I would like recommendations for Vascular access sites in urgent (not code) ER senerio for person that has:
a clotted upper arm fistula
a functioning fistula on the opposite side not accessed.
IJ not advised due to atherosclerotic veins.
possibly septic
unable to get labs in pedi tubes with finger stick. (no blood)
Has colateral veins at the auxilla/chest wall
No leg veins due depth caused by edema -cath would not reach.
Multiple leg stasis ulcers
no dialysis at hospital
Tiny Cephalics both arms.
I am looking for EBP for best access for ultrasound guided PIV to gain access for ER transport once stabilized. I have my thoughts but I want to see what other think.
You would need to do a literature search to get the published evidence. In my opinion, I would never use the lower extremities. I would never use the chest wall veins - there is a reason they are so visible and it usually means obstruction of some type. I would use the extremity with the clotted fistula and locate a vein with US preferably in the forearm or away from the fistual if possible. The other option is to assess the IJ with US and use it for short term infusion needs. The cephalic in the arm with the clotted fistula would work also, but you should start low and work upward in case you need more than one site to complete therapy. If this patient is a frequent flyer, it may be time to consider placement of an implanted port. Obviously, peripheral sites will not be available for repeated hospitalization 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
If you are in an emergent situation then you have to consider IO access. IO access is faster than obtaining IV access and is more then likely going to last for your transport compared the a small PIV access. The problem with placing PIV access in the same side as a fistula is that you have no idea where the occlusion is. Narrowing of the vessels in a renal patient is common and yoru IV may infiltrate in the process. This is really dependent on what drugs you are infusing. What is going to cause the least amount of delay to treat your patient and what drugs are required. EJ access may be an option I would do prior to a cephalic. I would also never use the legs or chest wall for there are no vessels there to allow you to maintain access. IF the renal patient has access peripherally with ultrasound you will find it in the fore arm or right above the AC. When they say the IJ is not ideal because of sclerotic vessels, how is the IJ more sclerotic then the sublcavian that they will eventually need access.
Jamie L Hamm RN, BSN, VA-BC
CEO
Vascular Access Plus
Possibly E J with U/S for transport ? Then definitive access in IR at the receiving center. Or a humeral I/O, as suggested.
Dave
David Bruce RN