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Cherokee people
Peripheral IV access in breast, chest. Submitted Monday, November 21 @ 1910

 

I've been searching for evidence based data about starting peripheral IV's in uncommon areas, ie, breast, chest, etc. I found this same question asked in the past on the forum. I agree with the answers that were provided, but is their any evidence out their to support not using these veins routinely? 

I would like to present this scenario to this group of experts: A female patient comes in to the ER that has a chronic condition and is frequently in and out of the hospital. Her condition is stable and not life threatening. She has had multiple central lines (IJ, SC, Femorals and PICCS) and has extinquished all veins appropriate for peripheral access even using ultrasound. She can no longer be accessed for a bedside PICC insertion by the IV Team. It is after hours and she needs access for fluids, antibiotics and pain meds. She insists that the ER nurse start an IV in her breast because that is all that can be obtained in her. The ER physicians do not want to attempt a central line. I'm not sure that an EJ IV was attempted. The IV is started in her R breast and she is admiited in to the hospital which of course after 2 days the R breast IV develops grade 4 phlebitis.

I agree this is dangerous practice and should not be done unless it is a life threatening emergency and used temporarily until the patient becomes stable and can be given better venous access. I also agree that the staff need education in order to change this practice but am unable to find anything to deter it. I would appreciate any help that can be given from this group of experts. I thank you in advance for your time and information.

Below is the posted past forum...

 

 


I would agree totally with

I would agree totally with Lynn on this and would add that intraosseous infusion should be thought of and used WAYY before you'd ever look at a breast vein.

Wendy Erickson RN
Eau Claire WI


This practice is danger and

This practice is danger and has absolutely no evidence to support its safety. Extravasation in this area could easily mean a mastectomy for the patient. This can and has happened with extravasation from central venous catheters. In fact, I have a legal case of this nature right now. So insertion of short peripheral catheters in the chest or abdominal wall has no scientific basis, and can be excessively risky. You must educate the nurses about this and do whatever it takes to get them to change their practice. But I would also listen to them about why they think it is necessary to use these sites. Is it truly a case of a crashing patient and there are no veins of any extremity to find? Is this a dehyrated patient and the peripheral veins do not easily distend? Is this a case where the nurses have never been taught the correct skills for locating and palpating peripheral veins? I see this as the primary issue in most cases. Nurses do not know how to palpate properly, so if there are no easily visible veins in the hands, wrist or antecubital fossa, they think there are no veins at all. This is simply not correct. If they do have a valid need for some patients, I think they should be trained in use of US for PIV or insertion into the EJ for temporary access. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Blog http://hadawayassociates.blogspot.com/

Office Phone 770


IVs in the breast

Does this make you crazy too??  It does make me crazy.  It is a rarity, but really......how long do they think this will last?  The only time I see this is from the ED.

 Gwen Irwin

Austin, Texas

 

 

 

lynncrni
There are no clinical studies

There are no clinical studies showing that these abnormal sites produce rates of complications less than, more than or equal to sites in the upper extremity. So no direct clinical evidence for or against these sites. But, I would use this fact against using these sites in a chest wall. We do know that implanted port access in the upper chest can lead to displacement of the access needle causing serious infiltration and extravasation injuries so serious that women have required mastectomies to treat this. I realize the design of a port access needle and a peripheral catheter are quite different, however these sites could be contributing to the issues of catheter stabilization. Additionally, skin on the extremity is dry skin with fewer numbers and densities of microorganisms while skin on the chest is oily with greater numbers and types of organisms. What will this mean for peripheral catheters in the upper chest area? Given what we do know and considering what we do not know, I think these sites must be avoided.

There is another option for patients such as you have described - using an infrared light device to locate veins. I am not talking about a visible light similiar to a flashlight. I am referring to products such as Vein Veiwer or Accuvein. US is designed to locate veins below 1 cm depth in the tissue and I am not surprised that it no longer works on this patient.  Infrared light is designed to locate superficial veins less than 1 cm depth or the veins we commonly use for venipuncture. Infrared light will allow you to locate veins that you can not see or palpate. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

IV GUY
PIV in chest, breast

The terms "emergency and "chronic" (frequent hospitalizations) indicate two different plans of care to solve the problem of iv access. As I have posted before, I have placed peripheral lines in non-traditional areas (never a breast though) in emergent situations for specific reasons based on the risk/benefit to that particular patient in that particular scenario. To "routinely" do that by definition increases the risk of having a complication. A"chronic" scenario as you describe requires medical management based on a team approach, perhaps an infusaport for example. I do not know if other avenues were explored with this particular patient PRIOR to her return to the ER with her LAST hospitalization. If not, they should have been. Is the patient aware of the risks of having an IV in her breast? Just because she insists and the fact that it was done before does not make it right nor safe.

Therefore, you then need to find a temporary solution in the ER before you can treat the chronic issue of poor vascular access. If the ER physician elected not to place a central line, I can assume then that the risks outweighed the benefits. Therefore I assume the patients condition was not seriously life threatening. Consequently, for the nurse to assume that risk by placing a "risky" PIV in the breast ("because the patient insists") in this situation is to walk a legal tightrope, especially (as Lynn indicated) if things do go wrong. IV fluids by themselves if infiltrated pose a risk for injury. IV pain meds & IV antibiotics increase that risk exponentially!! As a nurse, and as an "IV Specialist" I would ask: were other avenues explored? Can the antibiotics can be given PO or IM? Can the pain meds can be given PO or IM? Could the patient tolerate PO fluids? If not, and her conditon is NOT life threatening, can she do without fluids until a vascular surgeon is consulted? Is clysis appropriate in this case?  I personally feel intra-osseous is a bit extreme in the awake, alert, and non-emergent patient, but was this also discussed by the members of the ER team with the patient?

I'm not even going to discuss the problems inherent in sending this patient to a regular medical floor with a PIV in her breast!

In conclusion, I personally feel "routine" PIV starts in "non-traditional" veins is not appropriate by definition of the word "routine". These situations need to be handled on a case by case basis based on risks/benefits to the patient. In the scenario as you describe & based on the info provided, I personally would NOT have placed a PIV in the breast.

IV GUY

Cherokee people
Thank you for your response

Thank you for your response this was helpful.

lynncrni
I had one other thought about

I had one other thought about these sites. If veins on the upper chest wall are prominant and visible for venipuncture, I would have to ask why. It is certainly not the normal way that healthy people's chest walls apear. I would be concerned that the visibility of these veins indicated some pathophysiology such as venous obstruction for some reason like stenosis, thrombosis, etc. Infusion through these veins could easily add a huge risk for your patients. Lynn

 

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

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