Have a patient that had an IV from the ER when admitted to Medical floor, IV was infiltrated upon admission and promptly d/c'd. I was called to come assess for new PIV which I did with ultrasound to ensure vein size etc. Found a nice vein in left anterior forearm and started with ultrasound guidance with no difficulty at all. Obtained nice blood return and advanced catheter when I attached the extension set and checked for blood return it was still excellent and line flushed with no difficulty or pain for the patient. I was called minutes after I left the floor that the vein had blown upon flush per floor nurse. Patient states she has had the same problem in the past no matter how many times they re-started her IV's so I opted not to attempt again and notify the physician for alternate route for pain medication. The problem....this patient will likely go to surgery and now has no access. Is a PICC going to have the same outcome or possibly damage the vein as it is being advanced? should anesthesia opt for an IJ?
Since the patient is familiar with this problem, did she say anything about how they had managed her IV's in the past? I am curious about why she has such a problem. When placing the PIV, were you holding the probe leaving no hand to hold traction on the skin? If so, the catheter could have gone through the opposite vein wall, but if using a dynamic approach with US, I would think you could see that. Then it could be the method of stabilization. If only tape and/or dressing, there could have been movement of the catheter forcing it through the vein wall. A careful method to advance a PICC should not produce any vein damage outside of the usual risk. The tip in the SVC should not produce infiltration. Let us know what you decide. 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
Lynn,
I was able to visualize the needle tip in the vein, traction was held and the IV advanced smoothly. The physician has opted for no surgery therefore he decided no vascular access would be necessary at this time. I have never had a patient that this has occurred with and was curious if veins can become that fragile that they simply will not sustain a catheter dwell for any length of time? If a PICC is ordered I will definately attempt the insertion as now I am extremely curious to know if we would incur a similar problem with the PICC.
I two have had this happen and have always been curious. I asked our Hematologist but he did not have an answer.
I also had a long axis guided PIV that I could see in the center of the vein but could not advance the catheter past half way. I could visualize the flow perfectly. Weird.
I have a new term for all of you that I picked up from our engineers "vein purchase"
what is vein purchase? It is how much catheter is actually in the tissue and include the angle and how much catheter is in the vein. We have no established guidelines from any organization on PIV's to let us know what is a safe length. The 50% rule does not work if one has a 3/4 inch or 1 inch catheter in a forearm that has a deeper vessel. You do not have much catheter in the vein. Now that I know my BMI is at the range of obesity. a problem I need to tackle by the way, my tissue has grown and my veins are deeper. I need a longer catheter for the safety against infiltrations. No longer does the rule apply of the shortest length catheter but the shortest length to give adequate vein purchase is more the rule.
We are embarking on a world where the 24 gauge 3/4 and the 22 gague 1 inch is not going to be as acceptable in the patient population we are dealing with. We need studies on what percentage of catheter needs to actually be in the vessel to prevent infiltrations and extravasations. You may likely find you have the slightest bit of the tip of the catheter in the vein and the vein blows, infiltrates, with pull out.
It is a new era of new BMI's. I am a perfect example of the increasing BMI of the United States. Vein purchase will become the most talked about new subject in PIV's.
[email protected]
Bard Access Systems
This patient was of average size and I had 50%+ catheter in the vein as it was not a deep vein as it was on the anterior forearm.
I have experienced this issue as well. When I use US guided PIV placement, I use a 1 3/4in IV catheter. This usually provides enough length to get enough catheter into the vein for a secure IV. The other issue that can occur is that someone may place a blood pressure cuff above the IV and that may cause enough pressure to "blow the vein". It kind of "blows me away" that people do this but as an IV therapy nurse, the teaching portion of my job is never done.