# Large bore IV's



## Rykielz (Jan 19, 2013)

This is a serious discussion I'd like some input on.

Recently there's been a lot of discussion from various medics about the appropriate times to use a large bore IV. Some of the obvious responses: trauma, significant hypotension, cardiac arrest, etc. which are all easily justified. But are there other circumstances where a large bore IV is appropriate? Is it against the standard of care to be prophylactic in circumstances such as severe ETOH, STEMI, dyspnea, etc.?


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## NomadicMedic (Jan 19, 2013)

Depends on what you consider a large bore. For me, a large bore IV cath is an 18 or better. I rarely use anything bigger than a 20. STEMI and CVA get an 18.


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## Rykielz (Jan 19, 2013)

Large bore is an 18G or bigger where I'm from. Most patients get an 18 or a 20, however, I've been hearing of more and more medics going to 14's and 16's pretty often during the calls I listed above.


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## STXmedic (Jan 19, 2013)

14s and 16s are more of an old-school mentality (at least around here). I'll start a 14 or 16 if I expect the patient is going to need a blood infusion in the very near future, or if I'm going to start a pressor. ~90% percent of my patients will get a 20g. Every now and then I'll do 18s. 14s or 16s aren't too common, primarily given for the aforementioned reasons.


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## Shishkabob (Jan 19, 2013)

Shoot, we don't even carry 14s aside from needle decompression.  Most people get a 20 or 18.  

Sure, you'll get nurses who complain about blood and 'not working with a 20g', but that's hogwash and stupid of them.  It's not ideal, but a 20g in the hand is better than a 16g that you can't start.



Permissive hypotension, short transport times, etc not being included into the discussion either.


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## ffemt8978 (Jan 19, 2013)

We don't carry 14's either - our EMS administrator thinks they're "barbaric".  Most people get 20's, with a few exceptions.  Trauma and pregnancy get 18's, and occasionally will get a 16 for a second IV if indicated.


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## hibiti87 (Jan 19, 2013)

I normally use 20's and 18's. I cant recall an incident where a 16 was needed by the hospital.

Slightly off topic. I have heard in passing that a NS bolus can delay delivery in pregnancy. Can anyone verify this and perhaps provide an article on it if it is true?

thank you


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## Veneficus (Jan 19, 2013)

Rykielz said:


> This is a serious discussion I'd like some input on.
> 
> Recently there's been a lot of discussion from various medics about the appropriate times to use a large bore IV. Some of the obvious responses: trauma, significant hypotension, cardiac arrest, etc. which are all easily justified. But are there other circumstances where a large bore IV is appropriate? Is it against the standard of care to be prophylactic in circumstances such as severe ETOH, STEMI, dyspnea, etc.?



Large bore, which I would consider anything bigger than an 18, (some consider 18 large) is really only indicated for large volume infusion or the potential for that.

Having said that, placing a large bore needle requires practice, it is a bit different from the relatively smaller ones and if you don't do it regularly, you will not be able to do it when you need to.

Severe ETOH probably does not need a large bore but if the person is severely dehydrated from it, they may appreciate it. 

A lot of people get all upset over large needles mostly out of the psychological impact, not because of the actual insertion. 

I have noticed nurses are particularly seem a bit more adverse to large bore peripheral needles, but raise no objections to using a central line instead of a large bore peripheral.

(in my opinion it is caused by allowing emotion to interfere with judgement.)


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## Pavehawk (Jan 19, 2013)

If you're using a lock that may make your choice of gage moot. Most locks (not all) will gate down to a 20 gage. If you're worried about giving fluid consider a direct conection to the cath hub unless you know for a fact the locks and extension tubing you use are large enough to allow the flow you're looking for.


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## Rykielz (Jan 19, 2013)

Should these medics that start large bore IV's for less than obvious reasons be disciplined? Could this be construed as mistreatment?


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## ChorusD (Jan 19, 2013)

Rykielz said:


> Should these medics that start large bore IV's for less than obvious reasons be disciplined? Could this be construed as mistreatment?



Only if they're using it punitively.  For example, starting a 16 on a pt that doesn't need it just because this is the thirty second time you hauled that pt in a week.

It seems a bit much to discipline providers for doing things they were trained to do.  What may be less than obvious to you just might be crystal clear for somebody else.


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## abckidsmom (Jan 19, 2013)

Pavehawk said:


> If you're using a lock that may make your choice of gage moot. Most locks (not all) will gate down to a 20 gage. If you're worried about giving fluid consider a direct conection to the cath hub unless you know for a fact the locks and extension tubing you use are large enough to allow the flow you're looking for.



I notice the difference in gauges in a free-flowing IV, and always have a lock in. When the luer lock connection is open, it's open. It isn't as small as 20, because wide open with a 20 is significantly less than wide open with a 16.


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## VFlutter (Jan 19, 2013)

abckidsmom said:


> I notice the difference in gauges in a free-flowing IV, and always have a lock in. When the luer lock connection is open, it's open. It isn't as small as 20, because wide open with a 20 is significantly less than wide open with a 16.



a 20ga max flow is 60ml/min, a 18ga is 105ml/min and 220ml/min with a 16ga. So yes there is a significant difference in flow rates between the various gauges but how often will there be a clinical need for using a 16 over an 18?


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## blindsideflank (Jan 19, 2013)

Another consideration is if contrast dye will be used (CT). And drawing blood from something smaller than a 20 is annoying and "may" damage cells, skewing lab values (k+)


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## VFlutter (Jan 19, 2013)

blindsideflank said:


> Another consideration is if contrast dye will be used (CT). And drawing blood from something smaller than a 20 is annoying and "may" damage cells, skewing lab values (k+)



I have seen them give contrast through a 22 and ideally you should not be drawing blood from an IV.


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## Veneficus (Jan 19, 2013)

Chase said:


> I have seen them give contrast through a 22 and ideally you should not be drawing blood from an IV.



The catheter size for ct contrast is govered by the manufacturer rating of its strength.

Not all IV catheters are rated to be used for contrast. Not to say they will fail, only that they are not tested to withstand it,

As well, there may be institutional regulations or events where what could be gained outweighs the risks.


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## NomadicMedic (Jan 19, 2013)

Veneficus said:


> The catheter size for ct contrast is govered by the manufacturer rating of its strength.
> 
> Not all IV catheters are rated to be used for contrast. Not to say they will fail, only that they are not tested to withstand it,
> 
> As well, there may be institutional regulations or events where what could be gained outweighs the risks.



We resotck all of our IV caths from the ED, so that's not an issue for me. 

I was "told" several times that contrast had to be given in the AC and through an 18 or better. Two charge nurses and the interventional radiologist pooh poohed that and said, "Dude, get the line you can get. If they need the study right now, we'll use what we've got."


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## Veneficus (Jan 19, 2013)

n7lxi said:


> I was "told" several times that contrast had to be given in the AC and through an 18 or better. Two charge nurses and the interventional radiologist pooh poohed that and said, "Dude, get the line you can get. If they need the study right now, we'll use what we've got."



You know how it works, there is what you'd like, and what you really need.

I am sure you also know that some people, always seem to treat every "best practice" as the right vs. wrong way.

Somebody probably over-simplified "You should use an 18 whenever possible" to "you must."


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## Shishkabob (Jan 19, 2013)

hibiti87 said:


> Slightly off topic. I have heard in passing that a NS bolus can delay delivery in pregnancy. Can anyone verify this and perhaps provide an article on it if it is true?



Increase of fluids, decrease of release of ADH being released by the posterior pituitary leading to the 'side effect' decrease of Oxytocin being released by the posterior pituitary, which leads to a decrease of uterine contractions.


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## Outbac1 (Jan 19, 2013)

Linuss said:


> Most people get a 20 or 18.
> Sure, you'll get nurses who complain about blood and 'not working with a 20g', but that's hogwash and stupid of them.  It's not ideal, but a 20g in the hand is better than a 16g that you can't start.



I use an awful lot of 20ga compared to 18ga. Probably an 8:1 ratio. I agree with Linuss the 20ga you have beats the one you didn't get. Most pts are going to get some fluids and/or meds thru it. A 20ga is sufficient for either. 

 I notice though our lock extensions are called "Macro" and the common one at the local hosp. is a "Micro". The difference being the Macro takes 0.8mls volume and the Micro 0.4mls. The actual ga of these I do not know. The Micro appears fairly small. I don't see the point in putting in an 18 ga or larger IV and then hooking a Micro line to it. Yet I see it done at the hosp. by the nurses. They don't seem fazed by it. If I mention it I usually get "Well their going on a pump anyway". Just doesn't seem logical to me.


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## mycrofft (Jan 19, 2013)

I was taught a rule of thumb. Given that the needle will go in and the catheter will place properly, anything lower than 18 ga is for meds (micro drip) and anything 18 and over can carry volume (macro).

Our problem was nurses starting 22 gauges in the dorsal hand for dehydration patients and bleeders as well as post-ictal patients with an order for IV benzos then TKO. No, we didn't have pumps.

Also, our nurses ticked off the receiving hospitals by starting some JIC lines (Just In Case) with a 22 ga in the antecubitum because that is the vein they could find (see), but rendering it "out of bounds" for the hospital anesthesiologist (their rules, not ours, ask the hospital).


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## AGill01 (Jan 19, 2013)

I work with a medic that said he will only use an 18g. In my opinion it depends on the pt and what is going to be given through the IV. If the pt is an 80 yr old with little veins of course you are not going to use an 18g. But again in my opinion 18g is better for pushing D50 if needed.


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## mycrofft (Jan 19, 2013)

AGill01 said:


> I work with a medic that said he will only use an 18g. In my opinion it depends on the pt and what is going to be given through the IV. If the pt is an 80 yr old with little veins of course you are not going to use an 18g. But again in my opinion 18g is better for pushing D50 if needed.



Heck yeah, ever try pushing D50 through a 20 gauge? I'll stand by, go ahead.


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## mycrofft (Jan 19, 2013)

mycrofft said:


> Heck yeah, ever try pushing D50 through a 20 gauge? I'll stand by, go ahead.



Still waiting......


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## mycrofft (Jan 19, 2013)

mycrofft said:


> Still waiting......



YEP still waiting...:rofl:


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## Shishkabob (Jan 19, 2013)

mycrofft said:


> Heck yeah, ever try pushing D50 through a 20 gauge? I'll stand by, go ahead.



Yup, and a 22 as well.  Not preferred, but you work with what you get.


I try to avoid IOs in diabetics if I can.


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## AGill01 (Jan 19, 2013)

We just had a discussion regarding IO's in the ER. We have the means to start an IO but it is not in our protocols. We need some new protocols.


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## NomadicMedic (Jan 19, 2013)

I tend to dilute my d50 in a 100 bag. Makes it a lot easier with little veins/Caths.


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## Veneficus (Jan 19, 2013)

AGill01 said:


> I work with a medic that said he will only use an 18g. In my opinion it depends on the pt and what is going to be given through the IV. If the pt is an 80 yr old with little veins of course you are not going to use an 18g. But again in my opinion 18g is better for pushing D50 if needed.



If anyone starts anything less than an 18g on me, they better hope I do not wake up.


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## blindsideflank (Jan 19, 2013)

Chase said:


> I have seen them give contrast through a 22 and ideally you should not be drawing blood from an IV.



What do you draw blood with, a butterfly? If you mean drawing through a flushed lock it's no different than using a central venous/art line you just have to draw out waste. Agree or am I missing something? I've never been told there is an issue with doing so


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## Thricenotrice (Jan 19, 2013)

I try not start anything less than an 18 if I can (tiny frail people with impossible veins obviously the exception, that and children). 16 anytime I decide it would be beneficial, trauma, hypovolemia, some cardiac (svt comes to mind), etc. 

All needles are going to cause a little pain for a second.


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## hibiti87 (Jan 19, 2013)

Linuss said:


> Increase of fluids, decrease of release of ADH being released by the posterior pituitary leading to the 'side effect' decrease of Oxytocin being released by the posterior pituitary, which leads to a decrease of uterine contractions.



and how many field births do you have?


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## VFlutter (Jan 19, 2013)

Even with triple lumen central catheters the internal lumens are usually only 18ga, some have a 16ga.


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## MSDeltaFlt (Jan 19, 2013)

I've said this before and I'll say it again.  If it'll fit it, stick it.  Larger needles have more metal to make them sharper and thicker plastic to make the cathlons more durable making the IV less likely to go bad or infiltrate.  As far as STEMI's go, the larger the better.  If MI pt needs CABG, the CV surgeon will need as larger caths as you can get.

I don't use IV's with empathy or retaliation.  Doesn't hurt me at all to stick them.  I advocate for my pts plain and simple.


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## medicsb (Jan 19, 2013)

mycrofft said:


> Heck yeah, ever try pushing D50 through a 20 gauge? I'll stand by, go ahead.



Once pushed through a 24 in the thumb.  In retrospect, it probably wasn't the best idea (was still green at the time).   And yes, it took FOREVER to push.


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## Epi-do (Jan 19, 2013)

medicsb said:


> Once pushed through a 24 in the thumb.  In retrospect, it probably wasn't the best idea (was still green at the time).   And yes, it took FOREVER to push.



I've done something similar, except the 24 was in the foot instead.

And on a similar but unrelated note, I placed a 24 in a patient's index finger the other day for the first time.


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## BigLouie2314 (Jan 19, 2013)

16s and 14s are really becoming a thing of the past. 20s are pretty standard as are 18s. There is a lot of recent material suggesting that rapid fluid resuscitation in trauma pt's is actually more detrimental then beneficial. Research shows pt's have a better outcome when fluid resuscitation is limited in the field for trauma pts. The science behind it...if a pt is bleeding from somewhere, fluid viscosity if much less that of blood. All your doing by putting these rapid and extensive amounts of fluid in a pt is thinning whatever blood they still have circulating and potentially "washing" away any clots that may have formed. Better management of a bleeding trauma pt is bleeding control and airway management. 

As for large bores, if I'm putting a 16 or a 14 gauge catheter in a pt, I’m most likely putting it in the EJ, and it's most likely a cardiac arrest. Any semi-critical to critical pt should have at least one 18 or 20, preferably two and preferably in the same arm (i.e. hand and AC, AC and bicep etc. Should the pt have to go to the operating room, most CRNA's like to star their own IV's and leaving an arm for them to do this is good practice.)

I've used large bores in trauma pt's in the past, however coming from a major trauma center (Temple University Hospital in Philadelphia) we commonly go with 18s. Exceptions where rapid fluids are needed are inferior MI's, placenta abruptio...


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## mycrofft (Jan 20, 2013)

Anyone start a thirty in a bloodshot eye?

Old joke.

How did the thumb do with that D50 push?


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## Akulahawk (Jan 20, 2013)

Way back, once upon a time when Akulahawk graced the back of an ambulance... 

I used to primarily use 18 and 20ga IV caths when starting IV lines. I generally consider 14 & 16 ga to be large bore, 18 & 20 to be medium bore and 22 & 24 to be small bore. The main reason why I consider 18 and 20 gauge IV catheters to medium bore is that if for some reason I have a runaway IV line, the line will not run so fast that I won't be able to catch the runaway before most of the IV fluid has been infused. Generally speaking, I will not go any bigger then 18 gauge unless the patient really needs it. That being said, I have placed very very few IV lines bigger than that. In fact, I can count on one hand the number of times that I have placed a large bore IV.

I would have to say that more than 80% of the IV lines that I started were 18 gauge. This is mostly because that size IV line is useful for just about any purpose. If you need more IV fluid to go in, simply run it in with a pressure infuser. If you need to run a fairly thick fluid in, like D50, you can do it with a peripheral IV line of this size.

I'm not at all adverse to starting a line that's smaller than 20 gauge, I will happily place a 22 or a 24 if that's all that is going to work. Like the old saying goes, "any port in a storm..."


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## Akulahawk (Jan 20, 2013)

mycrofft said:


> Anyone start a thirty in a bloodshot eye?
> 
> Old joke.
> 
> *How did the thumb do with that D50 push?*


His thumb or the patient's?


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## mycrofft (Jan 20, 2013)

Akulahawk said:


> His thumb or the patient's?



Haha. I just picture this thumb all cold and necrotic from a "sugar embolus".

We had  a doc who was going to teach us to do femoral's, but they fired him before he could.

I'm actually unacquainted with interosseous infusions. Don't they make large bore IV's passé?


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## Akulahawk (Jan 20, 2013)

mycrofft said:


> Haha. I just picture this thumb all cold and necrotic from a "sugar embolus".
> 
> We had  a doc who was going to teach us to do femoral's, but they fired him before he could.
> 
> I'm actually unacquainted with interosseous infusions. Don't they make large bore IV's passé?


I would have to say a qualified "no" to that. Why? I'd much rather start a PIV than an IO. If I'm going to start an IO it's going to be because I can't start a PIV. I have nothing against an IO except that it makes a hole in a bone and I'm not too keen on punching things into bone, even though such a small hole (relatively) will not affect the structural integrity of said bone. If I have to do it, I'll do it. That being said, I've never had to.


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## EpiEMS (Jan 20, 2013)

mycrofft said:


> I'm actually unacquainted with interosseous infusions. Don't they make large bore IV's passé?



*Disclaimer: BLS provider here*

I thought that large bore IVs were preferred to IO for fluid resuscitation and that IO was, generally, a second-line, except in, say, cardiac arrest. Though IO is faster regardless, no?


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## Akulahawk (Jan 20, 2013)

EpiEMS said:


> *Disclaimer: BLS provider here*
> 
> I thought that large bore IVs were preferred to IO for fluid resuscitation and that IO was, generally, a second-line, except in, say, cardiac arrest. Though IO is faster regardless, no?


 I would say that in the hands of a person that is skilled in doing both, the IO would probably be faster. I suspect, however, that flow rate for a large bore peripheral IV would be or could be a bit faster then an interosseous line. As I said before: "any port in a storm…"


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## BigLouie2314 (Jan 20, 2013)

Both projects I work for use the Easy IO. IF a pt requires fluid resucitation and two peripheral IV attempts are unsuccessful, IO line must be initiated or if pt presents initially with poor peripheral access, IO is first line.

Rapid fluids can be administered via an IO line wioth ease if a pressure infuser bag is used. Just last night I had a volume depleted pt, placed an IO line in the left tibia, and administered 1L of NSS in approx. 5 minutes.


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## Rykielz (Jan 20, 2013)

A medic was recently fired for starting just a couple of these large bore IV's. All of which were on chest pain, asthma, or CHF calls. State EMS was alerted and now he's facing the possibility of losing his license as well.

How can this happen when IV gauge selection is never covered in protocols or discussed much? It's essentially punishing someone for being aggressive.


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## Handsome Robb (Jan 20, 2013)

Rykielz said:


> A medic was recently fired for starting just a couple of these large bore IV's. All of which were on chest pain, asthma, or CHF calls. State EMS was alerted and now he's facing the possibility of losing his license as well.
> 
> How can this happen when IV gauge selection is never covered in protocols or discussed much? It's essentially punishing someone for being aggressive.



If be willing to bet there's more to that story than you're getting. 

No one is taking your card for starting large bore lines unless its habitual and can be proven they're being vindictive or punitive with them. If that's the case then by all means they need to be talked to and if something doesn't change further actions should be taken but that's just my opinion.

18 or larger is considered large bore here. Most patients get 18s or 20s. Hospitals here like 18s so they can draw off of them, but they won't complain if we have some sort of access. Unconscious drunks tend to get 16s for practice, when you need those lines you need them badly, practice on the people that aren't going to feel or remember it. 

I understand going to an IO for patients in extremis but mandating after 2 attempts you have to use it is ridiculous. How many patients get drilled that one more peripheral attempt would have been successful? EJ anyone? 

On the topic of EJs what's your "standard" size for them?


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## Veneficus (Jan 20, 2013)

Robb said:


> If be willing to bet there's more to that story than you're getting.



I would hope you are right, but sadly I have my doubts.

There is this idea going around that large bore needles "torture people" more than they actually do.

As I said, it is most pervasive in nursing, but it makes its way to EMS circles too. 

Even when you are "trying" to use it as a punitive measure, if you take away the visualization of the needle from the patient, they really have no idea the difference. 

I not only tried this on myself with a friend in a pseudoscientific experiment, but if you notice your really frequent attention seekers are totaly oblivious to whatever needle you put in them.

Like I said above, if it really made that big of a deal, then everyone would be up in arms about central lines. But nobody even gives them a second thought. 

Hell, even drawing out of a central vein or artery isn't given any thought.  The only time I have seen anyform of anesthesia applied for a cut down is during surgery. 

I have even seen emergency cut downs without any anesthesia at all.

It is difficult to even argue infection risk with any level of intelligence. Most infections are caused by the body's own flora, which means there is no more introduction of organisms then is already present. It is the breaking of the skin barrier that poses the risk. Any needle you use is going to do that.

Now, if I provider is using "punitive" treatment of any kind, that is another story. You can be punitive with an oxygen mask and/or an ammonia inhalent. Even just give the patient a little tap with the clipboard or such. It doesn't take a needle.


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## jwk (Jan 21, 2013)

First to the weenies who think anything larger than a 22ga is torture - you know those needles the Red Cross and other blood donation organizations use to draw out a unit of blood from donors?  They're 15ga.  THAT is a large bore needle, as are 14's and 16's.  An 18 is not.  There are commercially available 10 and 12ga IV catheters available.  

Now, from my anesthesia/surgery standpoint.  If you have a trauma patient in the field, I will sing praises to your name if the patient comes to the OR with a 14-16ga IV in place.  Conversely, I will probably curse you endlessly if they roll in with a 22 in the ACF.  You may see the patient before they get into shock and when you can actually still find a vein.  If it's a trauma patient, and you see a big vein, PLEASE place something larger than a 20.  The further down the shock road they go, the harder it is to get a peripheral IV and the higher the chances that we're going to have to get central access.  I MIGHT not have to put in a central line if I have a peripheral IV that runs well.  Central lines are not an innocuous thing to do and have lots of nasty complications.

Those of you who think a 14-16 is "out of style" simply don't know what you're talking about, because in the proper situation, a really big honking IV (as we call them in the South) is a blessing.  A 20 on a trauma patient is simply too small for any significant volume resuscitation or for blood.  An 18 is better, but a 14-16 is da bomb.  Hey, if you don't want to flood the patient with fluids, fine - just turn down your flowrate.  But for those of us that deal with the patient shortly after you bring them in, my fluids/blood/FFP/colloids/multiple drips will go in much better with a larger IV rather than a smaller.

Oh - and as far as injecting IV contrast dye - using a larger bore IV in a larger vein such as the antecubital is desirable for several reasons, the main one being less chance of infiltration/extravasation.  IV contrast is thicker than IV fluid and harder to inject.  The tendency is to push it in - and of course when it's hard to push it in, most people just push harder, which leads to extravasation/infiltration, which is not a good thing with IV contrast.  Having a larger catheter in a larger free-flowing vein makes for happy patients and happy radiology techs.  But if all they have is a 22 in the hand, it'll do.  The tech will just complain more.


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## Christopher (Jan 21, 2013)

mycrofft said:


> Heck yeah, ever try pushing D50 through a 20 gauge? I'll stand by, go ahead.



I've switched to D10 when I can; man, woman, or child. Titrate to effect and works like a champ whether you have a 22ga or a 14ga.


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## Trashtruck (Jan 21, 2013)

A 14ga or 16ga is considered large bore around here. The hospitals want a 14/16ga for traumas. Granted, if you can't get it, you can't get it, but this is what they prefer. If you come in with an 18, they'll immediately start looking to place a 14/16ga.

Personally, I use an 18ga as my standard if I feel the need to start an IV for non-traumatic pts.

As far as punitive, or 'TORTURE'(Really? People think this is torture?), I don't buy into it. Like MSDeltaFit said, if it fits, I put it in. Like Vene said, this idea of torture is mostly in the nursing arena. 
I mean, really people, it's a couple mm's difference. Torture...smh.

I don't know of anybody getting in trouble, reported, reprimanded, or anything regarding IV's around here, and believe me, there are some completely unwarranted 14ga IV's being placed. I've seen nurses give quizzical looks, but that's about it. 
There's no protocol or rule stating what size IV can go where. Large bore goes in the EJ, too.
An IV in the penis anyone?


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## Veneficus (Jan 21, 2013)

jwk said:


> First to the weenies who think anything larger than a 22ga is torture - you know those needles the Red Cross and other blood donation organizations use to draw out a unit of blood from donors?  They're 15ga.  THAT is a large bore needle, as are 14's and 16's.  An 18 is not.  There are commercially available 10 and 12ga IV catheters available.
> 
> Now, from my anesthesia/surgery standpoint.  If you have a trauma patient in the field, I will sing praises to your name if the patient comes to the OR with a 14-16ga IV in place.  Conversely, I will probably curse you endlessly if they roll in with a 22 in the ACF.  You may see the patient before they get into shock and when you can actually still find a vein.  If it's a trauma patient, and you see a big vein, PLEASE place something larger than a 20.  The further down the shock road they go, the harder it is to get a peripheral IV and the higher the chances that we're going to have to get central access.  I MIGHT not have to put in a central line if I have a peripheral IV that runs well.  Central lines are not an innocuous thing to do and have lots of nasty complications.
> 
> ...



You make my point better than I do.

Have you ever heard a nurse say "instead of a central line, let's go with a large bore peripheral instead?"

I have never. 

I have heard anesthesiologists suggest that though.


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## Carlos Danger (Jan 30, 2013)

I think a better question is: Why would you start anything BUT a large bore IV? To me it only makes sense to place the biggest that'll fit.

Most IV's in the field are placed "just in case". Well, just in case of what? What rationale is there that supports the potential ability to infuse meds or small volumes vs. large volumes?




BigLouie2314 said:


> 16s and 14s are really becoming a thing of the past. 20s are pretty standard as are 18s. There is a lot of recent material suggesting that rapid fluid resuscitation in trauma pt's is actually more detrimental then beneficial. Research shows pt's have a better outcome when fluid resuscitation is limited in the field for trauma pts.



This is partially true. There are still plenty of patients who require large volumes quickly, especially in the OR. 



BigLouie2314 said:


> Should the pt have to go to the operating room, most CRNA's like to star their own IV's and leaving an arm for them to do this is good practice.)



Not sure where you heard that....I've never met an anesthesia provider (or any other provider in the hospital, for that matter) who would begrudge the fact that they have 1 less task to do.



Veneficus said:


> Have you ever heard a nurse say "instead of a central line, let's go with a large bore peripheral instead?"
> 
> I have never.



You haven't spent much time in ICU's then. Absent the need for multiple or vasoactive infusions or a lot of blood draws, I've never known anyone who would rather deal with the maintenance required for a central catheter vs. a good peripheral one. And these days hospitals are discouraging them by policy.



MSDeltaFlt said:


> *I've said this before and I'll say it again.  If it'll fit it, stick it.*  Larger needles have more metal to make them sharper and thicker plastic to make the cathlons more durable making the IV less likely to go bad or infiltrate.  As far as STEMI's go, the larger the better.  If MI pt needs CABG, the CV surgeon will need as larger caths as you can get.
> 
> I don't use IV's with empathy or retaliation.  Doesn't hurt me at all to stick them.  I advocate for my pts plain and simple.



EXACTLY.


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## Christopher (Jan 30, 2013)

old school said:


> Most IV's in the field are placed "just in case".



When I hear that all I can think of is, "they probably don't know sick from not sick." Most folks are kidding themselves when they say it is, "just in case."

Instead they seem to be started so the ED nurse is happy. I know if I start one (and draw labs) I move to the front of the line for a bed when things are busy. Just in case...I'd rather not sit and wait.


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## Carlos Danger (Jan 30, 2013)

Christopher said:


> When I hear that all I can think of is, "they probably don't know sick from not sick." Most folks are kidding themselves when they say it is, "just in case."
> 
> Instead they seem to be started so the ED nurse is happy. I know if I start one (and draw labs) I move to the front of the line for a bed when things are busy. Just in case...I'd rather not sit and wait.



Well either way, if you are going to expose the patient to the potential risks of the procedure - and there definitely are serious risks - it only make sense to place one that will be useful across the broadest range of circumstances.


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## Rykielz (Jan 30, 2013)

I'm waiting to see what the state of California has to say. It's a very serious matter when the state is getting involved. I know for a fact that none of the IV's were done punitively and they were all successful.


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