Access in restricted limbs

[Volatile]

What are y’all’s thoughts on IV’s in “restricted” limbs? Post-lymph node resections, AV fistulas. Will you access a chemo port if the patient has one as primary IV? Just curious, appreciate the input

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[IMGASMD]

What are y’all’s thoughts on IV’s in “restricted” limbs? Post-lymph node resections, AV fistulas. Will you access a chemo port if the patient has one as primary IV? Just curious, appreciate the input

I generally “honor” the restrictions from the patient….. never used an active av fistula.

Port access depends on the facility. I don’t access it at my current job. If they have an IV nurse who can access it, “correctly” so be it. Had a job before, if the preop nurse cannot get an IV and we are busy, they get a picc…..

 

[Arch Guillotti]

Had a job before, if the preop nurse cannot get an IV and we are busy, they get a picc…..

If only it were so easy.

 

[Arch Guillotti]

never used an active av fistula.

Has anybody?

 

[GravelRider]

Situationally dependent, but I will get access on a restricted limb if I need to. I avoid it if I can, but sometimes you can’t. If a patient has a port, I will usually look for a separate IV, but if the port is already accessed, I will use it. I have never used an AV fistula…maybe in dire circumstances I might. Again, a lot of these are dependent on the actual situation.

 

[chessknt]

Has anybody?

I put an a-line downstream of one on accident… had some interesting gas result results but waveform was surprisingly normal.

 

[Status Sciaticus]

Situationally dependent, but I will get access on a restricted limb if I need to. I avoid it if I can, but sometimes you can’t. If a patient has a port, I will usually look for a separate IV, but if the port is already accessed, I will use it. I have never used an AV fistula…maybe in dire circumstances I might. Again, a lot of these are dependent on the actual situation.

True. An unaccessed/restricted AV fistula is pretty useless in a dead or coding patient.

 

[anbuitachi]

never had to use a fistula, but i would in emergencies. if non emergent then i go elsewhere, other limb/leg/neck

I do not access chemo port, again i would if i need to in emergencies, but benefit is low for elective

i have done it for lymph patients. the risk is super low here. theres very little evidence either... if the patient tells me not to use it then i respect it.
sometimes if the patient is a difficult stick and only have vein on that lymph excised limb, i'll put it in, get her to sleep, then look for other veins. and then remove

dont think giving some fluid is a big deal thru a lymph excised limb. the fluid will go to central system in seconds. its not going to cause the arm to swell up if it had zero swelling to begin with.

 

[nimbus]

What are y’all’s thoughts on IV’s in “restricted” limbs? Post-lymph node resections, AV fistulas. Will you access a chemo port if the patient has one as primary IV? Just curious, appreciate the input

I would use in an emergency. Otherwise I avoid if there are other options and there are always other options.

 

[Beeftenderloin]

The whole concept of avoiding BPs and IV placement in a lymph excised extremity is absurd. There isn’t a shred of reliable evidence that these practices worsen lymphedema. There are plenty of emerging data that is is safe though. It doesn’t even make sense from a physiologic standpoint. Fluid doesn’t just leak out of in-tact peripheral veins. It leaks due to differences in hydrostatic and oncotic pressure at the capillary level, but doesn’t get there until first returning to the central circulation and then going back out to the rest of the body.

Now having said all that, patients, nurses (and even some doctors…) lose their **** when this subject is broached and it’s not a hill I have any interest in dying on. It’s usually easy enough to find something in a preferred extremity, especially with US available, so whenever possible I try to oblige.

 

[IMGASMD]

Has anybody?

Sounds like the op has?

If only it were so easy.

Right? I almost fell on the floor when I heard how they deal with “difficult” access.

 

[narcotics999]

I usually don't touch restrict arm. but if no choice, I may, depending on the situations. Not active fistula.

Chemo port? Yes, used a few times. Again no good other alternatives.

One of my vascular surgeons will give me an access through fistula.

I used dialysis catheters. Just remember the heplock.

Talk about IV access, has anyone used AccuVein? Light shining on the arm, all the vessels show up. Nurses love it. I has not been called to put IV for a while due to "difficult IV".

 

[Ronin786]

Got a call recently about needing a central line in a patient because they had AV fistulas in both arms.

Me: "Why do they need two fistulas?"
Hospitalist: "One of them isn't working"
Me: "Why are you worried about putting an IV in an arm with a fistula?"
Hospitalist: "Because it might ruin the fistula"
Me: ...

 

[nimbus]

I never understood the no NIBP rule after ALND. Can anybody explain it to me? How can checking a BP on that arm cause harm?

 

[anbuitachi]

I usually don't touch restrict arm. but if no choice, I may, depending on the situations. Not active fistula.

Chemo port? Yes, used a few times. Again no good other alternatives.

One of my vascular surgeons will give me an access through fistula.

I used dialysis catheters. Just remember the heplock.

Talk about IV access, has anyone used AccuVein? Light shining on the arm, all the vessels show up. Nurses love it. I has not been called to put IV for a while due to "difficult IV".

accuvein sucks. its ONLY use IMO may be for really dark skin since it just lights it up. otherwise you can clearly see the vein or palpate it. the deeper veins dont show up

 

[anbuitachi]

I never understood the no NIBP rule after ALND. Can anybody explain it to me? How can checking a BP on that arm cause harm?

imagine a case thats 10 hours long, with BP going every 3-5 minutes. it compresses blood/capillaries/etc, and causes swelling. causes nerve damage too

id rather do IV than BP on lymphed arm.

 

[Guillemot]

I always thought that BP cuff and IV fluid could worsen edema, but that in an emergency that using it was acceptable. Arterial lines would therefore not be contraindicated using that logic.

Fistula: avoid IV in same arm, as fistula could get infected. Still wouldn't put a BP cuff on a functioning fistula. Aline infection, accuracy?

Try to avoid accessing port as can get infect also.

This is what I was taught, but maybe its just lore that is unsubstantiated.

 

[IMGASMD]

I always thought that BP cuff and IV fluid could worsen edema, but that in an emergency that using it was acceptable. Arterial lines would therefore not be contraindicated using that logic.

Fistula: avoid IV in same arm, as fistula could get infected. Still wouldn't put a BP cuff on a functioning fistula. Aline infection, accuracy?

Try to avoid accessing port as can get infect also.

This is what I was taught, but maybe its just lore that is unsubstantiated.

There was definitely some more hardcore discussions here before. Maybe even Blade pull up some articles, that basically that limb alert is something that was made up long ago, and it was never challenged.

 

[nimbus]

imagine a case thats 10 hours long, with BP going every 3-5 minutes. it compresses blood/capillaries/etc, and causes swelling. causes nerve damage too

id rather do IV than BP on lymphed arm.

I wasn’t talking about a lymphedematous arm but a normal arm that had prior ALND. Seems like intermittent compression might be beneficial, perhaps it would prevent a DVT in that arm.

 

[Realgassy]

I dealt with this recently. Pt ESRD w/SBO s/f exlap had no iv access from the floor and was brought directly to OR due to cdiff (we can’t hold them in preop). She was demented & delirious - ripping everything out & family wanted everything done. She had already been poked everywhere and was covered in bruises. I was struggling to get an awake central line due to squirming/retching and bilateral stenosis of the IJ. She had an Avf on the left arm - my partner suggested access vs PIV below. She couldn’t get the PIV, but, if there was a vascular surgeon around (strangely none that day), I would have asked them to assist with accessing the AVF temporarily. I did not feel comfortable poking it. Eventually, I got a central line in.

In retrospect, subq sedation could have been helpful for the situation.

 

[Arch Guillotti]

I dealt with this recently. Pt ESRD w/SBO s/f exlap had no iv access from the floor and was brought directly to OR due to cdiff (we can’t hold them in preop). She was demented & delirious - ripping everything out & family wanted everything done. She had already been poked everywhere and was covered in bruises. I was struggling to get an awake central line due to squirming/retching and bilateral stenosis of the IJ. She had an Avf on the left arm - my partner suggested access vs PIV below. She couldn’t get the PIV, but, if there was a vascular surgeon around (strangely none that day), I would have asked them to assist with accessing the AVF temporarily. I did not feel comfortable poking it. Eventually, I got a central line in.

In retrospect, subq sedation could have been helpful for the situation.

Femoral.

 

[Realgassy]

Agreed I would have gone fem next. But, I generally try the IJ before fem unless I see documented stenosis in records. My partner was looking for other options while I was doing the line.

 

[nimbus]

I dealt with this recently. Pt ESRD w/SBO s/f exlap had no iv access from the floor and was brought directly to OR due to cdiff (we can’t hold them in preop). She was demented & delirious - ripping everything out & family wanted everything done. She had already been poked everywhere and was covered in bruises. I was struggling to get an awake central line due to squirming/retching and bilateral stenosis of the IJ. She had an Avf on the left arm - my partner suggested access vs PIV below. She couldn’t get the PIV, but, if there was a vascular surgeon around (strangely none that day), I would have asked them to assist with accessing the AVF temporarily. I did not feel comfortable poking it. Eventually, I got a central line in.

In retrospect, subq sedation could have been helpful for the situation.

Renal patients have the worst access. Neck veins/subclavians often thrombosed.

We had one guy who was a frequent flyer. Nice appreciative guy, everybody knew him. Eventually he needed an axillary artery to right atrial shunt. When that failed, he died.

 

[vector2]

I dealt with this recently. Pt ESRD w/SBO s/f exlap had no iv access from the floor and was brought directly to OR due to cdiff (we can’t hold them in preop). She was demented & delirious - ripping everything out & family wanted everything done. She had already been poked everywhere and was covered in bruises. I was struggling to get an awake central line due to squirming/retching and bilateral stenosis of the IJ. She had an Avf on the left arm - my partner suggested access vs PIV below. She couldn’t get the PIV, but, if there was a vascular surgeon around (strangely none that day), I would have asked them to assist with accessing the AVF temporarily. I did not feel comfortable poking it. Eventually, I got a central line in.

In retrospect, subq sedation could have been helpful for the situation.

Just drop a 2 or 2.5" angiocath into the IJ next time. Innominate/SVC stenosis is so common that it's not worth the hassle of trying to float 20 cm of a guidewire unless you really need central access and not just access.

 

[IMGASMD]

Just drop a 2 or 2.5" angiocath into the IJ next time. Innominate/SVC stenosis is so common that it's not worth the hassle of trying to float 20 cm of a guidewire unless you really need central access and not just access.

EJ?

 

[Arch Guillotti]

EJ?

"Midline" in the IJ.

 

[Status Sciaticus]

imagine a case thats 10 hours long, with BP going every 3-5 minutes. it compresses blood/capillaries/etc, and causes swelling. causes nerve damage too

id rather do IV than BP on lymphed arm.

Do arterial line and enjoy the extra two units for the case?

"Midline" in the IJ.

just be sure to tourniquet real good to get the vein to pop up

 

[IMGASMD]

"Midline" in the IJ.

I meant if that was all needed, why not just be the line in EJ?

just be sure to tourniquet real good to get the vein to pop up

The only way I know how to place an EJ…..

 

[GassYous]

I dealt with this recently. Pt ESRD w/SBO s/f exlap had no iv access from the floor and was brought directly to OR due to cdiff (we can’t hold them in preop). She was demented & delirious - ripping everything out & family wanted everything done. She had already been poked everywhere and was covered in bruises. I was struggling to get an awake central line due to squirming/retching and bilateral stenosis of the IJ. She had an Avf on the left arm - my partner suggested access vs PIV below. She couldn’t get the PIV, but, if there was a vascular surgeon around (strangely none that day), I would have asked them to assist with accessing the AVF temporarily. I did not feel comfortable poking it. Eventually, I got a central line in.

In retrospect, subq sedation could have been helpful for the situation.

Punch her in the leg for an io

 

[Arch Guillotti]

I meant if that was all needed, why not just be the line in EJ?

I think the IJ is a more reliable target.

 

[narcotics999]

I did a few times on the upper chest in vascular pts. Vascular surgeon recommends it.

 

[anbuitachi]

I wasn’t talking about a lymphedematous arm but a normal arm that had prior ALND. Seems like intermittent compression might be beneficial, perhaps it would prevent a DVT in that arm.

sorry when i say lymphed arm i meant arm that has undergone lymph excision, not lymphedematous

 

[anbuitachi]

Punch her in the leg for an io

definitely recommend IO. we dont do enough IOs. ED puts them in in so many patients

 

[coffeebythelake]

I usually don't touch restrict arm. but if no choice, I may, depending on the situations. Not active fistula.

Chemo port? Yes, used a few times. Again no good other alternatives.

One of my vascular surgeons will give me an access through fistula.

I used dialysis catheters. Just remember the heplock.

Talk about IV access, has anyone used AccuVein? Light shining on the arm, all the vessels show up. Nurses love it. I has not been called to put IV for a while due to "difficult IV".

yeah used accuvein a few times for pediatric patients, it's nice to identify the tract of the vein when skin color or other surface features make it more difficult. I'd say it has a niche role. but if the vein is small and fragile, still doesn't improve successful cannulation rates.

 

[vector2]

I meant if that was all needed, why not just be the line in EJ?



The only way I know how to place an EJ…..

The EJ is sometimes non-existent, and when it is there, compared to an IJ it's usually harder to stick (or thread off into). And even with a 2" catheter the EJ is less reliable vis a vis infiltrating, being positional/kinking, or being up against a valve. And the infectious risk for leaving an angiocath in the IJ for a day or two is probably no different than an EJ.

 

[drmwvr]

I always thought that BP cuff and IV fluid could worsen edema, but that in an emergency that using it was acceptable. Arterial lines would therefore not be contraindicated using that logic.

Fistula: avoid IV in same arm, as fistula could get infected. Still wouldn't put a BP cuff on a functioning fistula. Aline infection, accuracy?

Try to avoid accessing port as can get infect also.

This is what I was taught, but maybe its just lore that is unsubstantiated.

I'd worry about a graft but not a native fistula. Surely no worse than the fistula itself being accessed multiple times a week.