Is it OK?

A 65 y/o male, obese, with SOB and light chest pressure, came into ER just after midnight. After multiple attempts, the ER staffs were able to establish an IV access: a peripheral IV on the chest. Patient was transferred to Telemetry floor then went on to have a left heart cath in early AM. Pt was then D/C'd home the next day. It was uneventful hospitalization for the pt (except that 15 IV sticks in ER). My questions are:

1. Is it OK to have a PIV on the chest like that?

2. Is there any literature to discuss about this kink of PIV?

3. What kind of vein on the chest? Is it a collateral vein?

4. What should have been done differently? I did not know about the case until today, after the fact. I am a lone PICC RN in the hospital and also work in SameDay Service area, so, very busy. If the pt's nurse should have asked me to start an IV, I would have done it "conventionally" on the arm, using my US machine.

Thanks in advance.

No, it is not an acceptable

No, it is not an acceptable ROUTINE practice. However, I do recall that there is literature on the subject out there "Principles of I.V. Therapy" I believe is the title, cannot think of the author at the moment. These veins can be used according to the author, but NOT as a routine practice. As an I.V. therapist (and as an E.R. nurse) I have used these anterior collateral chest wall veins only as last resort (and AFTER reading the literature) on the following pts.: 1) Morbidly obese Pt with bilateral a.v. fistulas (L was functioning, R was not, but had significant edema in that arm) who was having an AMI. Central line placement was unsuccessful by E.R. doc and surgeon (HX of MULTIPLE Central lines and very short neck). 2) Trauma patient presenting as a bilateral traumatic upper extremity amputee with chest and hip trauma. 3)Pt in ARD (P.E. as provisional D.X.) with confirmed DVT's in BOTH upper extremities, requiring STAT CT scan. (Dye was manually injected).4) IV. drug abuser with severly sclerosed veins with septicemia and multiple abcesses. In 3 of these cases, ultrasound would not have helped. in case #4, ultrasound may have been beneficial, if at least to see if the sclerosing didn't extend into the deeper veins. In the first case, a PICC with jugular approach was attempted by IR w/o success. In the second case, the pt. expired d/t injuries rec'd. In the third case, a triple lumen was placed in the femoral vein after DX was confirmed. (which would not have helped with the CT scan as our hospital precludes using a triple lumen for CT scans, esp in groin as half-life of dye is too short and "picture" does not come out well at all). In the fourth case a central line was placed that night, and pt went AMA next day. According to the aforementioned reference, there IS an etiology behind "large" anterior accessory chest wall veins; usually as a compensatory mechanism d/t venous congestion (CHF, SVCS, to name a few). As you can see, the application is limited, not routine, and is viable for only a small pt population.

 

IV GUY

No, I do not think it is

No, I do not think it is acceptable practice. There is probably a pathological reason for distended veins of the chest. Usually this is some type of obstruction such as thrombosis. These sites can not be adequately stabilized. Also no outcome data to support the fact that this is or is not a safe practice. Having the availability of an infusion nurse specialist is paramount to meeting patient needs safely. As you said, the US machine would have allowed a much safer approach. It is the organizations responsibility for staffing to allow for correct practice. 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

kind of, sorry, typo.

kind of, sorry, typo.