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Do you want a cookie?
Consult for IV Start
- Thread starter ZzzPlz
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No I dont want a fuucking cookie. I was simply responding to the last post that said there is no need for nurses to use US for PIVs.
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RRN- surely you understand that your skills are advanced, and 99.9% of your average IV-inserting nurses cannot and should not be using ultrasound to place them.
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It's still a good idea to get better at starting IV's the good old fashion way since ultrasound might not always be available everywhere you go, and in good hands 99.9 % of IV's can be done in 3 seconds.
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Yes... he is super nurse 🙂
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Couldn't agree more... That is why every ICU should have trained nursing staff that are educated in differentiating veins from arteries, major nerve locations, and how to select proper catheter length. In my hospital only RRT and PICC nurses use ultrasound. MICU, T/SICU, CVICU, and BICU all have at least one member on the RRT. Plus there is always one rapid nurse available on call for these situations.
You have to forgive me, I have only worked at one hospital, that being a regional trauma center. I cant really speak to the resources/competencies of smaller facilities. It is valid point that in places where there is not the appropriate training or competent staff these techniques should not be used. I could absolutely see the complications that may arise if an untrained nurse tried to cannulate an artery with a 16 gauge catheter because they could not identify anatomical structures.
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What is with all the condescending remarks? Yes you should be able to place PIVs without ultra sound the vast majority of the time. For the other times its nice to have trained individuals that can get access without needing a central line. Im sorry but in my unit a single 24 gauge in the finger is not adequate access. Its my facilities policy to have a minimum of two WORKING 20 gauge IVs on all of our patients. If they are a GI bleed they need two large bore accesses.
I don't try to be "super nurse." I just take my job seriously and want nursing held to a high standard. I don't see how that is somehow offensive. Don't you want to be highly skilled at your craft? I simply want to be able to provide my patients with the same standard of care I would expect. If I cant see or palpate a vein easily why would I torture them by digging around for something Im not going hit anyways? If they need central access that is what they will get, but if you can easily/safely save them from getting a CVC and it's potential complications its a no brainer.
Im sure you did a rotation in MICU during your residency, you should be very familiar with the population of patients that come through. Can you honestly say you can hit a ESRD patient with grafts and +4 edema 99% of the time? Or get an 18 gauge in a 20 year IV drug user 99% of the time. I know sure as hell I can't.
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I think you are taking yourself too seriously and in the future you will be a one of those militant CRNA's who annoy me to death!
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Where is this that a nurse places alines and central lines?!?!?! Hell no. Where? So I can make sure no one I care about is ever there. No way.
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I think this is my favorite part.
I'm sure we all work and trained at tiny Podunk hospitals with all the dunce staff and don't know nuthin' about that serious medicine.
Or, maybe, level 1 trauma centers and major academic referral hospitals... where no nurse outside of the PICC nurses use an ultrasound to do anything.
I don't follow. You just perfectly described a patient that needs a central line or PICC and then talk about saving time and resources by placing a ****ty PIV in them. If you are placing enough PIVs with an U/S to feel like you are getting good at it, you probably aren't very good at starting IVs. And I say this as the person that gets called when nobody else can get the IV. If a patient needs a central line, placing an U/S guided PIV doesn't help them much at all.
Can an U/S be a useful tool for finding a vein for a PIV? Of course. Nobody would deny that. It's just extremely infrequently that you should be needing it.
Jealous of what?
I am anesthesia-trained but primarily practice critical care in a surgical ICU at a major academic hospital. I’d like to say that as an anesthesiologist, I am pretty good at PIVs, but I still do US-guided IVs not infrequently (i.e., less than 99.9% of my PIVs in the unit are without US-guidance, as someone above estimated).
The patients that come to the surgical ICU usually have undergone a procedure that requires considerable volume resuscitation, plus are in a fluid-seeking post-op phase that it’s not uncommon for these folks to be at least 20 liters positive after a few days. They become so edematous that it’s very difficult to palpate a good vein.
If they lose IV access, the nurses will usually try before calling me, and by then they’ve usually blown all the good targets.
More often than not, I can find a decent vein to put a 20 gauge in without ultrasound. But I generally like to place IVs proximal to previous attempts, so that nothing injected into that IV has a chance of extravasating. This limits the sites that I’d like to use.
A decent length PIV in the AC can last a long time. We have some in the unit that last at least a week, often times longer. Ordering a PICC takes time, and often does not get done until late in the day or the next. Plus if we draw blood cultures, policy dictates that blood cultures must be negative for at least 2 days to proceed with a PICC. Who can wait that long for IV access? Could we place a central line? Sure, but then we expose the patients to the risks associated with that. Complications from IJ central lines are estimated at 1-3%, so odds are something will happen if you do enough of them. All anesthesiologists know that. Furthermore, central lines take time (I’m at a teaching institution with junior residents who need at least 30 minutes from start to finish, and usually need step-by-step instructions).
Our surgical ICU patients often can be diuresed and return to normal volume status after a few days. By then, their veins might reappear. That’s short enough that they probably don’t need a central line, but long enough that a good AC PIV would be fine.
So, not infrequently, I’ll just throw in an AC PIV using the US because the patient is really edematous and easy veins are not that common. It only takes a minute. Patients are usually frustrated by being poked so many times that as this point, it’s usually the quickest and most comfortable thing to do, it’s convenient for us and it’s adequate for our needs.
The patients that come to the surgical ICU usually have undergone a procedure that requires considerable volume resuscitation, plus are in a fluid-seeking post-op phase that it’s not uncommon for these folks to be at least 20 liters positive after a few days. They become so edematous that it’s very difficult to palpate a good vein.
If they lose IV access, the nurses will usually try before calling me, and by then they’ve usually blown all the good targets.
More often than not, I can find a decent vein to put a 20 gauge in without ultrasound. But I generally like to place IVs proximal to previous attempts, so that nothing injected into that IV has a chance of extravasating. This limits the sites that I’d like to use.
A decent length PIV in the AC can last a long time. We have some in the unit that last at least a week, often times longer. Ordering a PICC takes time, and often does not get done until late in the day or the next. Plus if we draw blood cultures, policy dictates that blood cultures must be negative for at least 2 days to proceed with a PICC. Who can wait that long for IV access? Could we place a central line? Sure, but then we expose the patients to the risks associated with that. Complications from IJ central lines are estimated at 1-3%, so odds are something will happen if you do enough of them. All anesthesiologists know that. Furthermore, central lines take time (I’m at a teaching institution with junior residents who need at least 30 minutes from start to finish, and usually need step-by-step instructions).
Our surgical ICU patients often can be diuresed and return to normal volume status after a few days. By then, their veins might reappear. That’s short enough that they probably don’t need a central line, but long enough that a good AC PIV would be fine.
So, not infrequently, I’ll just throw in an AC PIV using the US because the patient is really edematous and easy veins are not that common. It only takes a minute. Patients are usually frustrated by being poked so many times that as this point, it’s usually the quickest and most comfortable thing to do, it’s convenient for us and it’s adequate for our needs.
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This is a perfect example of an arrogant, condescending remark. You tell me I am not very good at starting IVs and you don't even know me. For your information I am very good at placing PIVs with/without US plus I am pretty damn good at placing CVCs. At my hospital we don't consult anesthesia for access. If there is a super hard stick they call our rapid team because 98% of the time we can get a good PIV, if not they get a PICC or an IJ. There are many times that patients are as I described earlier and only need access for one or two IV antibiotics. Why would they need to get a central line for something that simple?
Does using a glidescope over a C-Mac make you less capable of intubating someone the "old fashioned way?" Its pretty damn simple, use the tools at your disposal to get the job right the first time. If someone is a super hard stick, sure I could get a PIV without ultrasound but it might take 2 or 3 tries shooting for a vein based on its anatomical position. Additionally, why would I choose to put in a 22/24 without US when I could easily put 18 in with US that will stay for much longer, not infiltrate, and be able to draw labs for days?
If a patient needs central access then absolutely they will get it but don't kid yourself thinking that every person who doesn't have visible veins needs one. I know you get to bill for placing a CVC but do whats best for the patient and at least attempt to place a PIV with US before going straight for the big guns.
You hold yourself in such high regards that you feel it necessary to put down skilled nurses. Next time before you decide to bash on my posts at least be knowledgable about venous access because the patient I described absolutely does not need a PICC!. Go place a PICC in an end stage renal patient and risk destroying a future graft site, Im sure nephro and the vascular surgeon will thank you.
I didn't want to get ugly but you provoke me with all your hateful remarks.
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I've never seen a person so proud to be able to place a ****ing IV.
You must be really insecure to spend so much time & effort trying to prove something on here.
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This is pointless...if I can't find an IV I just give all the meds IM...the prop induction is the least pleasant part
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In private practice the answer is either:
1) I'm busy
or
2) I'm not an IV starting service
1) I'm busy
or
2) I'm not an IV starting service
My wife is a nurse. I have nothing but respect for nurses. What I don't respect are people that portray themselves as an expert and describe less than expert level care. You claim to be really good at using an U/S to start a PIV. My point is that somebody really good at starting PIVs can't need an U/S that often and if they do they (by definition) aren't that good at starting the PIVs in the first place.
If you want to talk about being knowledgeable about venous access, please step off your high horse. Your knowledge appears so limited that I don't even know where to begin (an 18 g PICC being worse than an 18 g PIV in the same vein for future access??? WTF???). Am I an expert? Yes, board certified, battle tested, and ass kicking. So please, don't ask me to be knowledgeable about something I'm expert in. You're like the kid in the minors telling Clayton Kershaw how to improve his curveball.
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Well RRN, it's great that you have acquired a skill to place an IV and have become technically skilled at intubations and such. I think it might have gone to your head a little bit, that you have a skill that a lot of other people don't have. I could train a monkey to place an IV or to intubate. I think you should go on to become a CRNA. You've already got the "militant" part down pretty good. It doesn't take much to become a Crna. And you will never have to consult anyone ever for anything. You'll be that good.
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Gassdoc, we definitely need to TALK!
IN anesthesia we have the unique perspective to see soooo many IVs from ICU/ER/Floor, that are on a pump at 100ml/hr, that dont drip, dont draw back, kinked, are infiltrated (have been for days).
Based on no data at all, i would say around 5-10% of the IVs from these places need to be redone prior to induction..thats a lot
IN anesthesia when the person is in the OR, positioned, in a vulnerable situation, we NEED that IV to drip, give blood, that is literally our lifeline...
On the floor, it infiltrates for a couple days big deal, maybe we can call the IV team and in 3 hours someone will swing by...then well put it right back on the pump
Doing US guided PIVs in the AC (in my anecdotal experience) are likely do infiltrate (immediately, hours, or days later). They are deep and the catheters even at 2 inches are relatively short. And if you say well NOT MINE because I do X, I would say to consider how many may really have been infiltrated but have been on a pump and you just didnt realize it.
And for us, if we are getting out the US, in the same time we can do a AC PIV, we can do an IJ and be SURE of our access...I dont think we consider this as risky and bad as RNs do (oooh the possible complications). Yeah imagine the complications when that PIV with its tip in the AC vein becomes dislodged during surgery under the drapes and goes unrecognized for an important case... the risks of that vs the risks of the CVC, CVC all day
So that may help in understanding our skepticisim of the US PIV techique.
