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IV catheter size
Okay folks, I need your opinions and clinical thoughts. What criteria do you use to select IV catheter size for your patient? One way that I am hearing is use the largest bore needle you can get regardless of patient condition, i.e. stable vs. nonstable, or fluid resuscitation.
Replies to This Discussion
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Permalink Reply by Mike Rubin on -
The saying "go big or go home" was popular when I was in medic school. I think it's a crock. Why inflict pain unnecessarily, either from a larger needle or multiple attempts? Consider what you're administering through the IV. A large-bore catheter helps expedite high volume, but that's the exception. For most patients in the field, an 18- or 20-gauge should be fine.
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Permalink Reply by Nathan on -
Consider that a 20 gauge catheter is the smallest size that CT contrast can safely/adequately be infused. So, if you have a patient that you think may need a CT scan, dont go below 20g if you can help it. There is also some discussion as to the safety of using large bore IV caths in the hand since it tends to completely occlude the return circulation in that vessel distal to the IV site. 20g caths are usually adequate for everything except blood products. You may be surprised how much volume you can infuse through a 20g if you put a pressure bag on it, or even a BP cuff.
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Permalink Reply by Timothy Rossette on
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Depends on my mood. I tend to like the color green the most.
Just kidding of course.
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Permalink Reply by Eric on -
18g tends to be my iv of choice in the ac's as they are adequate for drug,fluid,blood, and contrast. unless of course they needs lots of fluids or may need lots of fluids fast
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Permalink Reply by TheCannulator on -
No one should be getting IVs in the hand- unless it's a 22 and only for drug use like analgesia.
In cardiacs for example you want the patient to be able to use their hands so cannulating their is hindering that. Besides they hurt like hell. Start at the wrist and work up.
Eric said:18g tends to be my iv of choice in the ac's as they are adequate for drug,fluid,blood, and contrast. unless of course they needs lots of fluids or may need lots of fluids fast
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Permalink Reply by Jonathan Gilliam on -
It just depends on the needs of the patient. No matter what size I choose, it's going to hurt, so the pain factor really doesn't play in with my decision making. If I'm just starting a saline lock, I'll more than likely go with a 20g in the hand or forearm. If I'm going to give a fluid challenge, I'm starting at least an 18g in the forearm or AC. Then comes the condition of the patient. If I have an old diabetic with brittle, tiny viens, I may only be able to get a 20g at best. The only times I've gone larger than an 18g is in a code, or in a major trauma where the patient will need a blood transfusion at the hospital. I am not for getting the biggest you can use, and the patient's condition be damned. I think that has a lot more to do with ego, and less to do with actual concern for the patient. When I'm on the truck I usually keep a small emesis basin on the bench seat stacked with an IV start kit, a couple of 4x4's and one each of 18g and 20g IV caths. Seems to be the ones I use 90% of the time.
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Permalink Reply by Derek on -
It is advocated and more of a norm in my area to use a 20g on your stable, medical patients that only need med access. Even for fluids if needed should the patient deteriorate, a 20g can be sufficient.
I always start distal, as in the hands, and work my way up unless the patient needs rapid fluid replacement, adenosine, or has other reason for larger vein cannulation.
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Permalink Reply by blair4630 on -
I think some things are mostly universal in gaining access. One of which is start distal, then move proximal for additional attempts. I know a few that love the AC to start, but there's 2 problems...first, that doesn't build skill in locating, visualizing, palpating, and cannulating the plethora of veins that are available...second, if you miss, you may have another palpable or visible AC, otherwise, if you don't have a vein in the bicep, you're shot for that arm. The other thing that seems to be across the board is the size, which seems to be 18 or 20 ga....that seems adequate for almost every pt.
That being said, I personally will go for a 18 or 20 ga. in most pt.'s, while following the distal to proximal rule. Here are some exceptions....
1) Fluids...if they need em'...you should try to go for a 18 or larger...however....if you don't think you can sink an 18, get what you can...if someone needs fluids, and you KNOW you can get a 20, and THINK you MIGHT get an 18, go with the 20, and get the fluids in you KNOW he needs, then try for a 2nd line
2) Adenosine...someone here already said it...18 or larger, AC or higher, arm up, 20cc or larger flush in the 2nd port ready to bolus, that 's how the drug work, nature of the beast, no exceptions...however...if you're not 100% sure about the rhythm, there are safer, and more comfortable alertantives, like Cardizem
3) Inferior/right ventricular MI...get a big line...the nitro might make a big drop in BP....get 2 lines if possible...and use fenanyl, not morphine, preferably
That's all that comes off the top of my head, thought more would come off the top, but sometimes I don't produce. I'll probably post this, and think of 8 more examples.
Two additional thought kind of related to this....
1) If you're using locks ( I love locks, use them always)...look at the lock you're using....The standard 7" locks with a 0.4 priming volume, the thin ones, or "micro" locks....flow at about the rate of a 20 ga., no matter what angio you use, so if your using an 18 ga. or larger, grab a "macro" lock (0.8 ml priming volume on a 7" set), and if you don't have a macro, go with a straight line, or you cancel out that large bore I.V. Personally, I only carry macro locks, I remove any micro locks I find on the truck.
2) This is a little off topic completely, but hell I'll throw it out there because it deals with anigo sizes....When you go to do a needle thoracotomy (chest decompression)....alot of people are left to use the 14 ga. anio that's in there I.V. kit. Most anigos are left between 3/4 and 1 3/4 inch in length to maximize fluid flow. Current research shows an optimal length for needle thoracotomy to be between 3 and 4 inches, and 14 or larger. I know NAR (North American Rescue) sells a 14 ga. 3 1/2" non-safety angio for just this purpose, but we use a kit that's just a 10ga. 3", a 12ga. 3", plus suction tubing (optional for use) in a kit. Point is, if all you have is a 14ga. that's less than 2", talk to your supervisor or medical director, you should switch to something longer to avoid possible failed thoracotomy attempts.
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Permalink Reply by Skip Kirkwood on -
Try doing a flow rate comparison. There is a maximum flow rate possible with each catheter/adapter/tubing set. Don't use a catheter larger than the max flow you can get, and will need for this patient - why inflict unnecessary pain? Yes, bigger needles hurt more than smaller ones, I can tell you.
Venous access in the joints are easier, but are often less effective unless you seriously immobilize the joint (causing additional discomfort, etc.). Distal, straight in access away from a joint is the kindest, if it is possible.
And you shouldn't be attempting a thoracostomy with a 14 ga 2" needle - you will too often wind up with a crooked catheter outside the pleura (which is really tough to penetrate).
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Permalink Reply by Chance Gearheart on -
Um, Nin. They are disciplining Medics and EMTs in Tennessee for doing that crap. You never use a large bore IV if you can avoid doing so for the reasons of pain control and reducing possible complications as a result of large bore IV access. There are other structures than vessels you can damage with large bore IVs, and most of the time they're not needed; plus you look like an idiot if you walk in with a 14 gauge INT. If you talk to the average ER Physician or Nurse, there is usually no need for a 14 or 16 gauge IV in all but the most critical of trauma patients. IV pumps and pressure infusers can push a substantial amount of fluid through an 18 gauge, and you can give blood through a 20 gauge unless you're slamming it in. The ER I work in only has 14 - 16ga in the Omnicells for teenage and adolescent trauma patients and decompressions/EJs. You really ahve to think of the applications you're using it for, and the underlying condition the patient has. It's utterly idiotic to try to throw a sixteen or fourteen gauge in a DKA or dehydration patient, as rehydrating them too fast can cause neurologic and electrolyte dysfunctions. If they're septic or in a clotting disorder, all you're going to do is cause phlebitis, venous rupture, and more holes for them to bleed from. Most medical patients rarely need anything hither than an 18 gauge, and my elderly patients often get a 20 or a 22 when I work the adult side of things. In pediatrics, think relative to body size. A 20 gauge would be considered large bore for an infant, and I've even started 26 gauges on newborn and neonate patients for fluid administration (which is a chore. The needle can bend before it even penetrates the skin!) Using a very large IV for situations they're not needed in, or potentially harmful to the patient is unnecessary and makes you look bad, to the patient and the recieving facility.
If you've got an exsanguinating trauma patient or a cardiac arrest, yes. Go big. If you have grandma who's 78 years old and in DKA, you can get by with a 22 or a 20. In pediatrics, always think small unless, again, they're a significant MOI. You can, with a BP cuff at 100, an IV Pump set to max flow, or a pressure infuser, push a 1l bolus through a 10gtt set and an 18 gauge in a matter of 5 to 8minutes. Just an FYI there.
And, people. Stop this crap about using IVs to punish your patients. It's cruel, unethical and uncalled for. Yeah, he may be drunk, but does he REALLY need a 14 gauge to teach him a lesson? It's not your place.
ANd I agree. My adult service I work for uses 3 1/4" BD 14ga Angiocaths, and we have a 12ga angiocath in the et roll for needle crichs. I really wish we used the NAR or the Cook Needle Thoracostomy kit, though. They're much better, and they include everything you need, no juryrigging a condom, glove finger or Ascherman Chest Seal to make a flutter valve.
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Permalink Reply by dr-exmedic on -
Nathan said:
Hmm, I wish we could get our CT people to put contrast through anything smaller than an 18. :( One more reason to know what the locals in your area think....Consider that a 20 gauge catheter is the smallest size that CT contrast can safely/adequately be infused.
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Permalink Reply by dr-exmedic on
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Chance Gearheart said:
I totally agree. Important thought--we're here to help people.And, people. Stop this crap about using IVs to punish your patients. It's cruel, unethical and uncalled for. Yeah, he may be drunk, but does he REALLY need a 14 gauge to teach him a lesson? It's not your place.
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