Large bore IV's

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).
 
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.
 
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.
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Heck yeah, ever try pushing D50 through a 20 gauge? I'll stand by, go ahead.
 
mycrofft said:
Heck yeah, ever try pushing D50 through a 20 gauge? I'll stand by, go ahead.
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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.
 
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.
 
I tend to dilute my d50 in a 100 bag. Makes it a lot easier with little veins/Caths.
 
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.
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If anyone starts anything less than an 18g on me, they better hope I do not wake up.
 
Chase said:
I have seen them give contrast through a 22 and ideally you should not be drawing blood from an IV.
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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
 
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.
 
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.
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and how many field births do you have? :D
 
Even with triple lumen central catheters the internal lumens are usually only 18ga, some have a 16ga.
 
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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.
 
mycrofft said:
Heck yeah, ever try pushing D50 through a 20 gauge? I'll stand by, go ahead.
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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.
 
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.
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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.
 
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...
 
Anyone start a thirty in a bloodshot eye?

Old joke.

How did the thumb do with that D50 push?
 
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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