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PED-EM-L  March 1996

PED-EM-L March 1996

Subject:

Re: MYTHS IN EM

From:

Tom Trimble <[log in to unmask]>

Reply-To:

Tom Trimble <[log in to unmask]>

Date:

Tue, 19 Mar 1996 13:07:10 -0800

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (111 lines)

At 03:31 AM 3/15/1996 -0500, Alain Vadeboncoeur wrote:
>Hello
>
>As a scientific director of a 1997 provincial congress starting to
>buildup the program, I would like
>to ask you two simple question:
>
>1. Name three common myths in EM (old habies not based on evidence)
>
>2. Name three hot topics (emerging new concepts based on evidence)
>
>Thanks by advance.
>
>***********************************
>Alain Vadeboncoeur MD
>Chief, Emergency departement
>Pierre-Boucher Hospital
>Longueuil, Quebec, Canada
>E-mail: [log in to unmask]
>***********************************
>
>
Hi,
 
        #1.   For myths in EM, I would propose the prevalent folk-custom of
removing field-paramedic-started IV lines and ED-started IV lines without
any other indication than an unfounded belief that such lines are "not
started under good conditions and are potentially septic."  CAVEAT: no OTHER
indication than a prejudice against the source; i.e., not reported as having
been started with compromised technique or care.
 
               Discussion:  Authority for the assertion is often claimed to
be Hospital Policy & Proceedures, or ACLS Standards {qvv.}  Automatic
removal upon transfer to unit or within 24 hours is then carried out.
 
                As a former paramedic and paramedic-trainer,  a university
med. ctr. nurse (4 yrs Neuro, 10 yrs ED), still in contact with many medics,
and one who  does F/U on admissions, I do not believe this is justified.
Skilled medics take as much care with their lines, as do skilled ED staff,
as do unit staff.  At no phase of hospitalization have I seen any greater
incidence of infection or phlebitis for such lines.  While circumstances may
in individual instances suggest prompt replacement, there is no
justification for a general practice.
 
                  It would seem that overly-zealous misinterpretation of
ACLS textual suggestion that some lines may need to be replaced, coupled
with elite-centric ethos of some practitioners and settings may lead to the
fallacious concept that "if we didn't do it here, it's gotta' be yanked."
 
                  Our institution's P&P merely suggests that lines placed in
an emergency *may* need replacement within 24 hours.  This is an approximate
echo of an ACLS suggestion.
 
                    Considerable cost-savings could be realized by the
rational practice of maintaining lines which are without signs of phlebitis
or infection or any reasonable instituitional limit on duration of dwell
unless there are specific indicators otherwise.
 
 
         #2.  "A large-bore IV cannula is necessary to transfuse
blood-products without damage to the cells."
 
         While large-bore lines are desirable for the massive
gravity-or-pressure transfused blood-product and crystalloid resuscitation
of exsanguinating patients, the merely "anemic" hemodynamically stable
patient [whether adult or neonate] can be safely and easily transfused
through even a 24 gauge cannula, especially with an infusion pump with
transfusion tubing.  Less trauma to the available veins will occur and more
sites will be usable longer.  Barring resuscitation, pumps will ensure an
accurately-controlled transfusion rate with less fluid-overload, and allow
greater focus upon **the patient's response to the transfusion** rather than
continually trying to keep the line going.
 
 
         #3.  {Corollary of #2}  "You can't draw blood through the IV
cannula without hemolyzing the cells unless it's at least a 20ga. or 18gauge."
 
                  The lab phlebotomists usually use a 21ga. to 23ga. needle.
In pediatrics, and in the severe "phlebopenia" (my term) of the aged,
chronically-ill, steroid-dependant, chemotherapeutic, or IV  drug abusing,
patients, the only draw or IV access may be with a 22ga.or 24ga. cannula, or
a 23ga. or 25ga. winged-needle.
 
                   Patients who are hemodynamically stable who only need
access for routine hydration and medications only need a small-bore line.
With a pump, a liter per hour X 24 hours/day = all but the most
extraordinary hydration needs, and medication rates can be accurately
controlled.  With less trauma to the vein from a smaller cannula, controlled
rates, and greater "flow-around blood flow" past the cannula to dilute the
drug and minimize irritation to the intima, IV sites will be more
comfortable, last longer, and preserve the few available sites, healing will
occur sooner and the vein will be available for reuse sooner.  Even,
patients with "good veins" benefit thereby, and should the stay be longer
than originally planned, fewer "good sites" will have already been used.
 
                  We commonly start smaller-bore lines freely with such
"difficult" patients and draw blood even with evacuated containers
**without** hemolysis.  Problems that infrequently occur are due to
turbulent flow of a poor site or other some such trauma directly to the
cells such as mishandling.
This is due to the same actions that hemolyze cells drawn through larger
cannulae, and in no greater frequency.
 
                                                         Tom
 
Tom Trimble, RN CEN
[log in to unmask]
 
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

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