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

IV Placement in Stroke Patients: Arm Selection Guidelines

For stroke patients, IV placement should be done in the non-paretic (unaffected) arm whenever possible to preserve the affected arm for rehabilitation and avoid potential complications.

Rationale for Using the Non-Paretic Arm

• The non-paretic arm is preferred for IV placement in stroke patients as it preserves the affected arm for rehabilitation activities and functional recovery 1
• Using the unaffected arm helps avoid potential complications in the paretic arm which may have compromised circulation, sensation, or movement 2
• Preserving the paretic arm is important for rehabilitation exercises and activities that will be crucial for recovery and improving quality of life outcomes 3

Clinical Considerations for IV Placement

• IV access is critical for administering thrombolytic therapy (r-tPA), which is the primary treatment for acute ischemic stroke within the first 3-4.5 hours 1, 2
• Proper IV placement is essential for:
  • Administration of r-tPA (0.9 mg/kg, maximum dose 90 mg) in eligible patients 1
  • Delivery of early aspirin therapy (160-325 mg) within 48 hours of stroke onset 2
  • Administration of intravenous fluids which may reduce risk of neurological deterioration 4
  • Prophylactic anticoagulation in patients with restricted mobility 2

Special Situations

• If IV access cannot be established in the non-paretic arm:
  • Consider alternative sites such as the external jugular vein or placement of a central line if absolutely necessary 2
  • When using the paretic arm becomes unavoidable, extra care should be taken to:
    • Use the most distal site possible to preserve proximal veins 2
    • Monitor the IV site frequently for infiltration or complications 2
    • Remove the IV as soon as clinically appropriate 2

Importance of Rapid Treatment

• Time is critical in stroke management - "time is brain" - so IV placement should be accomplished quickly to facilitate timely administration of thrombolytics 1, 2
• The NINDS trials demonstrated that patients treated with IV r-tPA within 3 hours were at least 30% more likely to have minimal or no disability at 3 months 2
• Delays in establishing IV access can significantly impact treatment outcomes and should be minimized 2

Common Pitfalls to Avoid

• Avoid multiple IV attempts in the paretic arm which may cause additional trauma and compromise rehabilitation potential 3
• Do not delay thrombolytic treatment for difficult IV access - consider alternative access methods if needed 2
• Remember that arm efficiency, not just capacity, affects long-term functional use of the paretic arm after stroke, so preserving it from unnecessary medical interventions is important 3

Monitoring and Follow-up

• Regular assessment of IV site for complications is essential, particularly in stroke patients who may have altered sensation 4
• Monitor for neurological deterioration, which may be less common in patients receiving adequate IV fluids (100ml/h of 0.9% NaCl) 4
• Ensure IV access remains patent for administration of medications and fluids throughout the acute treatment phase 2