Large bore IV's

[mycrofft]

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?

 

[Akulahawk]

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.

 

[EpiEMS]

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?

 

[Akulahawk]

*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…"

 

[BigLouie2314]

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.

 

[Rykielz]

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.

 

[Handsome Robb]

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?

 

[Veneficus]

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.

 

[jwk]

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.

 

[Christopher]

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.

 

[Trashtruck]

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?

 

[Veneficus]

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.

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.

 

[Carlos Danger]

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?

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.

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.

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.

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.

 

[Christopher]

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.

 

[Carlos Danger]

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.

 

[Rykielz]

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.