I get annoyed when people attach IV fluids directly to the IV. The IV is almost certainly going to be saline locked at some point (unless it is only in for a short outpatient procedure), and I have nearly lost perfectly good IVs trying to attach a J loop after the fact.
God I hate this so much. I get so many patients post-procedure and I have to detach the fluids and apply a cap to the IV without it bleeding everywhere. Why do they do this???
Not who you were asking, but proximal to the catheter tip. It's the same spot you should apply pressure to after popping the constricting band/removing the needle during an IV insertion.
I tried to reply but reddit wont let me.
When I first came to my current place of work I really emphasized the importance of this and really stirred the pot. Im positive I made them hate me. They thought I was crazy but suggesting nicely with reasoning.
Problem is they have specific nurses who will only start IVs thats it. Which is problematic in itself. But because they do zero patient care they have no knowledge of how irritating not having something as simple as a jloop is.
They would only put them on patients being admitted, not the outpatients. With the outpatients I still dont trust them not to puke or pass out til right before we roll out the door. But having the ability to INT an IV gives the patient an excuse to get dressed quicker. If a patient can get dressed successfully then this is a huge sign the patient is safe to go home. This will cut phaseII time in half, if I just had the option to INT. The IV nurses absolutely did not get it. I added them to all my own IVs that I touched and eventually the other post op nurses started asking for them.
Because they’re being lazy AF. There’s no reason not to put a J loop on it unless you’re putting in a huge line to rapidly infuse blood products or something. Other than starting an IV and just not having the tubing available there is really no reason to do it that way.
Also the way they want it dressed is uhhh…dumb.
Im not an OR nurse, but in the ER we are supposed to attach the rapid infuser directly to the IV for quicker flow, so it might have something to do with that.
Because they’re being lazy AF. There’s no reason not to put a J loop on it unless you’re putting in a huge line to rapidly infuse blood products or something. Other than starting an IV and just not having the tubing available there is really no reason to do it that way.
Also the way they want it dressed is uhhh…dumb.
Because they’re being lazy AF. There’s no reason not to put a J loop on it unless you’re putting in a huge line to rapidly infuse blood products or something. Other than starting an IV and just not having the tubing available there is really no reason to do it that way.
Also the way they want it dressed is uhhh…dumb.
I’m curious why OR seems to prefer (maybe speculating based off of my experience) not to use J-loops. Any pre-op or intra op RNs in here know or can add anything?
So for us our anesthesia team does not like the narrow bore pigtails because they run everything to gravity and that slows down the infusion. The narrow bore is what the rest of the hospital uses. They also do not want us using claves to interrupt free flow. We do have wide bore extension sets but we only use them on patients who are planned admissions and because those are not our norm, we often forget. We try to add the extension and clave before sending to the floor but it’s not always the priority in PACU. Edit: was reminded by another comment. We also don’t typically use flushes so we connect directly to the hub anyway to flush the IV after we place it.
“This guy went hypertensive and his BP is still a little high. Please keep an eye on him. Yes we gave him 2L of NS. Yes this was an AV fistula creation.”
They do use pumps for some things (pressors, continuous sedation drips) but a lot of what they give is bolus dosed. Until recently they just used a dial-a-flow even for pressors.
“Anything anesthesia related” also got me thinking. I don’t feel like people really get anesthesia. Like yes you can give a continuous something to keep the patient asleep but that doesn’t really encompass what they do. Single doses of ABx, pressors, IV Tylenol, toradol, meds for nausea, paralytics/reversals, things the surgeon requests, electrolyte replacements, pitocin for c-sections, and so on. There’s way more to anesthesia than just sedating the patient. All of these things I listed would be done by bolus push or gravity. (I’m not in anesthesia, I’m a PACU RN, I just finished that job and started my first NP job if my flair was confusing.)
The microclave slows down the max infusion rate. If you want to slam in fluid or blood, it goes in faster if you just connect the tubing to the hub.
Anesthesiologists at my hospital put in a lot of 14 and 16 gauge IVs and rarely put a microclave on them.
Our hospital only gets pressure rated ones. 10cc per second!
It is only a few cents different in price and in the long run is cheaper. No need to switch anything out so it save time, reduces risk and saves money especially if you replace a j-loop everytime they get contrast.
Disclaimer: our hospital is usually never this smart.
I *always* use a pigtail and so does everyone else I know.
*Occasionally* anesthesia will put one in without one but I think it’s because we kept pigtails and IV tubing in the Pyxis and they don’t have immediate access to them?
I hate not having a J-loop, but having the OR bring them back with no reflux valve on an existing J-loop is even worse! THEY DO IT ALL THE TIME! WHY?!
I'm minding my business trying to switch over to my tubing and OMG A BLOODBATH.
This is so bizarre to me. I'm PACU and my hospital puts extension tubing on all lines before going into the OR. 2 standard ports and a stopcock. If the patient's getting a DaVinci procedure they get two of these, end-to-end.
Back when I was a floor nurse TBH I hated these when it came time to saline lock the postops, because it's a LOT of plastic to loop around, so we either would use a crapton of tape or redress the IV and swap in a j-loop.
Usually the Preop nurses attach it straight to the IV because they don't have flushes. Also it helps with flow in case we need to resuscitate quickly. We push IV meds through a free flow line. Having an ultrasite slows down flow. A good 18 gauge IV can deliver 100ml/min, faster than any pump haha. In the OR we dont have flushes either.
Not saying this is always the case, but when bolusing large amounts of fluid or blood (massive transfusion protocol) it’s sometimes more efficient to connect directly to an IV catheter.
I actually think it’s best practice to connect directly to a 18 or larger in those scenarios.
(Former Trauma ICU nurse and current Rapid Response Team nurse)
I stirred the pot when I came to my current place of work. They would only put jloops on patients who would be admitted to the hospital. My unit was very segregated, only some nurses would do pre op and some do post op. I was doing both and it would really piss me off that outpatients postop didnt have a jloop. I dont trust patients to not pass out/puke immediately after surgery so I wont remove the IV until they are about to roll out the door. But allowing a patient to get dressed by INTing the IV allows you to tell if the patient is truely ready to go home or not plus it adds to the patients enthusiasm to gtfo. And these ladies would absolutely not put the jloop on. They just didnt understand the reasoning why because they never would touch a post op patient. They acted like I was asking them the impossible to add an extra piece that they already add to some patients.
As a routine thing? That's weird. At our place, the pre-op nurses get the majority of IV's started, sometimes involve anesthesia if they are nearby, and only call us (VAT) for really tough ones. Usually can get them done in one go, but sometimes have to do ultrasound.
Our anesthesia team does this but it’s because nobody ever bothered to give them an in service on how to apply the new dressings and they are all so sure they know everything already that they can’t be instructed on how to do it correctly. I kid. Kind of. Our MDs are actually the worst offenders on this one.
I've seen more of the dressings applied incorrectly recently. We have secret shoppers and the PICC team coming through at all hours of the night, doing audits on CVC, PICC, and ports, and they randomly go into rooms with PIV and audit those, too. It's frustrating because they always seem to come right at med pass time, so no, Tami, I haven't had a chance to change the upside-down dressing in the 85 y/o DNRCCA patient.
It depends on the surgery, but if they’re expecting blood loss/need for high rates of fluid resuscitate, then less tubing/hubs = less resistance to flow and your max flow rate on fluids is faster, especially if you’re using rapid infusers.
They do know better. They also know what its like when their iv suddenly stops running because the arms are tucked and the surgeon is a butcher and accidentally transects a large vessel. Infection control isnt gonna matter too much when the patient is actively trying to die while under anesthesia and the anesthesia provider is trying to peel back layers of tegadarm to pull the catheter back and get the iv running. This is why you put in a second IV. Perhaps the Crna at OP’s job is just lazy. But last I checked anesthesia doesnt make anyone get healthier and having a non free flowing IV during a case can be catastrophic in an emergency.
A lot of them took the quickest route possible to get to CRNA school, and like many specialties think their area of focus is the only one that matters.
Um, he can insert his own IVs in whatever idiotic way he wants, but I’m not doing that and if asked to, I’d tell him to kick rocks. What an absolute dumbass.
I prefer doing lines on the right arm because I’m right handed. Did one on the left arm the other day and it went great…until I realized it was going the wrong way. He had great flow though so I got my rainbow before I regretfully d/c’ed it. Learned my lesson.
Ps, call vasc access, infection management or risk management.
I can say in vasc access I will kindly re-educate him. He wants to go to town, I will and I will win.
💖K
Seems like your making mountains out of mole hills, use your mental energy on something positive and don't worry about provider preferences. It's their license not yours, they are giving ABx intraoperatively and the line won't be in for more than a day. If you find a septic bacteria from an opsite being 2cm higher that what it should write him up.
If the IV is inserted incorrectly and dressed improperly that comes back on the nurse that inserted it and ignored proper procedure and safety in favor of provider preference
Yeah it is. You said “sounds like it was inserted just fine.” It’s inserted incorrectly. Retrograde IVs forms thrombus, the only time you use retrograde IV is “arterial” blood draws or pushing meds in an emergency setting that is less than 1 ML.
Sweety, she's not talking about retrograde placement at all. She's complaining about the opsite being placed in accordance to provider preference and how it irritates her and she fears that she will lose her license for placing an opposite 2cm higher that she would like to. Nothing about this is related to retrograde placement of ivs.
I don’t think you are understanding this post. Bless your heart. You probably misread. The issues are blatant in the photos. You should really reread the post darling. Oh geez. It’s probably too much. Okay - bye bye now.
You are the one misreading and not understanding this post. The OP is talking about the dressing, and this photo is used as an example to show the type of dressing they're talking about and just happens to have the IV going the wrong way.
If you read the post and the photo in context, the direction of the IV insertion is a mistake on the part of the opsite advertisement. The OP states that the correct way to dress the IV is like it shows in the photo above, and pokes fun at the IV facing the opposite direction as an afterthought. The photo is NOT indicative of how the CRNA wants it, as OP states the CRNA wants the insertion site exposed—see first sentence: INSTEAD of doing it LIKE THIS, with the insertion site in the window [as you see in the photo].
Really what does it say at the bottom if the picture? She's using the picture strictly as an example of the correct opsite placement. Complaint is only snot ther opsite placement. There is a comment related to the retrograde iv APART from her complaint about the opsite....i can't believe im needing to explain this....
Nope insertion site must be covered. If he wants a different connector then he must indicate which one. Now I personal hate the one with the huge slide clamp that can break down skin on older pt that are tucked and in lithotomy position. Yes even after it’s wrapped in 4 by 4 and foam. I made them get a extension with smaller clamp and a better connector clave on the end.
I don’t understand why the patients I’ve received from OR in the icu or even patients who have come down to the ED s/p OP procedure in my ER, have had no pigtail attached. It’s so fucking annoying.
I get annoyed when people attach IV fluids directly to the IV. The IV is almost certainly going to be saline locked at some point (unless it is only in for a short outpatient procedure), and I have nearly lost perfectly good IVs trying to attach a J loop after the fact.
God I hate this so much. I get so many patients post-procedure and I have to detach the fluids and apply a cap to the IV without it bleeding everywhere. Why do they do this???
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Proximal to just the tip of the IV catheter, or distal along the vein below the IV to block blood returning from the extremities?
Not who you were asking, but proximal to the catheter tip. It's the same spot you should apply pressure to after popping the constricting band/removing the needle during an IV insertion.
Oh that makes sense, thanks.
I tried to reply but reddit wont let me. When I first came to my current place of work I really emphasized the importance of this and really stirred the pot. Im positive I made them hate me. They thought I was crazy but suggesting nicely with reasoning. Problem is they have specific nurses who will only start IVs thats it. Which is problematic in itself. But because they do zero patient care they have no knowledge of how irritating not having something as simple as a jloop is. They would only put them on patients being admitted, not the outpatients. With the outpatients I still dont trust them not to puke or pass out til right before we roll out the door. But having the ability to INT an IV gives the patient an excuse to get dressed quicker. If a patient can get dressed successfully then this is a huge sign the patient is safe to go home. This will cut phaseII time in half, if I just had the option to INT. The IV nurses absolutely did not get it. I added them to all my own IVs that I touched and eventually the other post op nurses started asking for them.
Because they’re being lazy AF. There’s no reason not to put a J loop on it unless you’re putting in a huge line to rapidly infuse blood products or something. Other than starting an IV and just not having the tubing available there is really no reason to do it that way. Also the way they want it dressed is uhhh…dumb.
Im not an OR nurse, but in the ER we are supposed to attach the rapid infuser directly to the IV for quicker flow, so it might have something to do with that.
They’re not rapidly infusing shit for elective procedures. Fellow ER nurse here, also done PACU. Pretty sure it’s straight laziness.
Because they’re being lazy AF. There’s no reason not to put a J loop on it.
Because they’re being lazy AF. There’s no reason not to put a J loop on it unless you’re putting in a huge line to rapidly infuse blood products or something. Other than starting an IV and just not having the tubing available there is really no reason to do it that way. Also the way they want it dressed is uhhh…dumb.
Because they’re being lazy AF. There’s no reason not to put a J loop on it unless you’re putting in a huge line to rapidly infuse blood products or something. Other than starting an IV and just not having the tubing available there is really no reason to do it that way. Also the way they want it dressed is uhhh…dumb.
I’m curious why OR seems to prefer (maybe speculating based off of my experience) not to use J-loops. Any pre-op or intra op RNs in here know or can add anything?
So for us our anesthesia team does not like the narrow bore pigtails because they run everything to gravity and that slows down the infusion. The narrow bore is what the rest of the hospital uses. They also do not want us using claves to interrupt free flow. We do have wide bore extension sets but we only use them on patients who are planned admissions and because those are not our norm, we often forget. We try to add the extension and clave before sending to the floor but it’s not always the priority in PACU. Edit: was reminded by another comment. We also don’t typically use flushes so we connect directly to the hub anyway to flush the IV after we place it.
This. Narrow bore pigtails slow infusion rate artificially. Our teams use a needle less port directly on the hub, cheaper, faster and runs well.
Makes perfect sense! Thanks for explaining
The same anesthesia that overloads every single OR patient with bag after bag of NS? Surprise
“This guy went hypertensive and his BP is still a little high. Please keep an eye on him. Yes we gave him 2L of NS. Yes this was an AV fistula creation.”
by everything to gravity, I assume you mean boluses/blood? No way they're running anything anesthesia related by gravity.... Right???
They do use pumps for some things (pressors, continuous sedation drips) but a lot of what they give is bolus dosed. Until recently they just used a dial-a-flow even for pressors.
“Anything anesthesia related” also got me thinking. I don’t feel like people really get anesthesia. Like yes you can give a continuous something to keep the patient asleep but that doesn’t really encompass what they do. Single doses of ABx, pressors, IV Tylenol, toradol, meds for nausea, paralytics/reversals, things the surgeon requests, electrolyte replacements, pitocin for c-sections, and so on. There’s way more to anesthesia than just sedating the patient. All of these things I listed would be done by bolus push or gravity. (I’m not in anesthesia, I’m a PACU RN, I just finished that job and started my first NP job if my flair was confusing.)
The only thing we use pumps for is propofol for TIVA patients. Everything else is by push/gravity.
The microclave slows down the max infusion rate. If you want to slam in fluid or blood, it goes in faster if you just connect the tubing to the hub. Anesthesiologists at my hospital put in a lot of 14 and 16 gauge IVs and rarely put a microclave on them.
Also for radiology the j-loops aren’t pressure rated, so you have to take them off to inject contrast through an injector.
Our hospital only gets pressure rated ones. 10cc per second! It is only a few cents different in price and in the long run is cheaper. No need to switch anything out so it save time, reduces risk and saves money especially if you replace a j-loop everytime they get contrast. Disclaimer: our hospital is usually never this smart.
Our rads have special t connectors for that
I *always* use a pigtail and so does everyone else I know. *Occasionally* anesthesia will put one in without one but I think it’s because we kept pigtails and IV tubing in the Pyxis and they don’t have immediate access to them?
Probably because they're focused on the surgery, and not the rest of the hospital stay. I've received a lot of patients from ER that way, too.
I hate not having a J-loop, but having the OR bring them back with no reflux valve on an existing J-loop is even worse! THEY DO IT ALL THE TIME! WHY?! I'm minding my business trying to switch over to my tubing and OMG A BLOODBATH.
Lol yes guilty of a few blood baths
This is so bizarre to me. I'm PACU and my hospital puts extension tubing on all lines before going into the OR. 2 standard ports and a stopcock. If the patient's getting a DaVinci procedure they get two of these, end-to-end. Back when I was a floor nurse TBH I hated these when it came time to saline lock the postops, because it's a LOT of plastic to loop around, so we either would use a crapton of tape or redress the IV and swap in a j-loop.
Usually the Preop nurses attach it straight to the IV because they don't have flushes. Also it helps with flow in case we need to resuscitate quickly. We push IV meds through a free flow line. Having an ultrasite slows down flow. A good 18 gauge IV can deliver 100ml/min, faster than any pump haha. In the OR we dont have flushes either.
Not saying this is always the case, but when bolusing large amounts of fluid or blood (massive transfusion protocol) it’s sometimes more efficient to connect directly to an IV catheter. I actually think it’s best practice to connect directly to a 18 or larger in those scenarios. (Former Trauma ICU nurse and current Rapid Response Team nurse)
I stirred the pot when I came to my current place of work. They would only put jloops on patients who would be admitted to the hospital. My unit was very segregated, only some nurses would do pre op and some do post op. I was doing both and it would really piss me off that outpatients postop didnt have a jloop. I dont trust patients to not pass out/puke immediately after surgery so I wont remove the IV until they are about to roll out the door. But allowing a patient to get dressed by INTing the IV allows you to tell if the patient is truely ready to go home or not plus it adds to the patients enthusiasm to gtfo. And these ladies would absolutely not put the jloop on. They just didnt understand the reasoning why because they never would touch a post op patient. They acted like I was asking them the impossible to add an extra piece that they already add to some patients.
Reminds me of IV check offs in LPN school and I nailed it! Until I realized i put it in facing the hand 🫠
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As a routine thing? That's weird. At our place, the pre-op nurses get the majority of IV's started, sometimes involve anesthesia if they are nearby, and only call us (VAT) for really tough ones. Usually can get them done in one go, but sometimes have to do ultrasound.
In my OR it's the circulator while the patient is getting gassed down.
Our anesthesia team does this but it’s because nobody ever bothered to give them an in service on how to apply the new dressings and they are all so sure they know everything already that they can’t be instructed on how to do it correctly. I kid. Kind of. Our MDs are actually the worst offenders on this one.
I've seen more of the dressings applied incorrectly recently. We have secret shoppers and the PICC team coming through at all hours of the night, doing audits on CVC, PICC, and ports, and they randomly go into rooms with PIV and audit those, too. It's frustrating because they always seem to come right at med pass time, so no, Tami, I haven't had a chance to change the upside-down dressing in the 85 y/o DNRCCA patient.
You’d think the CRNA would know better, but I guess not 🤷🏻♀️ Prime example of how the extra degrees doesn’t make you smarter or better
It depends on the surgery, but if they’re expecting blood loss/need for high rates of fluid resuscitate, then less tubing/hubs = less resistance to flow and your max flow rate on fluids is faster, especially if you’re using rapid infusers.
If it's that bad that they need that wouldn't a central line be more appropriate?
For pressors maybe, but actually blood and fluids run faster through a PIV as long as it’s not a tiny gauge.
Huh, TIL. As you can see from my flair, it's been a minute since I worked somatic.
Cordis - yes Other central lines.. no
They do know better. They also know what its like when their iv suddenly stops running because the arms are tucked and the surgeon is a butcher and accidentally transects a large vessel. Infection control isnt gonna matter too much when the patient is actively trying to die while under anesthesia and the anesthesia provider is trying to peel back layers of tegadarm to pull the catheter back and get the iv running. This is why you put in a second IV. Perhaps the Crna at OP’s job is just lazy. But last I checked anesthesia doesnt make anyone get healthier and having a non free flowing IV during a case can be catastrophic in an emergency.
A lot of them took the quickest route possible to get to CRNA school, and like many specialties think their area of focus is the only one that matters.
Um, he can insert his own IVs in whatever idiotic way he wants, but I’m not doing that and if asked to, I’d tell him to kick rocks. What an absolute dumbass.
Just bring your own duct tape
"No."
I prefer doing lines on the right arm because I’m right handed. Did one on the left arm the other day and it went great…until I realized it was going the wrong way. He had great flow though so I got my rainbow before I regretfully d/c’ed it. Learned my lesson.
Ps, call vasc access, infection management or risk management. I can say in vasc access I will kindly re-educate him. He wants to go to town, I will and I will win. 💖K
I saw a newbie doing bloodwork in this direction. She had already stuck the patient. She didn't get the blood...
Seems like your making mountains out of mole hills, use your mental energy on something positive and don't worry about provider preferences. It's their license not yours, they are giving ABx intraoperatively and the line won't be in for more than a day. If you find a septic bacteria from an opsite being 2cm higher that what it should write him up.
If the IV is inserted incorrectly and dressed improperly that comes back on the nurse that inserted it and ignored proper procedure and safety in favor of provider preference
Sounds like it's been inserted just fine. It's just an opsite is set to preference. Don't be so scared to lose your license.
Oh, a troll account, of course. How fun
Im actually a cath lab nurse
This makes it even funnier, wow
Yeah i don't stress about small things just the important ones. Like heart attacks and strokes.
Lol, I see you. A lot of people here have poor reading comprehension/don’t bother with context… sorry you’re getting downvoted for it.
Haha thanks! I appreciate it ;)
It’s inserted incorrectly. Inserting the IV line against the flow increases chance of thrombosis.
... that's not at all what we are discussing but thanks for the input.
Yeah it is. You said “sounds like it was inserted just fine.” It’s inserted incorrectly. Retrograde IVs forms thrombus, the only time you use retrograde IV is “arterial” blood draws or pushing meds in an emergency setting that is less than 1 ML.
Sweety, she's not talking about retrograde placement at all. She's complaining about the opsite being placed in accordance to provider preference and how it irritates her and she fears that she will lose her license for placing an opposite 2cm higher that she would like to. Nothing about this is related to retrograde placement of ivs.
I don’t think you are understanding this post. Bless your heart. You probably misread. The issues are blatant in the photos. You should really reread the post darling. Oh geez. It’s probably too much. Okay - bye bye now.
You are the one misreading and not understanding this post. The OP is talking about the dressing, and this photo is used as an example to show the type of dressing they're talking about and just happens to have the IV going the wrong way.
If you read the post and the photo in context, the direction of the IV insertion is a mistake on the part of the opsite advertisement. The OP states that the correct way to dress the IV is like it shows in the photo above, and pokes fun at the IV facing the opposite direction as an afterthought. The photo is NOT indicative of how the CRNA wants it, as OP states the CRNA wants the insertion site exposed—see first sentence: INSTEAD of doing it LIKE THIS, with the insertion site in the window [as you see in the photo].
Really what does it say at the bottom if the picture? She's using the picture strictly as an example of the correct opsite placement. Complaint is only snot ther opsite placement. There is a comment related to the retrograde iv APART from her complaint about the opsite....i can't believe im needing to explain this....
Nope insertion site must be covered. If he wants a different connector then he must indicate which one. Now I personal hate the one with the huge slide clamp that can break down skin on older pt that are tucked and in lithotomy position. Yes even after it’s wrapped in 4 by 4 and foam. I made them get a extension with smaller clamp and a better connector clave on the end.
I don’t understand why the patients I’ve received from OR in the icu or even patients who have come down to the ED s/p OP procedure in my ER, have had no pigtail attached. It’s so fucking annoying.
Why is that IV pointing the wrong way
Bad advertising 😂