Does anyone have a reference that does not say this:
Parenteral phenytoin should be injected slowly and directly into a large vein through a large-gauge needle or intravenous catheter. Each injection of intravenous phenytoin should be followed by an injection of sterile saline through the same needle or catheter to avoid local venous irritation due to alkalinity of the solution.
We are writing policy, I need references that state a small catheter.
thanks!
Unfortunately, no. This is a very common misconception in the literature about using a large gauge peripheral catherer. This could not be more wrong and there is no evidence to support this large gauge. The INS standards have always stated a basic priniciple of using the smallest gauge catheter that will accommodate the therapy. The only thing I can figure out about how this large gauge idea originated is because of the issues with small gauges and adequate stabilization - they can become kinked more easily whereas a larger and therefore stiffer catheter would not kink. The bottom line is consuming the vein diameter with the catheter, which is the same priniciple as choosing a PICC that will consume half or less of the vein diameter - blood can flow around the catherer to dilute down the med thrugh that small gauge peripheral catheter. So anatomy and physioloogy plus the INS standards are the main sources I would use to require a 22 g for phenytoin instead of an 18 g. 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
the pharmacy insert states the preferred site for infusion is the antecubital fossa. I looked at several online sites and found this repeating theme - large bore iv in the ac.
I just came across this study. Although the abstract does not specify dilantin, it clearly states that larger gauge catheters are a modifiable risk factor for phlebitis and PIV failure. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid...
Abstract
Objective. To assess the relative importance of independent risk factors for peripheral intravenous catheter (PIVC) failure.
Methods. Secondary data analysis from a randomized controlled trial of PIVC dwell time. The Prentice, Williams, and Peterson statistical model was used to identify and compare risk factors for phlebitis, occlusion, and accidental removal.
Setting. Three acute care hospitals in Queensland, Australia.
Participants. The trial included 3,283 adult medical and surgical patients (5,907 catheters) with a PIVC with greater than 4 days of expected use.
Results. Modifiable risk factors for occlusion included hand, antecubital fossa, or upper arm insertion compared with forearm (hazard ratio [HR], 1.47 [95% confidence interval (CI), 1.28–1.68], 1.27 [95% CI, 1.08–1.49], and 1.25 [95% CI, 1.04–1.50], respectively); and for phlebitis, larger diameter PIVC (HR, 1.48 [95% CI, 1.08–2.03]). PIVCs inserted by the operating and radiology suite staff had lower occlusion risk than ward insertions (HR, 0.80 [95% CI, 0.67–0.94]). Modifiable risks for accidental removal included hand or antecubital fossa insertion compared with forearm (HR, 2.45 [95% CI, 1.93–3.10] and 1.65 [95% CI, 1.23–2.22], respectively), clinical staff insertion compared with intravenous service (HR, 1.69 [95% CI, 1.30–2.20]); and smaller PIVC diameter (HR, 1.29 [95% CI, 1.02–1.61]). Female sex was a nonmodifiable factor associated with an increased risk of both phlebitis (HR, 1.64 [95% CI, 1.28–2.09]) and occlusion (HR, 1.44 [95% CI, 1.30–1.61]).
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
There are some other gems in that study too - operating and radiology suite vs ward insertions, clinical staff vs IV service. A decent size study too. Lots of good information, thanks for sharing!
I wonder what contributes to the higher rate of accidental removal with small gauge catheters?
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
Now that I actually think about it more...it's probably because smaller gauges tend to come in shorter catheter lengths. Maybe??
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
Keith I had the same question. When Claire Rickard spoke at INS Phoenix she said the studies were showing the catheter with the longest dwell was a 20 in the forearm. That has puzzled me all along. I can see the 3/4" 24 gauge being difficult to stabilize, but my BD 22's are 1 inch and should be able to get a good vein purchase and stabilize well. I don't know.
Vein purchase issues are only identified in the current literature for deep brachial or basilic veins of the upper arm when located with US. Vein depth is the issue so this could apply to bariatric patients with a site in the forearm as well, although no studies have focused on those sites. No studies have focused on catheter length of 3/4 or 1 inch in veins of forearms. The overwhelming amount of evidence is showing that sites in the hands, wrist, and antecubital are very high risk of all-causes of complications and catheter failure though. 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