Forum topic

9 posts / 0 new
Last post
smarison
AVA certification
Hi All, so excited the certification info is out.  I got the review book but was concerned.  On page 26 it states only solutions that can safely be infused through a short peripheral catheter can be infused through a midline.  SO, although Vanco isn't the best to give peripherally, it is still done, but I wouldn't give that through a midline.  Also, it talkes about starting down by the hands when inserting a PIV which I agree with, but also always thought you should avoid the hands due to more risk of nerve damage.  Just some thoughts as I read through this info, and think about what I have been taught over the years.  Any feedback would be great. Either way I think it is great that we have something specific for us to be certified in.  I was CRNI certified back when I did home infusion, which was appropriate, but for the job I am in now, all we do is place and care for PICC's.  Have a great day.  Susan
lynncrni
A midline catheter has the

A midline catheter has the tip located in a peripheral vein, just like a short peripheral catheter. The parameters for final solution osmolarity and pH are the same for both catheters. Vancomycin can never be admixed so that the pH will be above 4, below the lower paramater of 5. Therefore, neither a PIV or a midline should be used for this drug. Of course, you must consider the length of therapy. If you are using vanco as a perioperative antibiotic or you are awaiting the results of cultures to determine the length of time it will be required, then you may be forced to use a PIV. In those cases, you should follow the national standards of practice which states to use the smallest gauge catheter (24 or 22), avoid areas of joint flexion, and adequately stabilize the catheter. If you must use the wrist for a PIV, also use a handboard to stabilize the joint as well. The basic principle is always to start low and work upward. If the therapy involves the infusion of vesicant medications, you should avoid using the hands, however hands are used for many patients in the hospital. 

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

smarison
Thank YOU Lynn
Thank YOU Lynn
Leigh Ann Bowegeddes
I realize that the old

I realize that the old standard was to start low, and destroy as you go up, but I don't agree that this is always the best practice. Remember that this practice started 45 years ago, when we didn't have the IV catheters we have today. Nor did we have StatLock. We had steel needles and tape. With the soft IV catheter options we now have, as well as superior securement, you may consider beginning above the wrist on the flat surfaces, choosing a larger vein and smaller catheter, and securing with devices that proven to improve outcomes. While some people have fat, straigth veins on their hands, I have small and twisting veins on mine, and ALWAYS develop painful phlebitis with any access on my hand. Be aware also that the standard to use an armboard or handboard when any point of flexion is crossed with the PIV. Look at the back of your hand and move one finger - see the movement obvious on the back of the hand? EVERY point on the hand is a point of flexion, and requires a handboard if you cannulate there.

I agree with Lynn's comments about midlines and PIVs with irritants or vesicants.

Leigh Ann Bowe-Geddes, BS, RN, CRNI

Vascular Access Specialist

University of Louisville Hospital

lynncrni
Sorry but making a

Sorry but making a venipuncture below a previous one is still leading to serious complications. I just reviewed a legal case this week where the patient was stuck slightly below the AC and failed, then the subsequent stick was on the volar aspect or palm side of the wrist where there are veins in very close proximity to the median nerve. The injected fluid caused extravasation injury at both venipuncture sites. So starting low and working upward should always be the course of action. 

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

smarison
WOW you would think there
WOW you would think there wouldn't be an issue on the opposite side of the arm.  Susan
lynncrni
Veins are a network on the

Veins are a network on the extremity where all are connected. A problem low on the forearm can produce a problem at a venipuncture site higher on that same arm. 

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

smarison
Yeah, makes sense just never
Yeah, makes sense just never thought of it that way before.
momdogz
I teach to avoid using the

I teach to avoid using the metacarpal veins for routine cannulations. 

Get to know the venous anatomy of the forearm for PIV insertion very well, develop your sense of palpation, and you'll find you rarely have to use the hands.  Also recognize that there is considerable variation from person to person.  The basics are the same, generally: cephalic, accessory cephalic, basilic, median/median antebrachial (different names for that one).  Netter has very helpful images.  

The tributaries and branching veins from these is where you'll see more variation.  Even the cephalic vein in the forearm has variation - on some folks, it begins laterally and then travels more medial-anteriorally, and for others stays quite lateral.  FYI:  30% of the population will not present with a median cubital vein in the antecubital fossa - you'll note 2: median basilic and median cephalic veins.

We see a lot of sick patients, and are usually able to avoid the hand .  We teach the distal to proximal sequence when replacing, but I know that if I'm placing a PIV in the basilic vein that is slightly proximal to a problematic older site in the cephalic vein, especially if I can see that there are no branching veins connecting them - it would be a better site than a hand vein, for the reasons that Leigh-Anne mentions.  I also teach to avoid the 1st metacarpal vein, which can look quite tempting sometimes.  Lots of complications (court cases) have occurred with that one.  So then you're limited to other, often more tortuous, smaller hand veins.

Another thing I don't like about using hand veins:  even if using a catheter securement device, but especially when not - there is a lot more vein damage caused, armboard or no armboard, by the extension set getting caught on things with the patient's hand movements.  And then, even if you've taught everyone well, someone will come along and power inject into the hand IV.

All that being said, they're good veins for beginners who aren't able to rely on their sense of palpation yet, and sometimes we just have to use them. 

Midlines - we're using/teaching early vascular assessment for a number of reasons including NKF Fistula First vein preservation, and rarely have a good reason to put a midline instead of a PICC in.  Never put vesicants/irritants, infusates out of pH and osm. ranges through them.  If an infiltration/extrav occurs, there is so much more tissue that by the time you're aware of the problem, a lot of damage has been done.

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Log in or register to post comments