Forum topic

 I am just as eager to prevent severe infiltation and extravasation injuries as any other nurse, however you will never be able to get a CVAD inserted for every drug that is considered to be a vesicant for every patient situation. Here is a great example - uncontrolled diabetic with a very low blood glucose requires immediate injection of 50 mL of 50% dextrose. No time to place a CVAD. No extended need for a CVAD. Just this urgent one time dose is probably all that will be required. The risk of CVAD insertion would outweigh the risk of extravasation in this case. This does mean that the nurse inserting the PIV must be knowledgeable of all the decisions to be made about the PIV so that the risk is greatly reduced. These include avoiding areas of joint flexion such as the hand, wrist, and antecubital; choosing the smallest gauge catheter; adequate catheter stabilization using an engineered stabilization device; manual injection from the syringe while checking for a blood return every 3-5 mLs. Another example is Vancomycin. If you are waiting on culture and sensitivity reports to determine if the vancomycin will be needed for a lengthy course of therapy, you might be expected to use a PIV. Again the same prinicples of risk reduction do apply. As soon as the long-term plan of care is known, then a CVAD should be chosen if vancomycin is to continue. I have never seen a written document that would adequately cover all of these situations but hope someone has one to share. It comes down to nursing knowledge and appropriate judgment based on that knowledge. By the way, this content should be written as a practice guideline and NOT as a policy statement. Lynn

this is perhaps related - when the hospital installed Hospira smart pumps our committee decided to include prompts in the online drug library.  The pumps have cues for infusates requiring central lines and/or filters.  For instance, the drug appears AMIODARONE (filter).  Nurses get busy and the prompts help.