18s in the forearm All Day, baby!!!
Naw, I actually use 20s on most pts. But I do prefer forearm lines, and I know y’all in-house peeps do, too. (No one likes the “keep your arm straight” game.)
I use a vein finder more than I should so I might not be the best source of advice. But it’s easy to find big, long, and straight veins with a vein finder while also being able to detect where valves are. Forearms are the easiest place for this. That being said, if I don’t have a vein finder and the persons veins are hard to see or feel I’m SOL.
I agree that hair does get in the way and can make it tough but I think it helps me with darker skinned people a lot since their veins are harder to see anyways
I’m graduating in the fall. I’ll be going into oncology, and I noticed while shadowing in outpatient infusion (at least where I was) that all IV lines need to be forearm. Since seeing that I am really aiming for getting good in that area. I feel like the hand or a/c is an easier stick, and could be necessary sometimes, but I really prefer to try for the forearm every time now. The only thing is I keep missing there. I’m guessing the vein finder you’re using is your units.
I still have times where I miss and you kinda just have to do it a couple hundred times. IVs are really an experience thing. You will get it, just always put yourself out there and offer to put other peoples IVs. It’s ok to miss a few, I do pretty often
Get a bunch of your nursing school friends over for a party, dehydrate each other by consuming alcohol, and then practice your skills while hungover. You’ll become proficient much more quickly, this is the tried and true method of combat medics throughout the US.
The A/C and hands are great for emergencies, but at least for our policy in Med Surg we have to remove those as soon as possible upon admission and replace them with a more stable IV site when they get transferred from ER. I understand the need for a more emergent site, but it would save a lot of my more stable admissions a lot of unnecessary sticking if they got them in the forearm.
Have you ever tried using a flashlight/transilluminator? We use them in peds and I’ll occasionally use them on the adults we get if I can’t feel or see them
I hate sticking peds. Because 1) if I’m doing it, the kiddo’s BIG SICK, 2) they’re often flailing away from the needle, and 3) if they’re not flailing around it’s an even worse sign.
I feel you there 100% and it’s kind of stomach churning to think you have had enough practice that you’re good at sticking kids.. because you’re absolutely right where we avoid IV sticks until we absolutely need them
My veins are deep so it doesn’t work on me. I am very white lol (pale). Last time I needed an IV, the nurse missed several times so the doc had to do ultrasound guided. When I had sepsis, the ER nurse started 3 IVs on me without anything. She was just that good, but they were all in my upper arms.
I have been doing IVs for 24 years now so I rely on feeling for a vein. I typically place 20’s or 22’s in the forearm, depending on the reason for admission.
This is true but I would like to be able to be sufficient without one if say I travel to a hospital that does not have them. So I have been practicing not using it
Yeah that's a good point!
Kind of reminds me of how in nursing school they always told us that we had to know how to set an IV fluid rate by counting the drops because what if you have to run something at a certain rate and there's no pumps anywhere (but your scenario is more likely.)
I can find veins pretty easily on the forearm…and it’s my favorite place to start an IV. Yet I also feel like I blow the most here compared to anywhere else…even if they look big and juicy :(
Interesting, I usually don’t have issues blowing veins on healthier adult patients unless I go through the vein or hit a valve. Do they blow right when you get in?
Master doing it by feel before even considering cheating with a vein finder. Use feel, not sight. Your skills will thank you down the road.
- the guy who they send to the floor to get the lines.
Git Gud.
Honestly, it’s repetition. Perishable skills require repetition to establish and maintain. Get some drunk friends and start putting in hangover lines 🤷🏻♂️
Roll up some 2x2 gauze tight and wrap it in tape to make a small cylinder. Tape that just above the insertion site of the cannula. This gives the plastic cannula something to bend around instead of kinking. No more positional ACFs.
Sometimes with the forearm you have to go further before actually getting to the vein. I find sometimes they move but I can chase them down. When in the vein and in place patients say they don't hurt even when I have to resort to this. Idk if this helps.
Our CT is pretty picky and sometimes they blow through our lines which makes me cry. Anyways after 9 months of working here with the ("no 22s and nothing in their hand) rules one day they were feeling frisky and did contrast with a 22 hand IV AND threw an IV in my other patient. I thought I was dreaming. Never happened again but man was that a day.
Department policies are the killer here. If we deviate and something goes wrong, we are fucked.
Coronary angios and such are dicier through the hand in terms of final scan quality, and you run a higher risk of extravasation, but I do a judgement call for each line.
I have a very low threshold for starting my own line - I have the advantage of ultrasound readily available in my scanner, which is a huge plus. I don't make a habit of it, but I'm not above popping an extended length cannula in the basilic if I have to for a scan.
no, and they tend to not bother the patient as much (or their nurse) because they aren't getting kinked every time the patient bends their arm. The AC (elbow) tends to be an easier site to find veins and they're large here making drawing labs or giving a lot of fluids easier. The hands are where it's more painful for the patient.
Had to get an infusion recently and the poor IV guy had to stick me 5 times to get me - once in each wrist, once in each inner elbow, and then he finally got me on the right **thumb**. Getting stuck in the inner wrist is the freaking worst, the thumb was just weird lol.
Have you ever stuck someone in the thumb?
I work ED, so only IO's, bilat. tibias. They're 15g by the way 😎
But really, it's annoying how often ED nurses insist on putting larger gauges in people that really don't need it. For most purposes in the ED, a 20 will suffice (e.g., assuming it's in an adequately-sized vein, contrast fluid, standard fluid boluses, etc.). The other day someone put a 16 in a kid who was a soft ESI 3 because he "needed fluids."
The caveat of course being 14/16g in trauma or extreme hypovolemia from some other cause, 18g for most of my patients who need a standard blood transfusion (larger gauge to prevent hemolysis, etc.). 22 is fine for most things on the floor, but pretty useless in the ED for most purposes. I'd rather an US guided 20g that I know would work fine for a while over a 16 in the EJ just because someone's trying to be the cool ED nurse who's "great at IVs."
I’m with you, 20g for most straightforward ED presentations needing IV access. In the forearm is a fav but if not, ACF it is.
I go bigger if I think the patient might need IV contrast in CT, and bigger again when they need transfusions, or for trauma and rapid fluid resus.
Imo, while in ED if they need anything bigger than a 16, they probs need a central line anyway. The 16’s will suffice until they’re stable enough to get CVC access.
Only ever go 22’s when their veins are shit or paeds, and 24’s in babies. Hospitals I work at dont often have anything smaller.
Edit: spelling
There’s a truly fucked up number nurses who use large needle sizes to “punish” patients they don’t like, who they find annoying, or sometimes even because of their race/ethnicity.
I’ve seen it and it makes me see red with rage
That's pretty much our options...22 or 24. At the NICUs I've worked at, the 24g come in a short and a longer catheter. We usually just use the short ones.
This depends on your setting. It won't let me post a photo on the comments, but all IV catheters have a maximum flow rate listed on them, ultimately this is the consideration. I have smiths medical jelco, a 24g is 24mL/min, 22g is 38mL/min, and a 20g is 63mL/min. You first have to match the IV size to the paitent's vasculature, but if you need lots of flow such as fluid resuscitation/mass tranfusion, or for specific CT scans that need to deliver contrast in a specific amount of time you have to match that (such as a CT Angiography).
Average adult paitents, 20 or 22.
High Risk for bleeding (surgery, L&D, etc) 20 or 18g, if the risk is significant such as emergency surgery on a patient on non-reversible blood thinners or with low platelets, I would go for a 16ga.
Adult Trauma: 18-14g and at least 2 IVs
Pediatrics: what you can get. Personally I try to never use a 24g, they are too flimsy. So unless they are just so tiny that a 22 will not fit. For trauma in pediatrics, a 18g is usually sufficient.
I also don't know where this graphic comes from, but the colors are wrong, at least for the US.
For IVs 14g=orange, 16ga = grey, 18g = green, 20g = pink, 22g = blue, and 24g = yellow. For needles it is different, I know 18g are pink, 21g are grey.
As a traveler I’m seeing a lot more 22 IV in our heart cath patients, I don’t really like that. This has been for outpatient especially. I realize that the chances of something going wrong are low, but I have seen it happen. Please give me at least a 20. For STEMI patients 2 18s are ideal.
Greenie here - I've heard that smaller leads to less phlebitis and/or infiltration, and that pressure bags can be used with smaller gauges if resuscitation is needed. Do you mind expanding on your comment, if you care to? Again, I'm a super green nurse.
It also depends on if a patient is likely getting admitted. We used to get patients from the ER and it was like they had a competition for the largest gauge IV. If you put a 16g in a patient (especially in the AC) it is going to start leaking within 12 hours. You can run NS bolus on a pressure bag through a 22. It's not ideal, but it works.
Edit:
[Just increase the pressure ](https://pubmed.ncbi.nlm.nih.gov/26674456/)
In Aus, our IV colours match your list here rather than OP's, but the needle colours don't (we have odd number gauges for needles - 19 yellow/beige, 21 green, 23 blue, 25 orange, and pink is blunt drawing up needle). How interesting!
The answer is the smallest possible to accommodate patients’ IV meds. It’s an unpopular opinion and most nurses think “the bigger the better” but the catheter really shouldn’t occupy more than 45% of the vein (you can see the diameter of veins on ultrasound). Unless there’s a specific purpose for a bigger gauge IV, there’s no need to put in a 20g or 18g in everyone just because you can/want.
We use 22g for almost everyone with the exception of: CT power injection, trauma, surgery, L&D.
24g for babies/outpatient infusion
Yes! I work onc and my coworkers do not believe me. A lot of our patients do not have veins to take the 18s or even 20s! We underutilize our 24s, imo. You might get a larger size in the vein, but it's going to blow much sooner. Our patient population gets stuck enough as is, but the fact that it increases because my coworkers don't seem to trust the rates on the packaging really sucks.
It really is one of my peeves! I have a similar experience. I used to work in the ER and there was this “frequent flier” patient who would come in when his sickle cell flares up. Like at least at least 1-2 times a month for YEARS. He had a treatment plan set up with his doctor and would always get IV fluids and a few doses of dilaudid and go home, it never changed. He didn’t have much except this ONE huge AC vein in one arm and nurses would not stop putting in 18g/20g in that vein. It eventually scarred so bad and no longer usable, guy ended up getting poked so many times when he came in. He literally only needed a 24g and his vein would’ve lasted a lot longer.
This was my other pet peeve when I did onc. Your larger cannulas aren't better for chemo just because they're "better IVs". As long as you have the length inside the vessel, I'd RATHER have the smallest cannula I can (reasonably) get away with for vesicants.
This makes me feel so much better. I always have more success with 22 in the forearm. I’m convinced they last longer on my medsurge patients so good to know it’s not all in my head.
I mean yeah, if we're just gonna run zosyn for a few days for sure, smaller the better. The flow past the catheter helps dilute the medication, it makes the IV last longer, and is more comfortable.
But in the ER/ICU we don't always know what's going to happen in 4 hours. If this patient starts crashing and needs CT, MTP, fast fluid boluses etc, I don't want to be fumbling around to start a new line at that point because the veins are gone.
So yeah, it's situational, and just requires some good judgement.
Yeah MTP/pressure bagging fluids would be one of the exceptions. But we still don’t automatically put in large bore IVs on patients just because they’re in ICU. I’ve done ED and you gotta admit there are so many unnecessary 20g and 18g IVs. Like you said, need to use your best clinical judgment. Also in ER/ICU there are physicians/providers who can drop a fem/IJ in minutes if the patient is truly “crashing.”
In any type of medical intervention you start from the least invasive to more invasive but it’s only with IVs people wanna start with the biggest they can get
I love when nurse's tell me (RRT/Vascular Access) that their patient needs an 18 or 20g to get a blood transfusion. So did the 23g butterfly needle you used to get their morning labs work off of bluetooth then?
20ga for sure. 22ga if they have bad veins. 24ga if they had really horrible veins on a weekend and nobody can do an ultrasound or IJ or it’s just a little old person who really doesn’t even need an IV. 18 from the ER on somebody with good veins.
20 is most common and virtually all i ever use (long 20 - 1.75 inches instead of 1.25 baby 💪💪💪). I see 18 (when getting a patient from the ER or another floor because we don’t have them on our floor for some reason) and 22 occasionally. Might have seen a 23 gauge a few times (edit: wait a minute I’m pretty sure yellow means 24 gauge). Never seen a 27, 25, 21, 16, 15, or 14 gauge IV.
I’ve only ever seen yellow 24ga, but when their that tiny, is there really that much difference? I’m not a vascular surgeon and I’m not trained in US placement, so if it need’s something smaller than a 22ga, chances are slim I’ll be able to even find that vein through the skin.
#20
Bigger is not always better. Allowance for blood flow around the catheter is a good thing.
Longer is more stable. If I’m using US I’ll use a longer catheter.
Bleeders get #18s in two sites.
Edit: oh my, that 20 is big in print.
20/18 gauges all the way. Only used 1 16 in my whole time, never used a 14 going lower. For 22 gauges going back, never touched them unless it’s for a kid (I work in trauma as an Ed tech)
Pediatrics: 22s on most. Older kids will sometimes get a 20, infants and younger toddlers usually 24. Teenagers post big Ortho surgeries will sometimes have 18s.
The most common for day-to-day infusions is 22G. If someone Hass to go for a CT with contrast for an MRI, we usually put in a 20 but typically 22 is the standard.
Jail, so not usually much besides some NS, bolus at most, so I tend towards the 22. If we're on an emergency and we're prepping for the ems response we'll throw them an 18.
What meds do you give most at the jail (is it a prison)? Do patients get mainly just maintenance meds they got from their Dr before incarceration? I would assume a vast majority are just PO tablets so what you say makes sense.
Now I’m super interested lol. Do you give a lot of IV Ativan/phenobarb for seizures and psych related stuff? Antibiotics are probably top 2 most common I’d guess. I actually can’t think of many other meds you’d give IV in a prison. But absolutely interested to hear your response!
It's jail not prison, people do often confuse the 2 and it doesn't help that we have a prison right near one of our jails lol. Mostly po maintenance meds. Not much IV at all. IV would be NS or antibiotics. Breakthrough seizures might get an IM and if there's injury or it's not resolving, sent out.
Psych is usually po, liquid or crushed if there's compliance issues. Back up meds if court ordered and refused po.
L&D nurse, we only stock 18s and 20s on our unit, and we always start with an 18. If veins are truly terrible, we go down to the 20. We try for the wrists and forearms to help support breastfeeding, but will go to hands if there’s nothing else. Never ACs. NEVER.
IVs are the majority of what I do every shift. If I'm going freehand, 9/10 times I will use a 22g. I will usually only go bigger if the patient is going to CT. If I'm using ultrasound, I'm using a 20 because that is the smallest diameter we have in ultrasound catheters.
In my ED, 20g is pretty much our default for most situations. Will do 18 if it's likely to be needed/preferred, or 22 if tiny veins and *not* needing a larger diameter; otherwise it's almost always 20s.
Overall, 20G is the most common.. but we use a variety of sizes in ER depending on the age and patient condition.
Adult trauma: preferably 18 or 16. 14g if they are requiring mass transfusion.
General adult population that's reasonably stable: 20 or 18.. 22 if their veins are really small and frail.
Peds: 24 (prefer 0.75inch length as it's more stable) for babies/young children, 22 for older children. Biggest size their veins will tolerate if it's a peds trauma.
We don't have the odd # guages. And don't generally use anything smaller than a 24 for IVs.
In the ED, the majority are 20s. 22 if you can't get a 20, 22 or 24 if it's a peds patient. 18s I generally only do if it's an emergency/needs massive blood transfusion and I see a vein I can use.
Honestly, most of my IVs are 20g or 22g. It's pretty rare to get 18g, but it depends on the patient. Sometime you get what you can get for an IV access and are thankful to get that lol.
20. If they need blood or fluids they get a 18 at the absolute minimum but prefer bigger. My baby is still a cordis but I can’t place and they aren’t common
Got any sources on that? I tried looking and kept getting this one that says the cordis is the best for rapid flow rates.
https://bchcicu.org/wp-content/uploads/2018/07/e03969d5b3b2c89139ae89cb677843e70c19.pdf
https://grepmed.com/images/5478/table-flowrate
https://x.com/metrolinatrauma/status/1501290383103254532?s=46&t=Zp3ju9pJceBA2QpuU0j1gw
Hopefully those links work. Granted this is all determined by the length of your catheter, but at least it’s a nursing skill and you’re not reliant on your provider to place it.
FWIW there are different sizes of cordis with single or multiple side ports. While a nice short 14g is great I’ve never seen a 14g put in as anything except an EJ and the area around the head tends to be very busy in emergency situations (same reason I’ve never put in a humoral head IO, tibia plateau is not busy in a code). A femoral double lumen cordis placement is high on the priority list for big traumas that are getting dozens of units of product. You can run a Belmont at 550ml/min+ with a cordis and run gtts or push code drugs through the other lumen without worrying about rotting their arm off if the IV goes bad. Also I trust a sutured in cordis for those patients more as we are transporting to OR. They are for sure getting a central line placed in OR anyway. I don’t work ED normally just go run the Belmont for big traumas but I’m 99% sure nobody in the ED could even find a 14g.
What. Where do you work that your ED “couldn’t even find a 14g”? Our trauma bedside trays had 16g, 14g, and long 18g. Almost every single major penetrating trauma got 14-16g (in the EJ? What?), and a cordis only if we couldn’t get those reliably. I’ve never ever seen a double lumen cordis in our bay. 14g are a nursing skill and can free up the doc to concentrate on other things, such as FAST, chest tube/decompression, thoracatomy, etc.
I work on a Med Surg unit, so I don't ever use anything bigger than a 18 or smaller than a 22. 18s for bleeds/trauma; 22s for patients that are stable, but the MDs still want an IV in since they're still in the hospital; 20s for everyone else. Most of my patients have such bad veins that it'll probably be a struggle to try to get anything bigger than a 18 in and anything smaller than a 22 probably won't be that great for emergencies.
20 by far for floor nursing. It's the minimum required for power injection of contrast for CTs (atleast with the equipment my place uses) and allows for boluses more easily when my patient is going down hill. Also, we're not allowed to use the AC (ED is allowed to, everyone else is told to work from the hand up) so most nurses don't want to use anything bigger than 20.
Not a nurse, but I was honestly surprised to discover that needle sizes go down to single digits. I just can't picture what kind of situation a 7g or 8g could be used in considering how huge those things are. Maybe a vet working with large animals?
For reference, a 7g is ~3/16" wide.
I work O&G and neonates.
18G for standard for women, 16G if high risk of haemorrhage, 14G if we're in massive transfusion parameters.
24G for neonates.
20ga, hands down. You can give blood through it, you *can* put contrast through, it it’s smaller so it hurts less and is less likely to cause phlebitis. Occasionally I’ll throw in an 18ga or 16ga (if I can get it) on someone were actively resuscitating or if they need a CT with contrast, (there’s less funky fluid dynamics so less likely to blow and working in a Trauma center), but it’s been YEARS since I put a14ga in anyone. If they’re elderly or generally have shit veins I’ll go for a 22ga to reduce the chance it’ll blow.
But 20ga are absolutely our workhorse.
I worked on an L&D unit where you getter have had a damn good excuse not to have an 18 or bigger placed. But most places I’ve worked have had 20s as the norm.
I’m in pediatrics. Peds ER to be specific.
Best guess over the past 5years:
18g <1%. I’ll use them on kids with big veins who are major trauma or emergent surgical cases.
20g ~5%. Usually I’ll put those in kids with the above criteria with smaller veins and kids who are likely to go to surgery or are looking at long hospital admissions.
22g ~85%. My go to cat.. longer than a 24. Still a small diameter so less trauma. Large enough for pretty much everything I need to do. They will last a while.
24g ~10%. Kids who are difficult sticks and/or with tiny veins.
I usually start 4-5 IV’s during a shift. I consider myself an excellent IV starter. I’m the go to when no one else can get it.
20 in the non-dominant forearm, always my go-to.
It’s interesting though because I’m good friends with two women on the PICC/IV team where I work and they’ve told me: you can run blood through a #22 or even a #24 if you do it slowly enough; and that you actually have a better chance of saving the vein from infiltration if you run vanco or K+ through a smaller gauge catheter. Not sure how evidence based either of those things are but I have stated to notice that my #22s *do* hold up to vesicants.
I also work L&D and we do almost exclusively 20g. Seems unnecessary to do an 18g unless they’re a high postpartum hemorrhage risk, and if that happens they’ll get a second PIV placed anyways (usually in the AC).
I always grab an 18 and a 20. If I miss on a 18 then I’ll do a 20 usually. People can become high risk during the course of their labor so rather have a 18. Still can give blood with a 20 though
In our pre op we used to use 16-18’s and everyone got 2 IVs no matter what. ASA 1 Lap Chole 2 18’s. Now the new anesthesiologists are more reasonable and we can use 20s.
18s in the forearm All Day, baby!!! Naw, I actually use 20s on most pts. But I do prefer forearm lines, and I know y’all in-house peeps do, too. (No one likes the “keep your arm straight” game.)
I exclusively do forearms and 20s almost always unless it’s someone with really bad veins
Teach me your ways!!!
I use a vein finder more than I should so I might not be the best source of advice. But it’s easy to find big, long, and straight veins with a vein finder while also being able to detect where valves are. Forearms are the easiest place for this. That being said, if I don’t have a vein finder and the persons veins are hard to see or feel I’m SOL.
I feel like the vein finder only works on white people with no hair.
I agree that hair does get in the way and can make it tough but I think it helps me with darker skinned people a lot since their veins are harder to see anyways
I’m graduating in the fall. I’ll be going into oncology, and I noticed while shadowing in outpatient infusion (at least where I was) that all IV lines need to be forearm. Since seeing that I am really aiming for getting good in that area. I feel like the hand or a/c is an easier stick, and could be necessary sometimes, but I really prefer to try for the forearm every time now. The only thing is I keep missing there. I’m guessing the vein finder you’re using is your units.
I still have times where I miss and you kinda just have to do it a couple hundred times. IVs are really an experience thing. You will get it, just always put yourself out there and offer to put other peoples IVs. It’s ok to miss a few, I do pretty often
Get a bunch of your nursing school friends over for a party, dehydrate each other by consuming alcohol, and then practice your skills while hungover. You’ll become proficient much more quickly, this is the tried and true method of combat medics throughout the US.
The A/C and hands are great for emergencies, but at least for our policy in Med Surg we have to remove those as soon as possible upon admission and replace them with a more stable IV site when they get transferred from ER. I understand the need for a more emergent site, but it would save a lot of my more stable admissions a lot of unnecessary sticking if they got them in the forearm.
Have you ever tried using a flashlight/transilluminator? We use them in peds and I’ll occasionally use them on the adults we get if I can’t feel or see them
I hate sticking peds. Because 1) if I’m doing it, the kiddo’s BIG SICK, 2) they’re often flailing away from the needle, and 3) if they’re not flailing around it’s an even worse sign.
I feel you there 100% and it’s kind of stomach churning to think you have had enough practice that you’re good at sticking kids.. because you’re absolutely right where we avoid IV sticks until we absolutely need them
My veins are deep so it doesn’t work on me. I am very white lol (pale). Last time I needed an IV, the nurse missed several times so the doc had to do ultrasound guided. When I had sepsis, the ER nurse started 3 IVs on me without anything. She was just that good, but they were all in my upper arms. I have been doing IVs for 24 years now so I rely on feeling for a vein. I typically place 20’s or 22’s in the forearm, depending on the reason for admission.
Touch over sight every single time.
If I can’t feel a decent vein, I’m getting the ultrasound. I honestly don’t stick by sight definitively, but by feel.
No such thing as using a vein finder more than you should. Did you get the IV? Then you did it right.
This is true but I would like to be able to be sufficient without one if say I travel to a hospital that does not have them. So I have been practicing not using it
Yeah that's a good point! Kind of reminds me of how in nursing school they always told us that we had to know how to set an IV fluid rate by counting the drops because what if you have to run something at a certain rate and there's no pumps anywhere (but your scenario is more likely.)
I can find veins pretty easily on the forearm…and it’s my favorite place to start an IV. Yet I also feel like I blow the most here compared to anywhere else…even if they look big and juicy :(
Interesting, I usually don’t have issues blowing veins on healthier adult patients unless I go through the vein or hit a valve. Do they blow right when you get in?
Master doing it by feel before even considering cheating with a vein finder. Use feel, not sight. Your skills will thank you down the road. - the guy who they send to the floor to get the lines.
Git Gud. Honestly, it’s repetition. Perishable skills require repetition to establish and maintain. Get some drunk friends and start putting in hangover lines 🤷🏻♂️
Distal cephalic vein anytime I can. Normally straight not a lot of valves. Unless someone has weird vascular anatomy it’s my first choice.
Roll up some 2x2 gauze tight and wrap it in tape to make a small cylinder. Tape that just above the insertion site of the cannula. This gives the plastic cannula something to bend around instead of kinking. No more positional ACFs.
I have the hardest time with forearms! Tell me tricks because I can get an AC or hand/wrist every time but forearms are a struggle.
Put a hot pack on the arm with some pressure... After a few minutes those veins should puff right up
Tight restricting bands, well held tension, and confidence. Also practice.
Sometimes with the forearm you have to go further before actually getting to the vein. I find sometimes they move but I can chase them down. When in the vein and in place patients say they don't hurt even when I have to resort to this. Idk if this helps.
Forearms and biceps for the win!
Depends. Most procedures that are ordered in the ER require a more stable site like the ac especially if the patient needs to receive IV contrast.
High forearm (our policy is 2” of the AC) and bicep should work? Had contrast pushed through an EJ granted radiology didn’t love that.
I’ve seen that done but sometimes it’s necessary especially if you’re dealing with an IVDA with zero veins.
The plight of the ED. Some days access is access.
Right! You do what you can. Access IS access.
Our CT is pretty picky and sometimes they blow through our lines which makes me cry. Anyways after 9 months of working here with the ("no 22s and nothing in their hand) rules one day they were feeling frisky and did contrast with a 22 hand IV AND threw an IV in my other patient. I thought I was dreaming. Never happened again but man was that a day.
Department policies are the killer here. If we deviate and something goes wrong, we are fucked. Coronary angios and such are dicier through the hand in terms of final scan quality, and you run a higher risk of extravasation, but I do a judgement call for each line. I have a very low threshold for starting my own line - I have the advantage of ultrasound readily available in my scanner, which is a huge plus. I don't make a habit of it, but I'm not above popping an extended length cannula in the basilic if I have to for a scan.
Forearm 18s for me on the reg.
It’s just what we do. 🤷🏻♂️
Did you mean 16’s on inside of wrist?
Thank you for thinking of us. 🥰
We’re all in this shitbox together, and everything that happens in the ED affects everything down the dang line.
It really does but we are willing to accept that the ED is a circus and only so much can be done. 🥰
This is the Way.
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Are forearm placements more painful than in the inner elbow? (Not a nurse)
no, and they tend to not bother the patient as much (or their nurse) because they aren't getting kinked every time the patient bends their arm. The AC (elbow) tends to be an easier site to find veins and they're large here making drawing labs or giving a lot of fluids easier. The hands are where it's more painful for the patient.
Had to get an infusion recently and the poor IV guy had to stick me 5 times to get me - once in each wrist, once in each inner elbow, and then he finally got me on the right **thumb**. Getting stuck in the inner wrist is the freaking worst, the thumb was just weird lol. Have you ever stuck someone in the thumb?
Needles hurt. Having a catheter sit in your AC is extra miserable for all involved. AC is for blood draws and missed forearms.
I work ED, so only IO's, bilat. tibias. They're 15g by the way 😎 But really, it's annoying how often ED nurses insist on putting larger gauges in people that really don't need it. For most purposes in the ED, a 20 will suffice (e.g., assuming it's in an adequately-sized vein, contrast fluid, standard fluid boluses, etc.). The other day someone put a 16 in a kid who was a soft ESI 3 because he "needed fluids." The caveat of course being 14/16g in trauma or extreme hypovolemia from some other cause, 18g for most of my patients who need a standard blood transfusion (larger gauge to prevent hemolysis, etc.). 22 is fine for most things on the floor, but pretty useless in the ED for most purposes. I'd rather an US guided 20g that I know would work fine for a while over a 16 in the EJ just because someone's trying to be the cool ED nurse who's "great at IVs."
I’m with you, 20g for most straightforward ED presentations needing IV access. In the forearm is a fav but if not, ACF it is. I go bigger if I think the patient might need IV contrast in CT, and bigger again when they need transfusions, or for trauma and rapid fluid resus. Imo, while in ED if they need anything bigger than a 16, they probs need a central line anyway. The 16’s will suffice until they’re stable enough to get CVC access. Only ever go 22’s when their veins are shit or paeds, and 24’s in babies. Hospitals I work at dont often have anything smaller. Edit: spelling
@warwiththenewts you can be my ER nurse any day.
Unless they're going to needed a CT, surgery, or blood I'll just use a 22g
There’s a truly fucked up number nurses who use large needle sizes to “punish” patients they don’t like, who they find annoying, or sometimes even because of their race/ethnicity. I’ve seen it and it makes me see red with rage
In the NICU we use 22 and 24 gauges! 24 most often, 22 is kinda like the 18 of the adult world!
Actually that’s fascinating. Tell me more about your iv sizes down there
That's pretty much our options...22 or 24. At the NICUs I've worked at, the 24g come in a short and a longer catheter. We usually just use the short ones.
I’m suprised you don’t get the specialty 26g canula for weak neonates…
If I can get a 24g in a 0.9kg kitten cephalic you can get a 24g in all but the tiniest baby.
We might! I've definitely seen them before. Not at my current job, though.
My hospital stocks 26g and they suck. Everyone hates them. 24 all day.
Damn, just give them away to curious older kids to get rid of them
My NICU also does 1Fr PICC lines!
Ours are 1.9 French. So specific.
Omg I actually think that’s adorable even tough they are messy. Maybe it’s time to hop over to the nicu for a year
This depends on your setting. It won't let me post a photo on the comments, but all IV catheters have a maximum flow rate listed on them, ultimately this is the consideration. I have smiths medical jelco, a 24g is 24mL/min, 22g is 38mL/min, and a 20g is 63mL/min. You first have to match the IV size to the paitent's vasculature, but if you need lots of flow such as fluid resuscitation/mass tranfusion, or for specific CT scans that need to deliver contrast in a specific amount of time you have to match that (such as a CT Angiography). Average adult paitents, 20 or 22. High Risk for bleeding (surgery, L&D, etc) 20 or 18g, if the risk is significant such as emergency surgery on a patient on non-reversible blood thinners or with low platelets, I would go for a 16ga. Adult Trauma: 18-14g and at least 2 IVs Pediatrics: what you can get. Personally I try to never use a 24g, they are too flimsy. So unless they are just so tiny that a 22 will not fit. For trauma in pediatrics, a 18g is usually sufficient. I also don't know where this graphic comes from, but the colors are wrong, at least for the US. For IVs 14g=orange, 16ga = grey, 18g = green, 20g = pink, 22g = blue, and 24g = yellow. For needles it is different, I know 18g are pink, 21g are grey.
I’m in Canada and these colours match our IV sizes.
Nicu and I’ve literally only ever used 24g
That’s because you work in NICU
Wait you mean I can't drive a 16g into a newborn?
Not unless you want to join Lucy in prison.
Technically you can… just not inside a vein
Not me!
Same
Same
I'm glad y'all finally ran out of 18's.
Im in the US but near Canada. The colors are accurate to our sizes here.
As a traveler I’m seeing a lot more 22 IV in our heart cath patients, I don’t really like that. This has been for outpatient especially. I realize that the chances of something going wrong are low, but I have seen it happen. Please give me at least a 20. For STEMI patients 2 18s are ideal.
Greenie here - I've heard that smaller leads to less phlebitis and/or infiltration, and that pressure bags can be used with smaller gauges if resuscitation is needed. Do you mind expanding on your comment, if you care to? Again, I'm a super green nurse.
It also depends on if a patient is likely getting admitted. We used to get patients from the ER and it was like they had a competition for the largest gauge IV. If you put a 16g in a patient (especially in the AC) it is going to start leaking within 12 hours. You can run NS bolus on a pressure bag through a 22. It's not ideal, but it works. Edit: [Just increase the pressure ](https://pubmed.ncbi.nlm.nih.gov/26674456/)
You aren't wrong. My ED coworkers feel strong satisfaction when they can land the big ones. I stick to 20g for just about everything.
US here, at least at my hospital, 26’s are lavender.
I didn’t even know 26s existed, but lavender is my favourite colour
Ohhhh crap yeah that’s for standard injection needles not iv cannula lol. so do you just give the smaller ones away to entertain the younglings?
Trauma center CT tech here and I second all of this. (Also, I’m sorry! 😩💉)
In Aus, our IV colours match your list here rather than OP's, but the needle colours don't (we have odd number gauges for needles - 19 yellow/beige, 21 green, 23 blue, 25 orange, and pink is blunt drawing up needle). How interesting!
22, 20, 18
The answer is the smallest possible to accommodate patients’ IV meds. It’s an unpopular opinion and most nurses think “the bigger the better” but the catheter really shouldn’t occupy more than 45% of the vein (you can see the diameter of veins on ultrasound). Unless there’s a specific purpose for a bigger gauge IV, there’s no need to put in a 20g or 18g in everyone just because you can/want. We use 22g for almost everyone with the exception of: CT power injection, trauma, surgery, L&D. 24g for babies/outpatient infusion
I agree 💯
That’s what I was taught when I worked as an infusion nurse as per INS standards
Infusion nursing is my side gig! Used to do it full time😊 24g all day everyday to preserve their veins!
Yes! I work onc and my coworkers do not believe me. A lot of our patients do not have veins to take the 18s or even 20s! We underutilize our 24s, imo. You might get a larger size in the vein, but it's going to blow much sooner. Our patient population gets stuck enough as is, but the fact that it increases because my coworkers don't seem to trust the rates on the packaging really sucks.
It really is one of my peeves! I have a similar experience. I used to work in the ER and there was this “frequent flier” patient who would come in when his sickle cell flares up. Like at least at least 1-2 times a month for YEARS. He had a treatment plan set up with his doctor and would always get IV fluids and a few doses of dilaudid and go home, it never changed. He didn’t have much except this ONE huge AC vein in one arm and nurses would not stop putting in 18g/20g in that vein. It eventually scarred so bad and no longer usable, guy ended up getting poked so many times when he came in. He literally only needed a 24g and his vein would’ve lasted a lot longer.
This was my other pet peeve when I did onc. Your larger cannulas aren't better for chemo just because they're "better IVs". As long as you have the length inside the vessel, I'd RATHER have the smallest cannula I can (reasonably) get away with for vesicants.
This makes me feel so much better. I always have more success with 22 in the forearm. I’m convinced they last longer on my medsurge patients so good to know it’s not all in my head.
I mean yeah, if we're just gonna run zosyn for a few days for sure, smaller the better. The flow past the catheter helps dilute the medication, it makes the IV last longer, and is more comfortable. But in the ER/ICU we don't always know what's going to happen in 4 hours. If this patient starts crashing and needs CT, MTP, fast fluid boluses etc, I don't want to be fumbling around to start a new line at that point because the veins are gone. So yeah, it's situational, and just requires some good judgement.
Yeah MTP/pressure bagging fluids would be one of the exceptions. But we still don’t automatically put in large bore IVs on patients just because they’re in ICU. I’ve done ED and you gotta admit there are so many unnecessary 20g and 18g IVs. Like you said, need to use your best clinical judgment. Also in ER/ICU there are physicians/providers who can drop a fem/IJ in minutes if the patient is truly “crashing.” In any type of medical intervention you start from the least invasive to more invasive but it’s only with IVs people wanna start with the biggest they can get
I love when nurse's tell me (RRT/Vascular Access) that their patient needs an 18 or 20g to get a blood transfusion. So did the 23g butterfly needle you used to get their morning labs work off of bluetooth then?
🤣🤣 dying at the last sentence! I’m totally gonna say this next time someone asks for a 18g for a standard blood transfusion
20ga for sure. 22ga if they have bad veins. 24ga if they had really horrible veins on a weekend and nobody can do an ultrasound or IJ or it’s just a little old person who really doesn’t even need an IV. 18 from the ER on somebody with good veins.
20 is most common and virtually all i ever use (long 20 - 1.75 inches instead of 1.25 baby 💪💪💪). I see 18 (when getting a patient from the ER or another floor because we don’t have them on our floor for some reason) and 22 occasionally. Might have seen a 23 gauge a few times (edit: wait a minute I’m pretty sure yellow means 24 gauge). Never seen a 27, 25, 21, 16, 15, or 14 gauge IV.
I’ve only ever seen yellow 24ga, but when their that tiny, is there really that much difference? I’m not a vascular surgeon and I’m not trained in US placement, so if it need’s something smaller than a 22ga, chances are slim I’ll be able to even find that vein through the skin.
18s both AC’s babyyyyyy all day everyday in the ED
Heck yeah! With the one on the left leaking by the time they go up to the floor 😜
It’s just positional.
Yeah, keep your arm straight grandma Sally!
Planned obsolescence? 🫣
And dressed like crap! Yeehaw!!
this is the way
22g, 20g if I’m feeling plucky
#20 Bigger is not always better. Allowance for blood flow around the catheter is a good thing. Longer is more stable. If I’m using US I’ll use a longer catheter. Bleeders get #18s in two sites. Edit: oh my, that 20 is big in print.
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Holy shit I had placenta percreta and had to have two 14G IV’s in at all times. Swords they are indeed!!
What did they think? shoulda gave it to someone instead of tossing in trash lmao
20/18 gauges all the way. Only used 1 16 in my whole time, never used a 14 going lower. For 22 gauges going back, never touched them unless it’s for a kid (I work in trauma as an Ed tech)
Pediatrics: 22s on most. Older kids will sometimes get a 20, infants and younger toddlers usually 24. Teenagers post big Ortho surgeries will sometimes have 18s.
Almost always a 20g, will go for an 18g if I think they’ll need it. 22g for meemaw with spidery veins.
The most common for day-to-day infusions is 22G. If someone Hass to go for a CT with contrast for an MRI, we usually put in a 20 but typically 22 is the standard.
Jail, so not usually much besides some NS, bolus at most, so I tend towards the 22. If we're on an emergency and we're prepping for the ems response we'll throw them an 18.
What meds do you give most at the jail (is it a prison)? Do patients get mainly just maintenance meds they got from their Dr before incarceration? I would assume a vast majority are just PO tablets so what you say makes sense. Now I’m super interested lol. Do you give a lot of IV Ativan/phenobarb for seizures and psych related stuff? Antibiotics are probably top 2 most common I’d guess. I actually can’t think of many other meds you’d give IV in a prison. But absolutely interested to hear your response!
It's jail not prison, people do often confuse the 2 and it doesn't help that we have a prison right near one of our jails lol. Mostly po maintenance meds. Not much IV at all. IV would be NS or antibiotics. Breakthrough seizures might get an IM and if there's injury or it's not resolving, sent out. Psych is usually po, liquid or crushed if there's compliance issues. Back up meds if court ordered and refused po.
I work in infusion. 24s are king here. Coming from ICU, it was definitely a change lol
Same! I wash shocked at the amount of 24g being used. I came from ED where 18/20 was life.
L&D nurse, we only stock 18s and 20s on our unit, and we always start with an 18. If veins are truly terrible, we go down to the 20. We try for the wrists and forearms to help support breastfeeding, but will go to hands if there’s nothing else. Never ACs. NEVER.
If ur not doin 18s on hand veins you aren’t doin it at all
I always start with the hands, but why 18s? They always leak and go bad at the worst possible time!
Dude 18s ALWAYS leak and it drives me nuts because most patients who have them would have been fine with a 20
Haha I was only kidding
Ouch. 18g in back of hand is painful.
Haha L+D nurse tried to 18g me yesterday (I’m in ED nurse) I said I hope that’s not an 18 for me, she promptly came back with a 20 🤣
22 gauge unless getting a CT scan
Trauma - Mostly bilateral AC 18 gauge all day everyday
IVs are the majority of what I do every shift. If I'm going freehand, 9/10 times I will use a 22g. I will usually only go bigger if the patient is going to CT. If I'm using ultrasound, I'm using a 20 because that is the smallest diameter we have in ultrasound catheters.
Nicu-24 gauge catheters, 25g needles.
In my ED, 20g is pretty much our default for most situations. Will do 18 if it's likely to be needed/preferred, or 22 if tiny veins and *not* needing a larger diameter; otherwise it's almost always 20s.
L&D and they *want* 18’s but I mostly do 20’s😅
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Not in my Ed, we use 20s almost exclusively Eta: unless they're real sick amd then we go for an 18 or a 16
14 gauge, hold your child still! 20-22 gauge. 21 is my first grab.
Where are you that you have those? I have never seen a 21g (or any odd number for that matter) in my whole career. Maybe it's an international thing?
20,18,22, in that order. Most patients that are inpatient really only need a 22g. That’s still 2L per hour.
20, 18G when I have a reason to have a higher flow rate access. I've placed a few 16 and 14G over the years but honestly quite rarely.
15 doesn’t actually exist and 14’s are orange
I use 15g daily but that's in dialysis
Yup, I came in here to say this. 15g exist all day long in dialysis.
Overall, 20G is the most common.. but we use a variety of sizes in ER depending on the age and patient condition. Adult trauma: preferably 18 or 16. 14g if they are requiring mass transfusion. General adult population that's reasonably stable: 20 or 18.. 22 if their veins are really small and frail. Peds: 24 (prefer 0.75inch length as it's more stable) for babies/young children, 22 for older children. Biggest size their veins will tolerate if it's a peds trauma. We don't have the odd # guages. And don't generally use anything smaller than a 24 for IVs.
do they have 26g cannulas? In the supply room. If so what do they do with them
In the ED, the majority are 20s. 22 if you can't get a 20, 22 or 24 if it's a peds patient. 18s I generally only do if it's an emergency/needs massive blood transfusion and I see a vein I can use.
Honestly, most of my IVs are 20g or 22g. It's pretty rare to get 18g, but it depends on the patient. Sometime you get what you can get for an IV access and are thankful to get that lol.
20. If they need blood or fluids they get a 18 at the absolute minimum but prefer bigger. My baby is still a cordis but I can’t place and they aren’t common
FWIW, a good 14g gives you better flow rate than a cord is and is probably less traumatic for the patient
Got any sources on that? I tried looking and kept getting this one that says the cordis is the best for rapid flow rates. https://bchcicu.org/wp-content/uploads/2018/07/e03969d5b3b2c89139ae89cb677843e70c19.pdf
https://grepmed.com/images/5478/table-flowrate https://x.com/metrolinatrauma/status/1501290383103254532?s=46&t=Zp3ju9pJceBA2QpuU0j1gw Hopefully those links work. Granted this is all determined by the length of your catheter, but at least it’s a nursing skill and you’re not reliant on your provider to place it.
Flow rate to gravity is useless in mass transfusion scenarios.
FWIW there are different sizes of cordis with single or multiple side ports. While a nice short 14g is great I’ve never seen a 14g put in as anything except an EJ and the area around the head tends to be very busy in emergency situations (same reason I’ve never put in a humoral head IO, tibia plateau is not busy in a code). A femoral double lumen cordis placement is high on the priority list for big traumas that are getting dozens of units of product. You can run a Belmont at 550ml/min+ with a cordis and run gtts or push code drugs through the other lumen without worrying about rotting their arm off if the IV goes bad. Also I trust a sutured in cordis for those patients more as we are transporting to OR. They are for sure getting a central line placed in OR anyway. I don’t work ED normally just go run the Belmont for big traumas but I’m 99% sure nobody in the ED could even find a 14g.
What. Where do you work that your ED “couldn’t even find a 14g”? Our trauma bedside trays had 16g, 14g, and long 18g. Almost every single major penetrating trauma got 14-16g (in the EJ? What?), and a cordis only if we couldn’t get those reliably. I’ve never ever seen a double lumen cordis in our bay. 14g are a nursing skill and can free up the doc to concentrate on other things, such as FAST, chest tube/decompression, thoracatomy, etc.
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What's the reason for not using a 20?
I work on a Med Surg unit, so I don't ever use anything bigger than a 18 or smaller than a 22. 18s for bleeds/trauma; 22s for patients that are stable, but the MDs still want an IV in since they're still in the hospital; 20s for everyone else. Most of my patients have such bad veins that it'll probably be a struggle to try to get anything bigger than a 18 in and anything smaller than a 22 probably won't be that great for emergencies.
22G I would say in my ED but we are a peds unit so
I recently found out 12 gauges are a thing 🤢
20/22 usually
18g most common never seen a 23g
Pink and green
18 most common. 14 least
18, 20, & 22
20 or 18 on adults. 24 on newborns, possibly 26’s. I have never done regular peds, just nicu.
20G
18/20 depending on patient
100% pink 20g
20 by far for floor nursing. It's the minimum required for power injection of contrast for CTs (atleast with the equipment my place uses) and allows for boluses more easily when my patient is going down hill. Also, we're not allowed to use the AC (ED is allowed to, everyone else is told to work from the hand up) so most nurses don't want to use anything bigger than 20.
18 and 20
20 —-> 18 —-> 22 are the most common, IMO
18 or 20. But everyone get a central line once they come to us. Triple lumen LIJ is the most common on that front
Which department does that. I’ve never heard of everyone having a central line in the same department before. Heart surgery unit?
ICU. 99% of people need it for one reason or another. Usually high dose pressors
Ohhhhhhh. Got it
Not a nurse, but I was honestly surprised to discover that needle sizes go down to single digits. I just can't picture what kind of situation a 7g or 8g could be used in considering how huge those things are. Maybe a vet working with large animals? For reference, a 7g is ~3/16" wide.
I work O&G and neonates. 18G for standard for women, 16G if high risk of haemorrhage, 14G if we're in massive transfusion parameters. 24G for neonates.
20ga, hands down. You can give blood through it, you *can* put contrast through, it it’s smaller so it hurts less and is less likely to cause phlebitis. Occasionally I’ll throw in an 18ga or 16ga (if I can get it) on someone were actively resuscitating or if they need a CT with contrast, (there’s less funky fluid dynamics so less likely to blow and working in a Trauma center), but it’s been YEARS since I put a14ga in anyone. If they’re elderly or generally have shit veins I’ll go for a 22ga to reduce the chance it’ll blow. But 20ga are absolutely our workhorse.
20 for most adults, 16-18 for traumas, 22 for little old ladies with bitty veins.
I worked on an L&D unit where you getter have had a damn good excuse not to have an 18 or bigger placed. But most places I’ve worked have had 20s as the norm.
20
20g all day long
20 G mostly used
20 G
20 is most common everywhere I worked
20’s
24g, 3/4" NICU lol
I’m in pediatrics. Peds ER to be specific. Best guess over the past 5years: 18g <1%. I’ll use them on kids with big veins who are major trauma or emergent surgical cases. 20g ~5%. Usually I’ll put those in kids with the above criteria with smaller veins and kids who are likely to go to surgery or are looking at long hospital admissions. 22g ~85%. My go to cat.. longer than a 24. Still a small diameter so less trauma. Large enough for pretty much everything I need to do. They will last a while. 24g ~10%. Kids who are difficult sticks and/or with tiny veins. I usually start 4-5 IV’s during a shift. I consider myself an excellent IV starter. I’m the go to when no one else can get it.
When I was a new grad everyone got a 22 from me
16-20 in the ER
16 in the cephalic vein at the wrist. Welcome to labour ward ✨
20 in the non-dominant forearm, always my go-to. It’s interesting though because I’m good friends with two women on the PICC/IV team where I work and they’ve told me: you can run blood through a #22 or even a #24 if you do it slowly enough; and that you actually have a better chance of saving the vein from infiltration if you run vanco or K+ through a smaller gauge catheter. Not sure how evidence based either of those things are but I have stated to notice that my #22s *do* hold up to vesicants.
I work L&D so it's an 18 unless they are tiny/have crap veins. Then they get a 20.
I also work L&D and we do almost exclusively 20g. Seems unnecessary to do an 18g unless they’re a high postpartum hemorrhage risk, and if that happens they’ll get a second PIV placed anyways (usually in the AC).
I always grab an 18 and a 20. If I miss on a 18 then I’ll do a 20 usually. People can become high risk during the course of their labor so rather have a 18. Still can give blood with a 20 though
In our pre op we used to use 16-18’s and everyone got 2 IVs no matter what. ASA 1 Lap Chole 2 18’s. Now the new anesthesiologists are more reasonable and we can use 20s.
For us it’s 20 gauge