Hello everyone:
Are there any studies out there in regards to insertion of longer catheters for obese patients or patients with very difficult access for whom an US is needed?
At our facility we often are asked to insert a PIV in patients who are obese or have very diffucilt access. That, many times requires the use of an US machine. I have found that the standard length of peripheral catheters (1.25 inch) is too short and those lines will invariably malfunction shortly after insertion. I know that catheters come in different lengths and materials, but I would like to have more information as to the appropriateness of using them. I have looked into trying out a 1.75" catheter, but one of my co-workers has told me that a hospital she has worked for used to use the longer catheters, but were subsequently prohibited from using them due to problems with thrombosis and infections.
I have been searching for studies in regards to this issue, but have not found anything. Is there anyone who can provide me with some information?
Thank you in advance for any help you can give.
Maria
What search terms are you using? There are numerous studies on PIV insertion with ultrasound that documents using 1.8 or 2 inch long peripheral catheters. You have got to have a longer catheter to adequate purchase the vein - the length of catheter that is actually inside the vein lumen. A longer catheter in this patient population does not automatically mean more complications like thrombosis. Yes, the general priniciple is the shortest smallest catheter in the largest vein possible. And that is what you would be doing even with a 2 inch catheter due to the depth of the vein under the excessive superficial tissue. In fact, the rate of infiltraiton within 24 hour is greater with US inserted PIV's and it could be related to catheter length, vein depth and/or technique. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I am not sure about published data specific to the obese population. In our facility we find the need for ultrasound guided placement for anyone that is difficult to access. We base our placements on the same principals stated by Lynn.
In addition we do not place peripheral IV's at a depth greater than 1cm. We use a 1.75in or 1.8in catheter (inserter brand preference) so there is always at least 3.4cm in the vein. We also insist that it have excellent blood return. Even if you think it is in but up against a valve or bifurcation it is no good. The risk of infiltration with the greater depth is always a concern. The deeper layers (especially in the upper arm) can hold a lot more fluid before the infiltrate is noticed. We call these "silent infiltrates". Never good.
If you can't find a vein with ultrasound that is less than 1cm deep it is time to talk central line.
I would also consider your source. In our market preople often site what the "other hospitals" are doing. Frankly, what they are doing is often wrong. Follow the national governing bodies (INS, AVA, CDC etc) and check with the product reps about those problems. I find that facility based decisions are often knee jerk reactions to anecdotal evidence. Was there truly a problem with thrombosis and infection OR were there a few random events right in a row and the decision was to pull the product without looking at it further? I don't mean to question your co-worker. She may be absolutely correct. I would just dig a little deeper & make a decision for your facility based on good information.
I bring a bit of a unique perspective to this problem. I worked at 30+ facilities as an ICU travel nurse, nation wide. I saw HUGE variance in practices. What was a big deal or policy at one facility the next would not even consider it important. Even in our town not many nurses have worked at all the hospitals. I have. The "other guys" don't always do the right thing.
Martha