IV infiltrated but blood withdraw easy/drips well

[cleansocks]

Got ultrasound guided IV AC in super duper ultra mega morbidly obese pt, long (1.75") 20g angiocath. Threaded smoothly into plump IV, when I withdrew the needle from the catheter blood returned nicely, draws back blood no problem. Pt then complains of achiness at IV site during slow infusion. I attach saline flush syringe, easily aspirate blood very smoothly, and injection into IV feels smooth, but I do notice a little "bulge" swelling appearance around IV site upon injection of saline as if the IV is infiltrated. She nonetheless feels the effect of the medication we're providing and the microdrip tubing drips fluid no problem when disconnected from pump. Over the course of 45min the swelling seems to grow a little so eventually I just put in a new one. Under ultrasound right before pulling it, it almost looked like the tip of the catheter was in the vessel and maybe embedded in the side wall. Perhaps it was partially in the vessel, partially out, or through one of the walls of the vessel... does that happen with veins too? Ultrasound of superficial tissue above the vein definitely showed edema / signs of fluid infiltration.

Just found it strange - others have similar occurrence?

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[dchz]

How smooth was the placement?

The common mistake that happens with US placement of lines is that people tend to poke a hole in the target vessel without realizing. So your case could be explained by an undiscovered iatragenic venotomy either distal (away from the heart relative to catheter insertion) or proximal (closer to the heart relative to catheter insertion). Most likely it's distal, because the infiltration only became apparent when you increased the venous pressure by flushing.

I would not use this catheter, obv norepi is the infusion you absolutely want to avoid, but who knows what other drip is just so ever slightly too concentrated and cause a bad outcome? Furthermore, compartment syndrome is also a big deal.

I avoid the AC, while it's really easy for blind approach in an emergent situation, it's actually not a great vein to poke in my experience; Median nerve and the brachial artery is all right there. It also stops working if the pt bends the arm. For people with BMI above 50, i find that the cephalic vein at the arm is a nice vessel that is cushioned in subcutaneous fat. It is also superficial to the fascia, meaning it's very hard to cause compartment syndrome. Perfect for US guided placement.

The key to avoid accidental venotomy on ultrasound is to visualize your needle tip at all times. Keep in mind that you're trying to visualize a 3d structure in a 2d picture. If at any time you're not sure you're visualizing the tip, just scan away from your hand holding the IV catheter until you can't visualize the tip anymore.

Yes, i'm saying when it comes to US guided line placement, the slogan is "just the tip"

 

[DrAmir0078]

Yes, i'm saying when it comes to US guided line placement, the slogan is "just the tip"

It is indeed !

........

Try to use Angiocath with guide wire built in, the one you use for arterial line (it is awesome, but a bit painful)

Do you use longitudinal approach?

Just saying!

 

[deleted162650]

I do these all in plane. It helps.

 

[Urzuz]

My threshold for sinking a line in these patients has decreased drastically. Spending so long futzing around with a crappy PIV that may or may not be in just isn’t worth the headache or the time commitment (keep in mind that if they’re an inpatient your marginal IV will most certainly fall out / infiltrate the second she wakes up and reaches for a burger in front of her). I’ll give the saphenous vein one quick look if the patient is an outpatient...otherwise they get a CVP in their neck. Takes less than 5 min from needle stick to propofol and it is reliable.

I know of cases of infiltrated IVs leading to compartment syndrome requiring a fasciotomy. Not fun.

 

[sbhfl]

I know of cases of infiltrated IVs leading to compartment syndrome requiring a fasciotomy. Not fun.

Cruise ship doctor's error led to worker's arm amputation, lawsuit claims

The judgement ->

 

[pgg]

Cruise ship doctor's error led to worker's arm amputation, lawsuit claims

The judgement ->

That wasn't an IV infiltration.

Someone injected 25 mg of promethazine into an artery.

 

[vector2]

dchz's hypothesis is probably right. I don't F around with IVs if I have any suspicion that it's infiltrated, the site looks swollen, or the pt is complaining of pain at the site. Once in a blue moon, I'll blow a superficial vein close to skin entry but redirect and thread off the catheter easily into the vein a little proximally. I just tape the dressing tight over the skin entry to prevent hematoma and the catheter works fine because the tip is well upstream of the venotomy. Again, I only do this on superficial veins where I can obviously see or feel the catheter in the vein.

My ultramorbid fattos nowadays get a 12cm 20g ultrasound guided catheter in the basilic, cephalic, or axillary vein if they show up to the OR with poor access. Not only does it make the case run smoother, but having a reliable midline makes everyone's job easier through the entire hospital stay.

One tip if you are going to use U/S for a 1.75" catheter in a fatto: Make sure your initial approach angle is STEEP, then flatten out once you get flash. This will minimize the "deadspace" distance the catheter has to traverse before reaching vein. I've had these infiltrate on me after taking a shallow angle approach because only a minimal amount of the catheter was actually in the vein by the time I got flash and threaded off.

 

[DrAmir0078]

Let me share with you this tip:

In the short axis technique, better called Transverse one.
1- As you see the vein and you confirmed it that is not an artery, you just keep the transducer slightly touch the skin to accurately measure the depth of the vein by seeing the depth you set on the machine and by confirming it by using the guide dots too.
2- As you press tighter just before closing the vien lumen, poke the skin right in the middle of the probe (probe mark always to towards the left) with an angle of 70 to 80 (for me, more angle to get the advantage of the length - if you remember Pythagorean theorem - to shorten the leading oblique edge of a right angle scalene triangle) but poking should be close to the middle of the probe (no space prefer)
3- Once you poke the skin and you See the TIP, you may go straight to the wall of the targeted vein, and once you get flush with blood in the canister, and your tip in the middle of the vein, you can play right left to see your tip playing the same as you in the vein in the screen
4- Slightly move the transducer up proximally until the tip is about to fade out, then move the catheter more to see it again the tip in the middle of the vein (you will see, you are leveling off to get the tip in the middle of the vein), then slightly again move the transducer up again,, repeat this point 3 times at least.

Here I am guarantee that you will have at least 1 cm of the catheter inside the vein and easily to forward your plastic catheter smoothly.

This will minimize the kincking of the catheter, and by holding tight as I said and seeing the tip in the middle of the vein and repeating point 4, you are not allowing the catheter to accidentally moves up, especially if the patient move or the bulk of the fat and tissues are flimsy!

Thanks for reading me!

 

[anbuitachi]

Cruise ship doctor's error led to worker's arm amputation, lawsuit claims

The judgement ->

man what a unlucky doctor. seems like a good doctor too. messaged the guys arm all night. some of those claims are ridiculous. about how he didn't obtain informed consent to giving promethazine before giving it... pretty sure that can be charged against any one of us on any day

 

[sbhfl]

That wasn't an IV infiltration.

Someone injected 25 mg of promethazine into an artery.

That's the plaintiff's position, but the judgement document itself gives some doubt. The article only covers the plaintiff's complaint-- so I see why you're so quick in assuming it was arterial. But the patient already had a NS drip and Tylenol going in the arm (which he already complained of having pain) before pushing promethazine. The defense claimed it was in the vein and extravasated-- the expert physicians were split between extravasation and intraarterial injection.

It didn't matter for the judgement, but extravasation is more likely in my opinion.

 

[dannyboy1]

An IV should have the same rule as milk. When in doubt, throw it out....

 

[anbuitachi]

weird i had a similar case today. IV ran very well, and appeared unchanged in rate. induction meds went in and patient paralyzed adequately. i was concerned for infiltration because it was done under ultrasound, and the vein was fairly deep in the upper arm, and we only had short catheters so it barely reached. during the case the patient became hypotensive. i bolused a ton of phenylephrine, ephedrine with no effect. 0.4 glyco with no increase in heart rate. then Vasopressin 1-2U at a time with no effect. was concerned for infiltration even though 1L of fluid went in, with zero edema or tension in the arm..

 

[fakin' the funk]

To the OP - yes weird stuff happens with venous cannulation because veins are ****ty thinwalled floppy structures. Some angiocaths are very sharp, and some (like the Arrow art line 20g) are not.

The fatter our patients get, either the more infiltrations we'll have, or the longer catheters well have to use. I'm very wary of the normal 1.25" catheters in fatties.

Random ultrasound trick - to confirm the catheter is really in a vein, follow it proximally a few inches and watch under ultrasound while you bolus a few CC's under pressure- you should see the vein distend, some microbubbles, or color pulse on Doppler. Or, you could do a bubble study with surface echo...

 

[cleansocks]

I've done a few in-plane u/s guided IV's on this one patient who comes in every few weeks. Always goes well.

But... she is the only person I've ever seen whose blood I can literally see coursing through her veins. Looks like little tiny white particles swirling around and going at a constant slow rate. It's actually REALLY cool to see. But I dunno if I should be concerned for her. It's not the machine as I do other u/s guided iv's with the same settings.

Anyone ever seen this before? Veins are nice and collapsible. She's on lithium and cymbalta. 30's.