In a stroke patient, which arm is recommended for IV placement?

IV Placement in Stroke Patients: Arm Selection Guidelines

For stroke patients, IV access should be established in the unaffected arm (non-paretic side) whenever possible to preserve vascular access in the affected limb and avoid complications related to potential reduced circulation. 1

Rationale for Selecting the Unaffected Arm

• The unaffected arm typically has better circulation and venous access, which is critical for rapid administration of thrombolytics like r-tPA in eligible patients 2
• Using the unaffected arm helps preserve the affected limb for rehabilitation and avoids potential complications in an arm that may have compromised circulation 3
• Proper IV placement is essential for timely administration of thrombolytics, which must be initiated within 3-4.5 hours of symptom onset for optimal outcomes 2, 1

Clinical Considerations for IV Placement

• For patients receiving thrombolytic therapy (r-tPA), reliable IV access is critical as treatment must be initiated promptly - within 3 hours for strongest recommendation (Grade 1A) or up to 4.5 hours (Grade 2C) 2, 1
• When establishing IV access, consider:
  • Ease of access (unaffected arm typically provides better venous access) 3
  • Need for fluid administration (stroke patients may benefit from IV fluids - 0.9% NaCl at 100ml/hr has been shown to reduce risk of neurological deterioration) 4
  • Potential for early aspirin therapy (160-325mg) which is recommended within 48 hours of stroke onset 2, 1

Special Situations

• If IV access cannot be established in the unaffected arm:

  • Consider alternative sites in the unaffected side (hand, forearm) 1
  • Only use the affected arm if absolutely necessary and no other options exist 3
  • Document clearly that IV is placed in the affected arm to alert all providers 1

• For patients requiring intraarterial (IA) thrombolysis:

  • IV access should still be established in the unaffected arm 2
  • IA thrombolysis is suggested for patients with proximal cerebral artery occlusions who don't meet eligibility criteria for IV r-tPA 2

Common Pitfalls to Avoid

• Delaying IV access establishment - time is critical in stroke management, particularly for thrombolytic therapy 2, 1
• Using the affected arm unnecessarily - this may compromise future vascular access needed for rehabilitation 3
• Failing to secure IV access properly - dislodgement during patient transport or imaging can delay critical treatment 1
• Not considering the potential need for fluid administration - IV fluids may be beneficial in acute ischemic stroke patients 4

Practical Application

• Upon patient arrival with suspected stroke, rapidly assess using standardized tools like NIHSS 5
• Immediately establish IV access in the unaffected arm while simultaneously arranging urgent neuroimaging 1
• Ensure IV access is secure and well-documented to facilitate prompt administration of appropriate medications 2, 1