Recently management of the cat scan department at my acute care facility is requesting #20 & #18 gauge catheters for certain scans. The size is dependent on the area being scanned. The scans for #20 & #18 require infusion rates at 4ml/sec. and 5ml/sec. and typically complete in 32 seconds.
We are considering trialing DeltaVen Closed IV catheter (similar in design to BD Nexiva). The max flow rate for the #22 gauge 1" is 5ml/sec (warm or non-warmed contrast). Many times we cannot insert #20 or #18 gauge IV catheters or are requiring multiple IV insertions to do so.
1. The radiologists and techs have come out with a stance that absolutely no IVs for CTA exams (4-5mL/sec) should be placed in the hand. As a vascular access specialist, I am aware of the risks using the hand and this would be the last option and sometimes the only option. To make an absolute statement of no, in my mind is going to far. Their rationale is the language in their manual stating forearm, AC, and above the AC is preferred. I have discussed areas of flexion such as the AC increasing the pressure with them as well (patients do not keep their arm straight when the injection occurs).
Any other points that could be made? Sometimes on the inpatient side, the plan for a cat scan is unknown and the nurse inserts an IV in the hand because of their skill level. In this instance, CT's new position is requiring patients to have a new IV insertion, new location and large gauge if its not atleast #20. They are also recommending using only IVs less than 24 hours old. Nothing wrong with it, no complication, etc. Thoughts??
2. Our current IV catheter #22 gauge 1" has an injection rate of 9ml/sec but we need to add on macro bore power injection tubing. The radiologists have complained that when using a #22 the image is of poorer quality, therefore #20 request. The closed system that we are thinking of trialing is promoted for CT use, able to insert a smaller gauge catheter and still getting optimal injection rates. If we take the patient's vein out of the picture, wouldn't the current catheter be better than the proposed catheter? Does anyone have any experience with Nexiva or DelteVen?
3. I find it difficult when practice standards (radiology and infusion therapy) conflict. I want to limit # of attempts to place a catheter, leave it in until no longer indicated, avoid the use of the antecubital region and do not insert a short peripheral IV catheter above the AC unless using ultrasound and a longer 1 3/4" - 2 1/2" catheter. Am I being overly protective? Is there a middle ground? Is there literature to help in this situation to come to a happy medium between the two disciplines when dealing with acute care inpatients??
Extensive list of questions. Here is my very short answers, based on around 25 to 30 lawsuits involving contrast extravasation.
Don't know the new catherer you are speaking of. Is the the same as Nexiva or Nexiva Diffusics - big difference. Diffisics is specially designed for contrast injections and supported with a clinical study from Hopkins that a 20 g is equal to a traditional catheter.
ACR Manual on Contrast addressed most of your questions. Hand veins - nothing faster than 1.5 mL per second is recommended. Some CTs now require up to 8 mL per second. Large veins of forearm or AC is recommended. Put it in and take it out after CT. Much higher rates of extravasation after 24 hours, coming from oncology literature of other vesicants. Contrast is a vesicant!! You are correct about AC and flexion if arms over the head - a point I make a lot in depositions and court testimony. CT is all about rapid injection so contrast concentrates in the organ(s) being studied and the best images are obtained. Requires speed of injection. If new catheter is similar to Nexiva, then why are you adding another extension. It is only similar if it has a built on closed extension set and no other one is required. Appreciate your efforts in #3 but procedures like this should be treated a little differently than a catheter used for regular infusions. You are much better off regarding risk of extravasation and subsequent compartment syndrome and nerve injuiry to use a separate PIV for contrast. No evidence supports a PIV in for many days to survive a power injection for CT in addition to other infusions. Probably expecting far too much.
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
1. Current IV requires the addition of an extension. We will be trialing a new catheter of similar design to Nexiva, not diffusics.
2. Our current scans do not go past 5mL/sec. and the constrast is warmed therefore decreasing viscosity.
3. Are people really inserting and removing an IV just for cat scan? I can see this for outpatients but not inpatients. We in the acute care world struggle with veins that have been repeatedly cannulated for phlebotomy, PIV insertions, etc. Radiology requirements are just making positive patient experiences more difficult to achieve.