Recently, there have been demands from our CT department that CT scans require a 20g or larger PIV in the antecubital space. We understand the need for the larger PIV in a larger vein when power injecting. However, we have been asked to place 20g and 18g PIVs in the AC for pts who don't have veins that can tolerate that large of a catheter. Some pts may have only one arm available for PIV access and the veins in that arm are very tiny, some pts will comment that they are a difficult PIV start and have been poked many times in the past for PIV access, or veins are sclerosed due to chemo or drug use. Recently, I started a PIV using ultrasound and it took 4 attempts to get the PIV in place (I was able to insert the PIV and obtain a great blood return all 4 attempts but after connecting the extension set and flushing, the site would blow with flushing. 4th attempt was successful in upper arm and able to flush after insertion but site blew with power injecition).
What do other institution require for PIV access for CT scan power injection and what is the practice if venous access is so poor that a large gauge angio is not appropriate? Are there any articles to support the type of access required/needed for CT scan? Is it appropriate to use a 22g angio in a smaller vein? Are there any standards regarding PIV site/size required/needed for CT power injection? Would anyone be willing to share their policies (if any) regarding this issue? Please help as there is now tension between nursing and CT scan regarding this issue!
Actually there is a lot of information about this. I have had to find it because I have been the expert on at least 10 lawsuits involving severe complications from contrast extravasation. First you must understand the needs for CT. They do require a large gauge catheter in a large vein. Injection rates range from 3 to 10 mL per SECOND! 8 mL per second can be common for a CT angiogram and this equates to 28,800 mL per hour, to put in a context that infusion nurses are familiar with. This rate is necessary to have an adequate concentration of the contrast in the organ being studied. As CT scanning machine become more sophisticated, the technology is producing more slices and improving the ability to diagnose patients problems, thus driving the need for faster injection rates. This need must be weighed against the patient's peripheral venous condition. I gave a pressentation at INS in May of this year on these issues. This was an exhibitor theater sponsored by BD. In addition to my review of contrast and the deviations from the standard of care i found in these lawsuits, another nurse gave a short presentation on her experience with the new BD Difusics catheter. I hope I am spelling that name correctly. This catheter has a regular flow through the catheter tip, but is also has 2 side holes allowing contrast to ener the vein. This decreases the jet effect coming out of the catheter tip. And it is reported to allow for a smaller size catheter. Current research with regular PIV catheters show that you can use a 22 gauge if the veins will not tolerate a larger catheter, but this small size does limit the rapid flow rate that is possible. This could reduce the quality of the scan. The new BD catheter will allow the use of a smaller catheter in most patients while still allowing the faster injection rates. Additionally, there is one midline catheter by Access Scientific that is labeled for power injection. I also think that Bard has a new midline that is also labeled for power injection. Without these new technologies, the only other alternative is to insert a power-injectable PICC with all of its potential issues for such a short use. Then again, if your patient have this level of difficult veins and need infusion therapy as an inpatient, they may need a PICC for contrast and other therapies. The American College of Radiology has a Manual on Contrast that serves as guidelines for radiology, although the research on these new technologies is not included yet. My INS presentation is available for your local chapters if anyone is interested. Thanks, 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
Thank You Lynn for the information, this is very helpful. Just one more question-- Is it recommended to gain PIV access above or below the antecubital space instead of directly in the AC? Many of the CT pts end up staying in the hospital for several days or longer. Many times we are changing out healthy AC PIVs because it is inconvenient & uncomfortable for the pt, pumps alarm frequently, and nurse spends a lot of extra time/steps restarting the pump.
Vickie Teresinski, RN, CRNI
It is not easy to actually palpate veins above the AC on many patients. Making the puncture directly in the AC for contrast and then immediately removing it is probably the best method if your radiologist insist upon the AC. I would not want to deal with a catheter left in the AC for other infusions and if left, the complication rate is greater. So it would need to be removed. 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
Vicki,
You can contact me offline regarding peripheral IV's and contrast. I work in a 600 bed, Level I facility where we do 1000 CT's a month, and collected data on this type of problems with some ideas for you to work with CT on this project.
Ann Earhart, RN, MSN, ACNS-BC, CRNI
Vascular Access/Infusion Therapy Clinical Nurse Specialist
Phoenix, AZ
[email protected]
We have been using BD's Diffusics catheter for power injection for some time now and find it quite effective. Depending on the CT resolution needed, you can use a 22g where you needed a 20g or 18g and still get good images. We occasionally even use a 24g for those patients who only have tiny veins. This is a really excellent product because it doesn't piston nearly as much as a distal open end catheter so it doesn't infiltrate nearly as easily.
I don't do any work for BD.
The ASRT, American Society of Radiologic Technologists and the ACR, the American College of Radiology both issue guidelines regarding contrast injectiions. I recommend the ACR Manual on Contrast Media, which is updated yearly and can be obtained for free from the ACR website. (or you can email me directly and I will send it to you) The ACR Manual on Contrast Media states that contrast injections must be done via a 20G or larger PIV in the largest vein accessable at the AC or higher. Due to the high osmoality of all contrast, and high pH of most contrast media, the PIV should be removed after it is no longer needed for contrast injection. Also, the contrast injection should not be given via a PIV that is greater than 24 hrs old, as risk of contrast extravasation is higher the older the PIV is, and should not be given in PIVs that do not give a blood return.
The new PIV Diffusics from BD is ideal for use in contrast injections, as the multiple holes in the lumen decrease the pressure on the vein during injections. All other PIVs are acceptable for power injection of contrast.
There is only one midline (Technically) that is approved for power injection-the Power wand, and Bard has one that is in limited release. I caution you that these IVs have limited if any actual patient data, and the tip location of the lines can theoretically lead to complicaitons.
It is certainly a challenge iin many hospitals across the country. If a patient needs access for more than 5 days, and power injection in CT or MRI, I would still recommend a pressure injectable PICC as the best option.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
The ASRT, American Society of Radiologic Technologists and the ACR, the American College of Radiology both issue guidelines regarding contrast injectiions. I recommend the ACR Manual on Contrast Media, which is updated yearly and can be obtained for free from the ACR website. (or you can email me directly and I will send it to you) The ACR Manual on Contrast Media states that contrast injections must be done via a 20G or larger PIV in the largest vein accessable at the AC or higher. Due to the high osmoality of all contrast, and high pH of most contrast media, the PIV should be removed after it is no longer needed for contrast injection. Also, the contrast injection should not be given via a PIV that is greater than 24 hrs old, as risk of contrast extravasation is higher the older the PIV is, and should not be given in PIVs that do not give a blood return.
The new PIV Diffusics from BD is ideal for use in contrast injections, as the multiple holes in the lumen decrease the pressure on the vein during injections. All other PIVs are acceptable for power injection of contrast.
There is only one midline (Technically) that is approved for power injection-the Power wand, and Bard has one that is in limited release. I caution you that these IVs have limited if any actual patient data, and the tip location of the lines can theoretically lead to complicaitons.
It is certainly a challenge iin many hospitals across the country. If a patient needs access for more than 5 days, and power injection in CT or MRI, I would still recommend a pressure injectable PICC as the best option.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC