II. Types: Vascular Access Flow Rates
- Background
- Needle free connectors (e.g. Bionector, "bung") slow flow rates as much as 40% (esp. short, wide bore catheters)
- Pressure benefits all catheter flow rates (esp. longer catheters), increasing rates 60 to >100%
- Size 13F Dialysis Catheter
- Estimated Flow Rate to Gravity: 400 ml/min (infuses 1 L in 2.5 min)
- Size 14G Peripheral catheter
- Estimated Flow Rate to Gravity: 250 ml/min (infuses 1 L in 4 min)
- Size 16G Peripheral catheter
- Estimated Flow Rate to Gravity: 150 ml/min (infuses 1 L in 7 min)
- Size 8.5F Sheath Introducer
- Estimated Flow Rate to Gravity: 130 ml/min (infuses 1 L in 8 min)
- Size 18G Peripheral Catheter
- Estimated Flow Rate to Gravity: 100 ml/min (infuses 1 L in 10 min)
- Size 16G Distal Port Triple Lumen Central Catheter
- Estimated Flow Rate to Gravity: 70 ml/min (infuses 1 L in 15 min)
- Size 15G Intraosseous Needle (adult tibia)
- Estimated Flow Rate to pressure (via syringe): 60–100 ml/min of crystalloid
- References
- Fluid administration device flow rates (LITFL)
- Azim (2023) Crit Dec Emerg Med 37(4): 23-9
- Reddick (2011) Emerg Med J 28(3):201-2 +PMID: 20581377 [PubMed]
III. Approach: Peripheral Access
-
Peripheral IV Access (default initial line)
- IV Gauge determines maximal flow rates (18 G or larger is preferred)
- See above
- Initial Resuscitation with fluids
- Fluid infusion via 18 gauge peripheral IV is faster than via a triple lumen central catheter
- Medication administration including Antibiotics
- Intravenous Contrast administration (reliable 18 gauge IV needed for CTA, PE studies)
- Initial Vasopressors may be used peripherally if reliable large bore IV (until central access is obtained)
- Allows for venous lab samples on placement and later
- Requires wasting part of sample, and then Flushing line
- IV Gauge determines maximal flow rates (18 G or larger is preferred)
-
Intraosseous Access
- Rapid landmark based placement with multiple available sites (e.g. proximal tibia, Humerus)
- Emergent Vascular Access for Resuscitation when peripheral IV cannot be immediately placed
- Allows for infusion of most fluids and medications including Vasopressors (but not Sodium Bicarbonate)
- Limited flow rates even with pressure bags (incapable of rapid infusion)
-
Midline Venous Catheter (Ultrasound-Guided Antecubital Line)
- Alternative to central venous access when standard peripheral lines are difficult
- Extravasation is more common with deep brachial vein IVs
-
Rapid Infusion Catheter (RIC Line)
- Converts a 18-20 gauge peripheral IV into a large bore line (8 Fr)
- Seldinger wire is threaded through peripheral line and peripheral IV is removed
- Skin is nicked at IV entry site and dilator is threaded over wire and through skin
- Catheter is threaded over wire and into vein and wire is removed
- Allows for high flow rates via peripheral line
- Risk of destroying peripheral vein by threading it with too large of a catheter
- Converts a 18-20 gauge peripheral IV into a large bore line (8 Fr)
IV. Approach: Central Access
- See Central IV Access
- Background
- Central Lines are sewn in place and typically more secure than peripheral lines which may be dislodged
- Internal Jugular Veins are preferred central access points
- However, in Resuscitation, consider femoral lines which are out of way of Resuscitation efforts
- Convert femoral lines to other sites in first 48 hours
-
Central Line Types
- Triple Lumen Catheters
- Best for infusing multiple medications (including Vasopressors)
- Slower infusion rates (under pressure) than 18 gauge peripheral IVs
- Introducer Catheters
- Largest bore of the central catheter options offering high infusion rates
- Weingart recommends bypassing side port with commercially available product
- Hemodialysis Catheters
- Large bore catheter (12-13 french) with 2 ports
- Triple Lumen Catheters
V. Types: Pressure Bag
- Standard Pressure Bag
- Maximum pressure 300 mmHg (requires repeatedly repumping up bag)
- Superior to manually squeezing IV fluid bags (unable to reach the same pressures manually)
- When using large pressure bags (1 Liter) on smaller IV fluid bags
- Position the IV fluid bag at the inferior aspect of the pressure bag
- Mechanical Pressure Device (Belmont rapid infuser, Level 1 Infuser)
- Maximum pressure equivalent to standard pressure bag
- Applies constant pressure throughout infusion regardless of remaining fluid volume (unlike standard pressure bag)
- Also functions as a fluid warmer
- References
- Weingart and Swaminathan (2023) EM:Rap 23(11)
VI. Complications
- See Central Line-Associated Bloodstream Infection
- Vessicant or Iritant Extravasation
- See IV Extravasation of Catecholamines
- See Chemotherapy Extravasation
- Risk of Soft Tissue Injury and necrosis (esp. vessicants)
- Solutions best infused by central access
- Acidic (pH <5.5) and basic (pH >8.5) solutions
- Highly osmolar solutions (>600 mOsm) are Vesicants
- Hypertonic Saline (3%) has osmolarity >1000 mOsm
- Sodium Bicarbonate has osmolarity >2000 mOsm
- Calcium Chloride has osmolarity >2000 mOsm
- Calcium Gluconate may be safely given instead via peripheral IV
- Calcium Gluconate dose given should be 3 fold higher than Calcium Chloride dose
- Vasopressors
- However, Norepinephrine and Vasopressin are frequently started peripherally
- Low dose Vasopressors may be used via a reliable large bore peripheral IV for up to 24 hours
- Dextrose
- D10 may be preferred with less sclerosing adverse effects, and less rebound Hypoglycemia than D50
- Adverse Effects with too rapid of boluses (slow IV push over 2 minutes or infused in bag)
- Benzodiazepines (apnea risk)
- Fentanyl (Chest wall rigidity)
- Ketamine (laryngospasm)
- DopamineAntagonist Antiemetics such as Metoclopramide, Prochlorperazine (Akathisia)
- Furosemide (Ototoxicity)
- References
- Nordt and Rech (2024) EM:Rap, 9/30/2024
VII. References
- Weingart and Swaminathan in Herbert (2021) EM:Rap 21(4): 5-7