What gauge IV to use?

[Hilinenursegrl]

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?

[bjaeram]

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

.

I don't get this. You can easily blow a liter of fluid in through a 20 guage or even a 22 in less then an hour on a standard pump. You can do it even faster with a pressure bag or rapid infuser.

[RedCell]

You don't really believe that do you?

You know your patients dont' even believe that, just ask them, they know many reasons for visiting are not emergencies...

-MB

Look dude, I put in 14 and 16 gauge catheters everyday in the OR when I go to see my patient in preop. I put in 3 today. My patients never complain. They cannot tell whether I am sticking in a 24g or a 12g. I use a 1% lidocaine solution mixed with bicarb prior to each insertion.

The notion that nurses cannot give 0.3ml of 1% lidocaine (3mg) is asinine. It is more dangerous for a nurse to be giving PO ASA. If you cannot use a local anesthetic, how about using saline instead. It works as well.

[RedCell]

I don't get this. You can easily blow a liter of fluid in through a 20 guage or even a 22 in less then an hour on a standard pump. You can do it even faster with a pressure bag or rapid infuser.

MP5PDW was referring to ml/min. With a properly placed 14g you can get a liter infused in 3 minutes without a pump, pressure bag, etc. Also, 20 and 22g catheters are not designed for rapid infusers. Again, relating to the whole radius, distance to be infused, length of catheter situation (Poiseuille's Law)....a 20 and 22 gauge catheter can't work through a rapid infuser. That is why they make 12 14 and 16 gauge catheters.

[nghtfltguy, BSN, RN]

its very easy....

NEVER USE ANYTHING LESS THAN A 20 GA.... unless... and only unless it is on a lil kid below 5 years old.. and then.. just use a 22 because those tend to bend sooooooo easy when getting threaded in... i prefer the 18 on most everything.. in the AC.. as so many ppl have stated before... there are so many tests that ct requires an ac.. *which i don't understand*... i got in a fight one night with the radiologist... i had a pt that was a really hard stick... had a very patent 18 in the forarm... wanted an ac but pt just would not be stuck anymore.. was refusing... yet they took a pt w/ a 22 in the ac before that.. same night....needless to say... or needlesness lol to say... i won.. pt got the contrast ct w/ a forearm 18....

my rule of thumb is... start w/ a 20 or an 18 depending on the pt if they are in the ER...

[iluvivt, BSN, RN]

1. Always use the shortest and smallest cannula that will meet the pts needs....well if that is an 18 gauge so be it...i tend to place an 18 insyte or 18 introcan for ED pts in case they need a CT scan...i try to find out if one is ordered or is likely to be done based upon the chief complaint or dx. as an aside never use the intima for a CT scan...it is not rated for that use...and can break and leak

2. you are supposed to start low (ie hand) and work your way up. Again,it is a judgemnet call. If I only have one arm to use...I always start low...if the pt is crawling with veins..i usually go start in the low forearm....for a CT scan I get as close to the ACF as possible..but not at it usually so site will not be positional

3. if all you can get in is a 22 gauge...well that is what you use...and you will be grateful for it...i always am....LOL

[ZippyGBR, BSN, RN]

IVs in the dorsal veins of the hand suck for the patient and blow for the nurse far too easily ...

18 (or 20) in the forearm is the weapon of choice

rationale

against going in the dorsum of the hand

1. limits patient's abilityies to carry out ADLs

2. likely to get dislodged

3. unless they've got larger hands increases the risk of mechanical irritation

4. again unless they've got large hand s it will be positional

against the AC

1. saves the ACF if they need a 14 or 16 at some point

2. saves the ACF if they need a PICC

3. saves the ACF for blood sampling if they are in long enough to get a second line in the other forearm on a time since in sertion removal and resitpolicy

4. ACF can also be positional and have increased mechanical irritation becasue it's over a joint.

a 14 or 16 in the ACF or EJ is also a very good way of getting high volume access comparitively easily.

in certain situations though 'any hole is a goal'

[Lexiesmom]

Our Er has guidelines for IV catheters, pretty much like I saw in another reply here. Sounds to me likeyou are concerned regarding the behavior of this particular nurse. Putting a large bore IV in someone should not be because you can or for fun/punishment. A large bore IV should certainly be used if there is even a hint that lots of fluids will be needed. YOu are not going to be sorry if the patient gets into trouble. But for routine stuff, I usually go for an 18. And I do start in the had too. OUr ICU would prefer we dont use up the AC, and of course the lab too. So we usually look in a hand first and use a stabilizing device. Large amounts of fluids, someone who needs quick action/resusciation, go for the AC and a 16 or bigger if you can. And I always try for two in a critical patient.........it is Murphy's Law that one will blow just when you need it the most.

If your concerns are the ethics of this nurse, which I what I think I am hearing, you should talk to someone about that behavior.

[gonzo1, ASN, RN]

You can get more information on this topic at the infusion nurses website. The size of the catheter must be chosen based on what the pt will be needing. It is abusive to go "big" just because you can.

The larger the catheter the greater the risk for pain and other problems.

I have worked in ERs that mandate no smaller than 18 and in ERs that mandate no larger than 20 unless it is a trauma or another type of emergency.

To state that if the person is in the ER it must be an emergency is turning a blind eye to the current state of affairs.

From my experience most of the ER visits are not an emergency. We have become the "clinic" for many people and for many different reasons.

Some nurses hate this and do not want to adapt.

I personnally have accepted these non emergency patients because they provide great job security for all of us. And it is the humane thing to do.

Most of these people have a hard enough time and I am not going to "punish" them by putting a "garden hose" in them.

Accept the realities of where you work and stop punishing people for turning to you even if you don't agree with why they are there.

Being able to start garden hoses is a great skill (one I don't have), but I hate to think this is what constitutes a "great nurse"

[AndyLyn]

To state that if the person is in the ER it must be an emergency is turning a blind eye to the current state of affairs.

From my experience most of the ER visits are not an emergency. We have become the "clinic" for many people and for many different reasons.

Some nurses hate this and do not want to adapt.

I personnally have accepted these non emergency patients because they provide great job security for all of us. And it is the humane thing to do.

Most of these people have a hard enough time and I am not going to "punish" them by putting a "garden hose" in them.

Accept the realities of where you work and stop punishing people for turning to you even if you don't agree with why they are there.

Being able to start garden hoses is a great skill (one I don't have), but I hate to think this is what constitutes a "great nurse"

THANK YOU!

[MikeyBSN]

It depends how annoying they are! Just kidding.

I'm not as aggressive with smaller gauges as I was when I started. Now, most of the patients I see get a 20. If grandma just needs some fluids, and I don't anticipate a CT scan with contrast or blood products, then I'll put in a 22. If the patient has chest pain or I anticipate blood products, I'll use an 18. Trauma patients and ST-elevation MI's get a 16 or a 14. I actually prefer the 14 to the 16, because our 14's are shorter in length and I find them easier to work with.

[LLLLiiiFFEsaveer]

OK!

SO...

My name is Ian. Nice to finally join up, you know.. I have been lurking since 05 after school just prior to my first RN job in Busy Trauma Regional Center- still working there.

In my honest opinion, and please really think about it for at least 1minute before thinking of your reply to what I am about to mention:

If you are profficient in your, uhh uh, choosen "specialty", such as critical care in such an incredible environment as that found in the ED, well then- that sure is a loong run-on sentance.

Practice makes perfect,and so long as that heroin overdose muscular male presenting to the front entrance (with ropes everywhere) (conveniently dropped off by his friends in the most appropriate spot, on our curb!). Well then buddy, it does not matter to me if the overall result is an upcoming newer ED nurse to succsesfully be more prepared for future endeavers requiring 14ga access, AND all whatever kinda bruise you are sure to be left with!... Even after you are done puking/swinging at us/possibly spitting/wondering where you R, and how you got there, and etc.../and MOST importantly, and equally amazing unuff (seeing as you are now declaring to me that "No, man I don't use heroine", uhh uh - allready tested positive for it there mister) and AND the fact that you have now just within the past 30 seconds or so, to the last 2 minutes or so,have started breathing again...

Practice makes Puurfect, right?

I mean we will probably not even recieve any sort of compensation from U directly,you know, for saving your life and all, maybe even for saving your life, sigh... yet once again, right?

Later,

Ian

[GilaRRT]

OK!

SO...

My name is Ian. Nice to finally join up, you know.. I have been lurking since 05 after school just prior to my first RN job in Busy Trauma Regional Center- still working there.

In my honest opinion, and please really think about it for at least 1minute before thinking of your reply to what I am about to mention:

If you are profficient in your, uhh uh, choosen "specialty", such as critical care in such an incredible environment as that found in the ED, well then- that sure is a loong run-on sentance.

Practice makes perfect,and so long as that heroin overdose muscular male presenting to the front entrance (with ropes everywhere) (conveniently dropped off by his friends in the most appropriate spot, on our curb!). Well then buddy, it does not matter to me if the overall result is an upcoming newer ED nurse to succsesfully be more prepared for future endeavers requiring 14ga access, AND all whatever kinda bruise you are sure to be left with!... Even after you are done puking/swinging at us/possibly spitting/wondering where you R, and how you got there, and etc.../and MOST importantly, and equally amazing unuff (seeing as you are now declaring to me that "No, man I don't use heroine", uhh uh - allready tested positive for it there mister) and AND the fact that you have now just within the past 30 seconds or so, to the last 2 minutes or so,have started breathing again...

Practice makes Puurfect, right?

I mean we will probably not even recieve any sort of compensation from U directly,you know, for saving your life and all, maybe even for saving your life, sigh... yet once again, right?

Later,

Ian

So, unresponsive heroine abusers with good veins require 14 ga IV placement because "practice makes perfect?" Hmm, and I always thought size selection was based on patient condition and required the nurse to make a medical judgment call? I guess a new grad feeling some machismo because he managed to place a 14 is critically important. Silly me.