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.

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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.
Depends on my mood. I tend to like the color green the most.

Just kidding of course.
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
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
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.
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.
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.
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).
Nathan said:
Consider that a 20 gauge catheter is the smallest size that CT contrast can safely/adequately be infused.
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....
Chance Gearheart said:
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.
I totally agree. Important thought--we're here to help people.
My I go for what I can get if that,s only a 22g in a little old lady so be it. I look at every thing when picking a cath
I like 18g in ac but most of the time a 20g in the hand will do.
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.

Try a 3-way stopcock, like the ones you'd use on a pediatric IO for bolusing. If you see the tension pneumo building again, just release pressure and re-close.

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