Our infusion center also collects stem cells for bone marrow transplant. The cellular techs start a 16 gauge peripheral IV in an antecubital and a 18 gauge in either the hand or the wrist for return. The RN is responsible for monitoring the pt and giving medications. ACD is used during the collection and can deplete the calcium. Our MD wants us to replace the calcium thru the 18 gauge in the hand/wrist. The standing order is 500 mg Calcium Gluconate IVP followed by 2 grams in 250 cc NS over 4 hours. Cellular states this is ok because our policy states calcium is only a vesicant if injected IM or Sub Q. My thought is that if the hand IV infiltrates, that is infact sub Q. What would you do??
what tissue it comes in contact with. Vesicants, irritants, infusates outside of pH 5-9 and hypertonic solutions all damage at least the tunica intima/endothelial layer of the vein, as well as the tunica media. Much chemical trauma occurs. Then, add the mechanical trauma of a cannula in the antecubital area where even the slightest movement causes the cannula to poke the inside of the vein....it's a set up for septic phlebitis, and/or permanent damage to the vein.
Calcium gluconate has a pH of 3 something, and is very damaging. Don't use the hand or wrist; risk of nerve damage and inadvertant arterial puncture are higher there. Risk exists in the antecub area as well, so if the only option is that it's infused through a peripheral IV, use smallest gauge possible in a large vein, and then remove the line after administration.
Unfortunately, clinicians of all stripes can be very cavalier and dismissive about vascular access issues, and will cling to incorrect, and very destructive practices. It's very good that you're questioning, and that you are an advocate for your patient.
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Calcium gluconate is always a vesciant when it escapes from the vein and enters the SC tissue. When given IV, all calcium products are considered to be vesicants, although calcium gluconate has slighlty less risk than calcium chloride. Your challenge would be to ensure that you use all methods to prevent extravasation injury. This would include meeting the standards on site selction, catheter selection, catheter and joint stabilization and medication administration. Your process has already violated the first and second - smallest size catheter in largest vein. An 18 g in the hand or wrist poses the greatest danger of extravasation injury. See the following article about this risk:
1. Kagel E, Rayan G. Intravenous catheter complications in the hand and forearm. Journal of Trauma. 2004;56:123-127.
Are you placing these hands/wrists on a handboard? If not, you should be if you hope to be infusing any vesicant through them. You absolutely must be able to bet a blood return before, during, and after each dose. Also, I would have a huge problem with putting any calcium on a continuous infusion for 4 hours and walking away from it. I am sure you will put this on a pump. That means that the pump will continue to force fluid into the SC tissue if there is any slight damage to the vein wall. Pump alarms are not designed to indicate fluid pathway or to detect infiltration. When infusing any vesicant med, this is preferably through a CVC. If peripheral, the nurse must be checking for a blood return every few mLs. But I doubt you have the staff to have one permanently assigned to remain at the patients bedside for 4 hours. So all in all, this is not a safe situation. I have been the expert on cases involving serious necrotic ulcers from calcium extravasation injuries, so it can and does happen. 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