Thanks, I know. I will be training a few experienced nurses on each trauma floor to use the ultrasound that they currently have on their units and then they will be the ones to use the skill not teach the skill. It will be taught by me and overseen by the Senior clinical nurse in trauma. That way we will have some semblance of control. We will also be following complications along the process to improve outcome. Currently the only liturature I have found is based in the ER in short acute situations. Any help would be greatly appreciated. :twocents:

iluvivt, BSN, RN · Mar 12, 2010

NAVAN just had a presentation on this at their last national meeting and listed some practice recommedations and guidelines . I saw it once but I will be getting a copy from my friend....I believe they said to not use the Brachial vein..as soon as I get it..I will post the source and outline the contents and we can clarify what they said..and believe me I know the dilema we face but I also know that first you do NO HARM

Madam PICC · Mar 16, 2010

That would be great I would be interested in seeing that article please let me know where to find it so i can use it for our policy. Thanks

:yeah:

Rexie68 · Mar 16, 2010

I would also love to see that article. Of course we want to first do no harm, but there are times that not having IV access causes harm. Just yesterday I put a PICC in the brachial vein.....the only vein available for access in either arm. I caused no harm. The patient now has access and is thrilled, as are the doctors, nurses, lab techs, etc. Again, it's never my first choice, but it was an available vein to be used. I followed the vein up until I found a place where the artery and nerve weren't compromised by my needle, as long as I went slow and stayed on course. The same principles apply when inserting a peripheral IV with ultrasound guidance. Also, when inserting the 2 lumen CHF aquapheresis catheter the only two veins that can be used are the basilic and brachial. The cephalic vein does not work. Basilic is preferred, but brachial works. Just food for thought. Again, I'm glad that the facility I work in does not limit our vein selection, but rather leaves that choice to us....the experts. :twocents:

iluvivt, BSN, RN · Mar 17, 2010

I understand your position Believe me I do... I have been accessing veins for 27 LONG years....but as soon as the crisis is over..you should take that catheter out of the brachial and get some type of CVC. I swear that if that is all I see and the patient clinically has the time...I would much rather just put the PICC. and we do or get some kind of CVC. I will post a review of that presentation as soon as my friend brings it to me.... I have already checked with Lynn Hadaway and she said the same thing..basically use it for the emergency and take it out ASAP. I really do not see a problem with the Aquadex catheters being used in that vein at all..and have done that myself..b/c you see you eliminate the problem of infiltration and extravastion going undetected b/c of the length of that catheter. So lets just see what the experts say and yes clinically I understand risk versus benefit. I do know however, that if that line infiltrates as they often do and usually within 24 hrs and it is not caught early and harm comes to the patient.. the nurse insertor gets dragged into it. Patients do not take kindly to losing any function in their arm or worse yet any part of it...usually the nurse LOSES in these situations..no matter what the situation was. We saved a ladys life about 2 yrs ago..BUT an ICU nurse started a Levophed drip on a PIV that was 48 hrs old and had been used to administer some Dilantin...Hmmm I guess he did not notice that the patient had A Triple lumen PICC...... that patient was with us for the next 6 mos with multiple surgeries.partial amputations of her fingers, a wound vac in place for a very long time..so was it the Dilatinn..the levophed or combination. Sadly, there was no way that should have happened b/c she had the triple lumen in place and even if she did not they would have said..get some kind of GOOD line in place...YES all the nurses the lawyers could blame..... they DID . the patient kept telling us she would not sue.....but she did......they had no chance b/c they did notfollow the standard of care . SO as is my policy I will share that info as soon as I get it BUT continue to practice prudently b/c unfortunately nurses get dragged through the MUD no matter what GOOD you may have done at the time....YEAH its a sad thing....I will keep in touch :heartbeat:heartbeat

Madam PICC · Mar 18, 2010

Hey Craig the first time I read your thread I also thought that you had place a PIV in the patient Brachial but when I read it again I saw it was a PICC. I think for PIV placement brachial vein should not be used but for a PICC it is an acceptable site R/T the risk for infiltration/ extravasation. I also feel that the "just get me an IV" attitude needs to change. I was just speaking on this very subject yesterday. These are not just IV these have some very real issues and should not be placed just 'willy nilly' and really need some thought behind the action. Someone else spoke to our crede "First Do No Harm" and this also means just because it did no harm today what about tommorow. I mean just because you can get an IV in does not always mean you should. :twocents: