18 GA for Stroke Alert

[Markhk]

Does anyone else here have protocols that require a 18 gauge IV or larger inserted in a suspected stroke?

I am trying to figure out the rationale for why so many county protocols require, at a minimum, an 18 gauge?

Here are some thoughts before anyone jumps to conclusions:
1. CT Contrast needs at least a 20 gauge to be injected, per the radiologic technologist in order to survive the 3ml/sec injection...so a 20 gauge should be fine
2. But per AHA recommendations, a suspected stroke patient should receive a NON-CONTRAST head CT so the contrast can't be the reason why we need an 18 gauge.

Other thoughts include: (i) blood products (ii) the need for a larger lumen to inject tPA (seems unlikely?)... I can't seem to shake the feeling that the 18 gauge requirement is a non-clinically validated protocol requirement.

I've asked docs, nurses, medics, the radio technologists...no one can give me a straight answer. And yes, I've looked at my paramedic textbook a bunch of times...

 

[Flight-LP]

I've never heard of a size or location requirement for IV access on a CVA pt. You are correct that the initial CT is a non-contrast CT, so the IV is not applicable. Now the chest CT on the other hand does need a larger size, in the A/C, due to the volume and speed of the contrast infusion.

Should an embolic CVA be identified and the onset was within 6 hours (3 hours for some "old school" docs), the larger IV can help with TPA or Retavase administration. Perhaps that is why the protocol was written???

 

[Markhk]

Flight, that's a great thought. But I'm curious if there is a more firm directive from the lytic makers...in the prescribing information I can only find that the suggest an 18 gauge NEEDLE to reconstitute the drug...rather than to administer it. (See http://www.stroke-site.org/guidelines/activase.html) Some fibrinolytics like TNKase don't even need to be infused since it only requires a bolus. Perhaps I should be thinking flow rate differences between an 18 gauge and a 20 gauge?

 

[Doughboy]

I've heard of 18 ga. minimum for head injury in case the ED wants to administer mannitol... that was explained to me as due to molecular size of the drug. I'd be inclined to agree with Flight, but hey, that's just conjecture.

 

[Ridryder911]

Flight, that's a great thought. But I'm curious if there is a more firm directive from the lytic makers...in the prescribing information I can only find that the suggest an 18 gauge NEEDLE to reconstitute the drug...rather than to administer it. (See http://www.stroke-site.org/guidelines/activase.html) Some fibrinolytics like TNKase don't even need to be infused since it only requires a bolus. Perhaps I should be thinking flow rate differences between an 18 gauge and a 20 gauge?

You are describing a 18g filler needle not an 18g IV needle... two separate things. The needle is large to reduce air bubbles in which TNKase is notorious to happen, (you should always swirl NOT shake it). Otherwise it is a b*tch to administer and may not be effective.

There is very little flow rate difference between 18g and 20g IV cath (not needle) and of the lumen of the vessel.

Mannitol? Geez have not heard of that in decades.

R/r 911

 

[Markhk]

R/R, that's actually my point...the prescribing information for alteplase only state the 18G Needle for reconstitution, nothing regarding an 18 gauge IV catheter. I'm still struggling to find some sort of justification for 18 gauge IVs in stroke patients.

 

[Doughboy]

Mannitol? Geez have not heard of that in decades.

Haha, yeah, yeah... it was just the example that came to mind to affirm that the concept exists.

 

[Ridryder911]

You will find most literature suggest large bore (18g>) for administration of medications as well as a good "access" vein. Especially giving any fibro or large molecule type substances (including D50w).

Also a FYI.. according to most manufactures; Valium is NOT to be administered in hand veins due to the s/e of Valium producing constrictive properties.

R/r 911

 

[MSDeltaFlt]

I realize this may be splitting hairs, so please forgive me, BUT...

The protocols on my ground service, when they state large bore, they mean 16's and 14's.

Small bores are 22's and 24's. So I deduct (nothing concrete stated or written that I could find) that 20's and 18's are standard bore.

Someone please correct if I'm wrong, but here's how rationalize it. You can freeflow blood through 18's and 20's, but you have to watch it on the 20's. 16's and 14's, you can pressure bag blood in and not worry about it. 22's and 24's need a pump to push blood VERY slowly.

Any critical pt ought to get at least an 18g, however (especially in my little corner of the world), you get what you can get.

Some protocols will state to keep your pt's SaO2 at least 95% prefferably by NRM. So I'm guessing if your pt needs an IV, get one prefferably with an 18g.

I might be way off here, but that's my 0.02

 

[ERnurse17]

Go big or go home!

 

[fma08]

go with what you can get is a decent rule, i use it myself, but just because you can get a 14 in a pt. doesn't really mean they need it. I usually put an 18 in all my pt's that need an IV, if i can find a suitable site for it, and i believe it is considered a "large bore" around here too.

 

[Arkymedic]

Does anyone else here have protocols that require a 18 gauge IV or larger inserted in a suspected stroke?

I am trying to figure out the rationale for why so many county protocols require, at a minimum, an 18 gauge?

Here are some thoughts before anyone jumps to conclusions:
1. CT Contrast needs at least a 20 gauge to be injected, per the radiologic technologist in order to survive the 3ml/sec injection...so a 20 gauge should be fine
2. But per AHA recommendations, a suspected stroke patient should receive a NON-CONTRAST head CT so the contrast can't be the reason why we need an 18 gauge.

Other thoughts include: (i) blood products (ii) the need for a larger lumen to inject tPA (seems unlikely?)... I can't seem to shake the feeling that the 18 gauge requirement is a non-clinically validated protocol requirement.

I've asked docs, nurses, medics, the radio technologists...no one can give me a straight answer. And yes, I've looked at my paramedic textbook a bunch of times...

Only one of our local hospitals has a stroke team and if you have a CVA you are to announce it as "code stroke". The guidelines laid out by the stroke team ask for bilat 18ga's.

 

[Arkymedic]

You are describing a 18g filler needle not an 18g IV needle... two separate things. The needle is large to reduce air bubbles in which TNKase is notorious to happen, (you should always swirl NOT shake it). Otherwise it is a b*tch to administer and may not be effective.

There is very little flow rate difference between 18g and 20g IV cath (not needle) and of the lumen of the vessel.

Mannitol? Geez have not heard of that in decades.

R/r 911

Rid Mannitol is still a required state checkoff item here in AR...