I had a recent discussion about the value of the 20g 1 inch and the 20g 1.25 inch peripheral catheter. I would like to here your reasons for using or not using both in the adult population. Please respond
Other than the fact that it is NOT the smallest gauge and length, I would use it if I needed to have a unit of blood go in over a very short time frame, or I was in a trauma situation. Otherwise, INS standards encourage the use of the smallest gauge and shorest length for the prescribed therapy. Rarely does my populi need anything bigger than a 22gauge, and that soaking wet, 90 lb female, she gets a 24 gauge.
In most patients, I have not seen much, if any, difference between a PIV that is 1 inch vs 1.25 inches. The one possibility for a problem with the longer catheter is for younger patients with a greater frequency of venous valves as these valves could pose an obstruction to completely threading the longer catheter. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Office Phone 770-358-7861
The longer catheter is good for the patient with edema as it won't get pulled out of the vein as the swelling increases. The longer catheter is useful for ultrasound piv insertions when the vein is deep. That's all I can think of for choosing the longer one, otherwise, the guidelines say smallest and shortest that will deliver the therapy. Why irritate more intima than necessary?
I place most of the piv's I am called to do with U/S guidance and almost always use the 1.25 inch 20 gauge catheter. Based on years of experience using the U/S to place piv's I strongly believe that the extra .25 inches of catheter makes a vast difference in avoiding complications such as infiltration and the overall longevity of the piv. I have not seen the extra .25 inches cause increased phlebitis rates. Many pt's now are bigger and more obese with deeper veins and many also have very poor muscle mass and very "loose" tissue". In these types of pt's, which are the majority imo, the 1 inch catheters are more prone to infiltrating, becoming dislodged, especially if placed in the a/c, the upper arm, or the underside of the forearm. As a side note, I generally will not place an U/S guided piv in a vein deeper than .75 cm or so, unless it is a virtual last option or an emergency. And in those cases I will use the 1.75 in, 20 gauge piv that we save from some of our picc kits. Of course, proper anchoring is key. We use the statlock which I think works well if put on correctly.
I would like to ask more of this discussion. Some in our team across several hospitals are saying they think there will be less phlebitis when the longer 20 g PIVs are used for PE protocols. In our facility this is a very high pressure injection. We have seen plenty of phlebitis from contrast injection but I don't really think that the length of the catheter has as much to do with it as the age of the PIV does and what was infused beforehand. Any thoughts from anyone else. One facility is pushing for all of us to change to a standard 1.25" 20 g PIV for everyone needing a 20 g. I'm not sure that is appropriate. I'd like some help. I agree with the issue about valves. Sometimes I would like a 0.75" 20 g. Thanks everyone.
Mary Penn RN Vascular Access Team
St Charles MO
Indeed, there is more to discuss if your are talking about PIVs for contrast injection. Last May I gave a showcase for BD at INS on contrast extravasation. I looked at 10 legal cases of contrast extravasation where I had been an expert. This is a significant problem and growing larger, although the published rates are still only 1.2% of CT scans. This rate has grown from around 0.25% (don't remember exactly) in the early days of CT use. There is also an early animal study showing a jet effect coming from the catheter tip that can cause the catheter to be forced out of the vein. There is a published lab study on the concept of having a peripheral catheter with side holes near the catheter tip. This allows for plumes of the agent to exit and decreases the jet. At this showcase, a nurse from Oregon also gave a presentation of her early outcome data with a new peripheral catheter that BD has released that has these side holes, Diffusics. Her experience showed that contrast could be delivered through this catheter with a smaller gauge size. It has not been fulled demonstrated yet, but it is possible that this extra 1/4 inch length could allow for a more secure "purchase" of the vein. Please note that this extra length idea has not been studied and is only my conjecture. I do not agree with the thought about lesser rates of phlebitis with a longer catheter. This goes against the basic principles of infusion therapy. But phlebitis is probably a smaller problem than extravaation injury from power injected contrast. I have never seen any published data on phlebitis rates with catheters used for contrast injection. Do you have outcome data or is your thought about high phlebitis rates based on what you have seen clinically? Age of the catheter is a significant problem also. ACR's Manual on Contrast states that catheters older than 24 hours should not be used for contrast. You should also consider other aspects such as site selection - never in hand or wrist, ACF veins only if it is removed at the end of the procedure; adequate secure catheter stabilization with an engineered stabilization device; following all other recommendations from ACR on contrast injection. Lynn