our IV therapy department learned quickly about some of the downfalls of doing this. Through trial and error and as well as doing a literature search here is what we do for any iv placed in this manner.
1.We use only a 1 and 3/4inch catheter or an 18 21/4 inch catheter above the ACF. We found that if we used anything shorter they would start leaking within 24 hours or worse yet infiltrate within 24 hours. We special order the long 18 gauge catheter.
2. We will not use the brachial vein ever. If this is our only option we put the PICC in. We rather use the basilic only in the lower third of the upper arm (after that it usually gets deeper, We also will use the cephalic which stays fairly shallow all the way up the arm.
3. If the nurse insertor accesses the vein and most of the catheter ends up under the skin with very little in the vein,such as a 1/2 inch or so we take it out. When this has happened the site would infiltrate within hours,
4. We discovered that the nurses could not detect infiltrations early in these sites.even when we provided them with education and we decided the risk for injury was too great.
5. We will use the cephalic and lower basilic for CT scan injection and then d/c the site.
6 We evaluate the patient for a PICC length of therapy etc.
our ED educator asked me if it was a problem that MDs RNs and techs were using US to place IVs, and I stated all of the below (and that they should complete a training and competency).
I also reminded them that our facility reports federally that we have a team that specializes in IV insertion (per CDC recommendations yada yada), so that if the ED staff are having difficulty starting an IV, they should be paging us instead of going right to the ultrasound.
Mary Anne - what needles do you use for the longer lengths(brand)?
Mari Cordes, BS RN
Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
We use the 18 gauge 2 1/4 inch Braun Intocan b/c technically anything 3 inches or longer would be considered a midline. I agree ED nurses should not be using US to place PIVs unless they have been given a set of guidelines in addition to documented training. Our ED staff calls us. We use a Site-Rite 5 that we have nicknamed Rosie. The nurses know the jargon and say bring Rosie,even our patients say "Go get Rosie". MDs are another matter and I am sure they will not like to be told what to do. Interestingly enough most of the articles I found related to this practice came from ED journals. Google it an see what pops up. I told our supply RN to check and see if Braun makes a 20 gauge 2 1/4 inch Introcan as we have found that the 18 gauge works really well and without leaking or infiltration or backtracking. I also included a special section in our peripheral protocol to cover us in performing this task and included special considerations and specifically stated the Brachial vein was not to be used.
Totally agree with Ferannini. I get called a lot to place PIV for CT Scan, Use Ultrasound everytime (I love the Sonosite). If a peripheral vein images deeper then 1cm I WILL NOT PLACE A PIV IN IT. NO MATTER WHAT. I learned this the hard way too, after a few disaterous contrast infiltrations.
I refuse to use special "longer" angiocath. If no vein images shallower then 1cm, I will insert a PICC for CT SCAN.
At AVA this past week, a new device, the AST (I think Accelerated Seldinger Technique) was introduced which will solve this problem. No 510K yet, I think, but promising. Do a google search.
At AVA this past week, a new device, the AST (I think Accelerated Seldinger Technique) was introduced which will solve this problem. No 510K yet, I think, but promising. Do a google search.
no longer place PIV above AC in basilic or brachial with ultrasound.
for those placed above AC, very short dwell time, less that 24 or 12 hours -- very difficult to detect infiltration
our IV therapy department learned quickly about some of the downfalls of doing this. Through trial and error and as well as doing a literature search here is what we do for any iv placed in this manner.
1.We use only a 1 and 3/4inch catheter or an 18 21/4 inch catheter above the ACF. We found that if we used anything shorter they would start leaking within 24 hours or worse yet infiltrate within 24 hours. We special order the long 18 gauge catheter.
2. We will not use the brachial vein ever. If this is our only option we put the PICC in. We rather use the basilic only in the lower third of the upper arm (after that it usually gets deeper, We also will use the cephalic which stays fairly shallow all the way up the arm.
3. If the nurse insertor accesses the vein and most of the catheter ends up under the skin with very little in the vein,such as a 1/2 inch or so we take it out. When this has happened the site would infiltrate within hours,
4. We discovered that the nurses could not detect infiltrations early in these sites.even when we provided them with education and we decided the risk for injury was too great.
5. We will use the cephalic and lower basilic for CT scan injection and then d/c the site.
6 We evaluate the patient for a PICC length of therapy etc.
ditto
our ED educator asked me if it was a problem that MDs RNs and techs were using US to place IVs, and I stated all of the below (and that they should complete a training and competency).
I also reminded them that our facility reports federally that we have a team that specializes in IV insertion (per CDC recommendations yada yada), so that if the ED staff are having difficulty starting an IV, they should be paging us instead of going right to the ultrasound.
Mary Anne - what needles do you use for the longer lengths(brand)?
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Totally agree with Ferannini. I get called a lot to place PIV for CT Scan, Use Ultrasound everytime (I love the Sonosite). If a peripheral vein images deeper then 1cm I WILL NOT PLACE A PIV IN IT. NO MATTER WHAT. I learned this the hard way too, after a few disaterous contrast infiltrations.
I refuse to use special "longer" angiocath. If no vein images shallower then 1cm, I will insert a PICC for CT SCAN.
I agree with Rivki. The secret for me is not to place an IV deeper than 1cm.
Cheryl Kelley RN BSN, VA-BC
Cheryl Kelley RN BSN, VA-BC
Rhonda Wojtas, RN PICC Team
Lowell MA
Rhonda Wojtas, RN,BSN, VA-BC