Whats your "criteria" for starting iv access on a pt?

Peak said:
I've only used the regular nexivas, I like them for EJs and patients with HIV or hepatitis. I refuse to use them on kids though, you just can't feel the same with them.

Do you find that the diffusion still flow quicker with blood or albumin?
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I have used them with kids, though I don't like to. Like you, I have found that you don't have quite the same feel with the Nexiva catheters as you do with a "standard" catheter. Another issue is that our "standard" catheters were 1/4 inch longer so that actually made it a little easier. The Nexiva product pretty much requires that you puncture the skin and nearly immediately also puncture the vein to ensure good placement, especially if the vein is a little deep. All of our "standard" catheters that we stock now are 2-2.5 inch length and we use those for US placed lines. Every great once in a while I'll grab one of those and use it for a regular PIV stick. I just wish they'd purchased the slightly longer Nexiva caths...

One interesting side benefit of these is that I can rotate the needle to do a bevel-down insertion technique if I need to. I don't do that very often, but it can help obtain placement in certain situations.

Incidentally I have noticed slightly better flow rates with the Diffusic catheter when infusing more viscous fluids than with a standard catheter. The biggest "benefit" of the Diffusic is that the catheters are a bit more stable (apparently) during pressure infusion (like contrast CT) than standard catheters and they do have a slightly higher flow rate so you can use a 22g for a CTA. You still must use the same sites for CTA as with a standard catheter but when your patient has smaller veins, going 22 vs 20 can certainly improve the chance of successful placement without turning your patient into a pincushion. My default for most adult patients is an 18 or 20g, though a 22 will do if necessary.
 
Akulahawk said:
I have used them with kids, though I don't like to. Like you, I have found that you don't have quite the same feel with the Nexiva catheters as you do with a "standard" catheter. Another issue is that our "standard" catheters were 1/4 inch longer so that actually made it a little easier. The Nexiva product pretty much requires that you puncture the skin and nearly immediately also puncture the vein to ensure good placement, especially if the vein is a little deep. All of our "standard" catheters that we stock now are 2-2.5 inch length and we use those for US placed lines. Every great once in a while I'll grab one of those and use it for a regular PIV stick. I just wish they'd purchased the slightly longer Nexiva caths...

One interesting side benefit of these is that I can rotate the needle to do a bevel-down insertion technique if I need to. I don't do that very often, but it can help obtain placement in certain situations.

Incidentally I have noticed slightly better flow rates with the Diffusic catheter when infusing more viscous fluids than with a standard catheter. The biggest "benefit" of the Diffusic is that the catheters are a bit more stable (apparently) during pressure infusion (like contrast CT) than standard catheters and they do have a slightly higher flow rate so you can use a 22g for a CTA. You still must use the same sites for CTA as with a standard catheter but when your patient has smaller veins, going 22 vs 20 can certainly improve the chance of successful placement without turning your patient into a pincushion. My default for most adult patients is an 18 or 20g, though a 22 will do if necessary.
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I wish they made longer nexivas period. I find myself favoring at least a 0.75 in 24 and 1.75 or longer in anything bigger.

If they get too difficult I just get a 22, a baby wire, and a 2.5F RA kit an use that for IV access; although with ultrasound its pretty rare that I get that desperate.

With the exception of CTAs and triple phase livers I can hand push contrast so the catheter size doesn't bother me that much, but I would love to see some flow rates with albumin or blood since I think the diffusics could potentially bring a lot to the trauma arena. Placing RICs and cordis (what is the plural of cordis? cordi? cordises?) takes too much time, if 14 or 16 diffusics existed that would be amazing.

Every once in a while the do gooders in our system like to point out that technically the regular nexivas are not pressure rated and shouldn't be used for CT, so I've been tempted to push the diffusics instead but the cost difference is pretty substantial espeically since nobody seems to be able to show a single ruptured catheter or extension in a freshly placed nexiva.
 
Peak said:
if 14 or 16 diffusics existed that would be amazing.
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I absolutely agree with this! The flow rate from such a beast would be mind-blowing.
 
Peak said:
Every once in a while the do gooders in our system like to point out that technically the regular nexivas are not pressure rated and shouldn't be used for CT, so I've been tempted to push the diffusics instead but the cost difference is pretty substantial espeically since nobody seems to be able to show a single ruptured catheter or extension in a freshly placed nexiva.
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The problem isn't that the regular Nexiva's can't be used for CT w/ contrast, it's that they shouldn't be used for CTA procedures because of the pressure/flow rates required to get a good study. If you need to push for the Diffusics vs regular Nexiva products, at least push for a small supply of them for patients for whom you would need a CTA. The 20g Diffusics can flow 10ml/sec at 325 psi. That's 36L/hour. The 18g version can do 54L/hr. Stock 'em for use in cardiac/stroke/trauma rooms (in the ED or ICU) for initial IV placement. Pretty much everywhere else should be able to do OK with the regular Nexiva catheters.

My hospital went basically to standard Nexiva catheters on the floors but the ED and ICU uses Diffusics for everything except 24g and US placed IV caths (due to length reasons).
 
The thing I don't like with the new IV angiocaths that don't dribble (or pour) blood is you can't get blood out of them to check glucose while you are sticking the IV.
 
johnrsemt said:
The thing I don't like with the new IV angiocaths that don't dribble (or pour) blood is you can't get blood out of them to check glucose while you are sticking the IV.
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That's true most of the time, but not ALL the time. The standard Nexiva and Nexiva Diffusics catheters can be basically "bloodless" but what happens is that the tubing fills up with blood and the vent cap. If I need labs, I will usually attach a clave port to the tubing and do the draw. If I need to check blood glucose right then, I'll have that set up and ready to go because once I detach a syringe from the clave port, there's usually a little venous blood right on the end of the port or I can push a little drop to the end of the syringe and test that drop. It's not that different from having your glucometer ready when you're doing the initial stick and getting the blood off the hub vs off a clave port or out of a syringe.

Most of the anti-dribble stuff I've used over the years are simply one-use one-way valve systems. When you put a loop on the end of the catheter, it destroys the valve and you can draw any lab stuff off that loop before you flush the loop. I'm a big fan of saline locks for a number of reasons, this is but one of them.
 
For my ground job, I generally only do IVs in two circumstances:
1) I'm going to use it for something (mostly meds, primarily fentanyl and zofran. I very rarely give fluids working 911)
2) There is the potential for the patient to need an urgent or emergency treatment but does not currently need it ("anticipated clinical course")

For my flight job, I very rarely start IVs. In the past year, I've probably started less than 5. Same basic rules apply as above, though I'll also add in if the patient is coming in as a trauma I'll generally make sure they have good access. I've done more IOs than I have IVs working flight.
 
My protocols are pretty specific. If they're stable "condider" it. If they're not, get it. If you can't and they need it, drill 'em.
 
I have a pretty loose criteria for starting an IV even if I don't plan on doing anything with them. If I can justify it I normally will, not just for treatment but because call volume here can be a little low (usu 1-3 ALS calls per shift) and I'm still newish as a medic (less than a year) so I'm trying to hone my skill.

The other reason is just having a better relationship with the hospitals. My service is one of those that hires everyone with a patch and a pulse then turn them loose with a week's worth of FTO time so hospital staff can have really low expectations/be really dismissive. I've had them express surprise (and thanks) when I come in with a pt who has an IV started and I know there are medics here who miss everything or refuse to try starting them or both. A couple days ago I brought someone in from an assisted living and the ER nurse just assumed the line was started by the facility. Starting IVs (as long as it's not for a silly reason) is just me trying to signal I might be competent enough to listen to.
 
I start a line if I’m considering or administering medications, fluid or if their clinical course will require access immediately on arrival, like a stroke going directly to CT.

Starting an IV for no good reason is just silly. And it doesn’t prove you’re competent, it just proves you can place a catheter in a vein. Don’t ever make the mistake of confusing simple skills competency with anything else.
 
Tunnel Cat said:
I have a pretty loose criteria for starting an IV even if I don't plan on doing anything with them. If I can justify it I normally will, not just for treatment but because call volume here can be a little low (usu 1-3 ALS calls per shift) and I'm still newish as a medic (less than a year) so I'm trying to hone my skill.

The other reason is just having a better relationship with the hospitals. My service is one of those that hires everyone with a patch and a pulse then turn them loose with a week's worth of FTO time so hospital staff can have really low expectations/be really dismissive. I've had them express surprise (and thanks) when I come in with a pt who has an IV started and I know there are medics here who miss everything or refuse to try starting them or both. A couple days ago I brought someone in from an assisted living and the ER nurse just assumed the line was started by the facility. Starting IVs (as long as it's not for a silly reason) is just me trying to signal I might be competent enough to listen to.
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On the receiving side I am frustrated when a sick patient who needs access doesn’t arrive with at least an attempt or the EMS provider telling me that they couldn’t find a site. This is very rare.

Often placement by EMS does not help all that much. IVs that don’t draw back are useless for CT or other vesicant administration. I also typically draw labs with an IV, so if the line doesn’t draw or come with blood I’m going to be drawing anyway.

It is very frustrating when there are multiple blind and unsuccessful attempts made, especially on kids or patients with limited peripheral vasculature (typically done by smaller lower volume services). I have tools at my disposal that many in the field do not (weesight, ultrasound, et cetera). Shredding vasculature just makes it harder to place access on arrival, and doesn’t benefit the patient. I’d far rather a sick patient come in with an IO that I pull after placing a good IV than have no access and difficulty even finding a peripheral site due to multiple blind unsuccessful attempts.

While I may not be confident in an EMS provider who does not place access in a patient who is clearly sick and needed one, I don’t expect said EMS provider to do my job for me.
 
NomadicMedic said:
Starting an IV for no good reason is just silly. And it doesn’t prove you’re competent, it just proves you can place a catheter in a vein. Don’t ever make the mistake of confusing simple skills competency with anything else.
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Peak said:
On the receiving side I am frustrated when a sick patient who needs access doesn’t arrive with at least an attempt or the EMS provider telling me that they couldn’t find a site. This is very rare.

Often placement by EMS does not help all that much. IVs that don’t draw back are useless for CT or other vesicant administration. I also typically draw labs with an IV, so if the line doesn’t draw or come with blood I’m going to be drawing anyway.

It is very frustrating when there are multiple blind and unsuccessful attempts made, especially on kids or patients with limited peripheral vasculature (typically done by smaller lower volume services). I have tools at my disposal that many in the field do not (weesight, ultrasound, et cetera). Shredding vasculature just makes it harder to place access on arrival, and doesn’t benefit the patient. I’d far rather a sick patient come in with an IO that I pull after placing a good IV than have no access and difficulty even finding a peripheral site due to multiple blind unsuccessful attempts.

While I may not be confident in an EMS provider who does not place access in a patient who is clearly sick and needed one, I don’t expect said EMS provider to do my job for me.
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I'll say I don't start them for no reason. It's not like I'm sticking say, a sprained ankle or a simple cough or a pulled g-tube. I definitely don't stick peds unless I know I need it. I don't stick blind and when I've got someone who looks difficult stick I consider whether I'm likely to just mess up the vasculature for the ER. But earlier on I definitely struggled with IVs and needed the practice. And I've definitely been groused at for not getting an IV on patients even when there was nothing I needed it for. There's one hospital in particular where they seem to always want me to have an IV no matter the patient.

But thank you. I'll keep all this in mind.
 
Looking back over the years. Some of you may notice the evolution of procedures you do today. An awful lot of non viables were delivered to get where we are now..

-Grab and run. Only permitted intervention was direct pressure, or by physician orders over often faulty radio coms. (This is where my name on this forum comes from. Two of our ambulances were retired hearses.)
-Limited intervention procedures. All had to be authorized by a physcian.
-Slightly expanded procedures. Pre EMS days when physicians great fear was medics and nurses would be practicing medicine without blah blah blah.
-EMS getting established. Standing orders for a wider variety of procedures. Code blues were still grab and run.
-EMT II's hit the scene. This was in part motivated by medics returning from the Vietnam war griping loudly about their abilities being restricted. IVs were in the standing orders under a strict list of conditions.
-An odd period when all non ambulatory patients had a line established.
-Followed by expanded standing orders, a long list of conditions where a line was established and physicians could be requested to authorize for conditions not on the list.
-And finally, full ACLS and a report sent to EMS required with every run where a procedure besides evac was performed. IVs became discretionary.
And so on. As the saying goes. a long strange trip... and still evolving.


And just saying, if a practice, procedure, position or title (like DoN) isn't that way where you are doesn't mean it doesn't exist or is BS. The emergency medical responses and training vary from location to location. Want an IV established here? You have to have an RN riding on the ambulance. One county west, no such thing outside of hospitals. EMS? Paramedic? Several dozen countries have never heard of such things. In other countries, ambulance attendants are trained in field surgical intervention procedures inclusive of chest and abdominal surgery.
 
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Almost all of my transports get IV's, but almost all of them are ALS and sick; due to the fact that they are all long distance and none are BS transports (after 12 years I almost miss BS transports).
FT job closest hospital is 45 miles away (longer depending where we start from) up to 90 miles. PT job closest is 110 miles to 130 miles.
 
It’s up to my discretion in my system but typically I just do a IV if I wanna start fluid or meds. If not then I won’t bother. There is two or so ERs that I will get one for even if it’s nonsense just to be nice since they like it.
of course any trauma/stemi/ stroke needs a line. Which I have pretty much discretion where except for an EJ in a stroke or STEMI patient
 
Usually I have to either be giving fluids or meds. That or STEMI/CVA/trauma. Sometimes other calls will get one from me if I feel like being helpful and am more than 5 minutes from a hospital. On rare occasion if I hit a rare slump I may throw a few easy shots in to break it.

But as a general practice? No courtesy lines.
 
Indications for IV? Immediate need or expected clinical course. Fairly straightforward I would have thought.

I would add for the OP that a nurse’s criticism in isolation doesn’t equal wrong doing. They, like everyone, have their own pressures, biases and stressors and not every piece of feedback is going to be a well reasoned critique of your practice. Don’t ignore it. You should always reflect on your own practice. But don’t get to bent out of shape.

Not sure if it was ever published but we had some quality improvement data a while back showing a very concerning number of prehospital IVs were associated with subsequent infection. No doubt we needed procedural improvements and we did that. But you’ve got to ask yourself why you would place an IV outside of the criteria I list above if it is associated with some risk to the patient.

I recall a study from a while back indicating that a huge number of IVs placed in EDs were never used. Yes IV are low risk. But they aren’t no risk. So if you put in enough IVs for not much reason, then eventually a patient is going to come to grief. Not to mention from a patient experience point of view, they’re pretty unpleasant.

NPO said:
Really? It seems like at least 50% of patients flown around here are pretty stable. We just had one come in for "palpitations". Everything else was normal.
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Wow....why?
 
AusPara said:
Wow....why?
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That particular patient? The crew didn't want to transport and wanted to go back to station. That was the flight crews interpretation anyway.

That service is known for lazy and poor standard of care. I can't attest to much about their actual quality, but it's incidents like that, that given them a poor reputation.
 
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