What gauge IV to use?

classicdame, MSN, EdD · Mar 23, 2009

Most ER's will go for the larger bore needle "just in case". However, the dorsal veins of the hand are not a good choice for many reasons. I would think the brachial or cephalic veins in the forearm or ac area are preferable.

Blee O'Myacin, BSN, RN · Mar 23, 2009

A person with chest pain is going to get at least a 20g in the upper forearm or AC for a CTA. If they look like they are going to need blood, then an 18g or a 20g. I put large IVs in drunks and DKAers also - the larger the gauge, the quicker the fluids go in. Ditto for ODs - if their veins can take it, better to have the largest possible bore IV just in case you need it. (I'll sink a 14g into someone who's veins can take it if necessary.)

So I guess I'm trying to say that I'll put an 18 into anyone whose veins can take it because you never know. And I don't even look in the hand unless the patient asks me to, or there is nothing to stick anywhere else.

But rereading your post, I think you are trying to gather if we think this nurse has a "problem". Well, IVs shouldn't be punitive. And I wouldn't put anything larger than an 18g in a hand unless I had no other option. But at that point, I'm nagging the doc for a central line.

pattyrn376 · Mar 23, 2009

at my hospital the 16s are only used in open heart surgery and icu. the 16 can stay in 24 hrs where an 18 or more 72 hrs. my ER usually uses 18s because the pt may need blood and it goes better thru an 18. on the ward we usually use a 20. an etoher I would use an 18 or 20 not a 16

Aneroo, LPN · Mar 23, 2009

For traumas or MI's, the bigger the better. If there is any chance of them getting a CT chest r/o PE, they need at least an 18g in the AC or else CT won't do it (even though I've seen it given through a 22g in the wrist).

I wouldn't put anything bigger than an 18 in the hand unless I had to though. I remember they put an 18g in my hand when I was having my child and it hurt like a mofo. When I was a patient myself recently for GI problems, I gave the nurse the same vein and she used a 20g and it didn't even hurt.

billythekid · Mar 23, 2009

So I know that if you have a trauma or something major come in you should get in an 18, or two. We have a nurse here who is what we all call a trauma junky. Our ER is small and we don't get alot of action, just usually alot of clinic stuff. In the last week I have watched her put a 16 gauge in the hand of a person who was in for ETOH intoxication who needed a banana bag, and an 18 gauge in the hand of an individual whom we were sending out for a cervical CT. Her theory is, "If the vein will take it why not use it?" I say it doesn't matter much since banana bags or IV hydration is set on a pump, usually 125-250ml/hr.
It really bugs me that she doles out IVs this size so frequently when they don't seem needed. She even made a comment about the ETOH pt, who is a FF, that, "Once I knew it was him, I had the 16 all ready to go in his hand."
Does this honestly sound like a problem or is it just my problem?

As another poster stated.. IVs should NOT be punitive. That being said it can be difficult to determine what a person's motivations are. Alot has to do with experience as well. For example, with a background of being a paramedic, our gold standard was an 18 gauge IV. The philosophy is that even tho not a 14 gauge :cry: if fluids needed to be rapidly run, the 18g was a good hybrid and could prevent the patient having to get stuck a second time for appropriate access. So, from this standpoint, starting an 18g IV is practical and efficient.

Still, not every patient has the proper vasculature for such a peripheral IV, so clinical judgment (ie common sense) needs to be exercised.

And to be clear, using a larger angiocath (14 or 16 g), should not be a punishment for your FF's...

TexasNurse2008 · Mar 23, 2009

I would an use an 18g automatically if the vein could take it "just in case". I would also look in the hand first - that's what I was taught to do in school and I've continued the practice since then.

MP5PDW · Mar 23, 2009

Allways bigger is better. Here are the flow rates for IVs

22ga X 1 inch =35ml/hr

20ga X 1.16 inch = 60 ml/hr

18ga X 1.16 inch = 105 ml/hr

16ga X 1.16 inch = 220 ml/hr

14ga X 1.75 inch = 330 ml /hr

Notice how the flow rates increase almost exponentially? It actually increases by the power of 4. look up the Hagen–Poiseuille equation or law.

Avoid the AC unless you're placing a RIC line those are 7 or 7.5 french.

No one ever said " Darn I wish I had not put in a big IV."

Nothing wrong with the dorsum of the hand.... it allows you to move up the arm if the IV infiltrates.

RochesterRN-BSN, BSN, RN · Mar 23, 2009

Damm I never knew they even made 14s! lol In the Med ER I worked in for a short time--Granted it was a Level 2--had 16s --biggest bore they had. And they seldom used them. Masive GI bleed, yeah x2, and and MI maybe, but never ever in the hand. I know from having all three sizes as a patient--22, 20 and 18 that the 18 kills compared to the 22! And unless my butt is gonna die don't even think about a 16! Forget a 14...thats bigger then a dart!!! lol As far as using a 16 for an alcoholic FF just cause it bugs ya he's there......thats wrong. Don't get me wrong I work in the Psych ER now so we get all the drinkers once stable......under BAL of 300, if you call that stable! lol So I know what they are at risk for, etc. I also know that they can be difficult and a PITA to deal with their constant misuse of the ER......however many of them also have other mental health dx and so I try to be understanding.....and don't feel they should be torchured with some huge IV they don't really need. Yes maybe things to make their stay a little less like the hilton are okay......we tend to limit the food.....all the water and ginger ale they want to hydrate but we discourage the "3 hots and a cot" drunks by not giving out food unless they are diabetic or something and their BG indicates they need it. (Though that is few and far between)

I have to wonder if this nurse the OP writes about has ever had a large bore IV placed in her hand!!! lol

And by the way I am a fan of the hands and wrists for IVs as long as you don't need a large bore/large vein as I think it gives the patient more freedom to move their arm and not occlude--then the nurses don't have to run in every 5 minutes when they bend their arm and the pump is beeping........that opinion is as a nurse and a patient once......and especially with geri's they can't get the concept of keeping their arm straight and the arm boards dont' really work great........

RedCell · Mar 23, 2009

My mentality has always been if they are in the ER, must be an emergency, 14 gauge it is. I especially like the 1.25 inch Cathlons because they thread in like butter. Plus with a potential flow rate of 325ml/min (without a pressure bag) it comes close to competing with a 9fr cordis. If you want to be nice give a little lidocaine prior to insertion. If you are REALLY nice, mix some bicarb with the lidocaine for an even faster onset.

Then again, you will always have the dialysis, chronic IV drug users, morbidly obese etc, where your only choice is a 24 gauge in the thumb.

RedCell · Mar 23, 2009

Notice how the flow rates increase almost exponentially? It actually increases by the power of 4. look up the Hagen–Poiseuille equation or law.
.

radius to the fourth power. Man, I was pimped on that guy more times than I care to remember!

RochesterRN-BSN, BSN, RN · Mar 23, 2009

My mentality has always been if they are in the ER, must be an emergency, 14 gauge it is. I especially like the 1.25 inch Cathlons because they thread in like butter. Plus with a potential flow rate of 325ml/min (without a pressure bag) it comes close to competing with a 9fr cordis. If you want to be nice give a little lidocaine prior to insertion. If you are REALLY nice, mix some bicarb with the lidocaine for an even faster onset.
Then again, you will always have the dialysis, chronic IV drug users, morbidly obese etc, where your only choice is a 24 gauge in the thumb.

Yikes you scare me! Where do you work?.......I go in for unbreakable severe headaches now and again--like maybe once a year or less-- and yes I am in the ER but I certainly don't need a 14G cath!!! Yikes! Overkill!!