Confirmation of tlc's & ett placement in OR

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    I posted this in the ICU forum but could you guys help? Do you use a c-arm to confirm the placement of a TLC- and if so do you write orders to confirm placement so that the ICU nurse doesn't have to worry upon assuming care? If not, than who assumes the responsibility of reading the cxr afterwards?
    Thank you for any responses!

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    We receive many post op patients directly from the OR (PACU bypassed) who receive TLC's from the anesthesiologist right before induction. Recently, a case came over on a vent and the nurse refused to give the ordered rbc's because there was no mention of CXR performed to confirm placement although there was IVF running to the TLC upon arrival . In the OR-they don't usually do confirmation of ETT placement either. A big ordeal was made of the incident-should she have just gotten an order from the surgeon or the anesthesiologist to use the line or demanded (like she did) a CXR to confirm placement?
    I'm thinking from a liability stand point.
    Thank you for any responses.
  2. 5 Comments so far...

  3. 0
    We do routinely get CXRs post line placement. If they are not mentioned in report, the order/reading should be on the computer by the time you get them. If not, check with radiology themselves or the anesthesia dept. As to the ETT, these are not routinely X-rayed. It is not policy in our OR but again, one can be ordered by the ICU physician in charge if you want placement verified.
  4. 0
    Most physicians placing central venous lines (subclavian, IJ, EJ) will not obtain an xray in the OR since it is obvious one has venous access through the line due to aspiration of blood. The only question is how far advanced is the CVL. If it is atrial, usually it doesn't cause any issue, but if dysrhythmias occur, then these are easily determined on continuous ECG monitoring. Xrays can be obtained in the PACU or ICU if the CVL is to be maintained.
  5. 0
    subclavian lines can, at times, head "north" and end up in the jugular vein.
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    [color=#483d8b]i have also seen several lines placed from the left side of the patient (either ij or subclavian) not quite make it into the svc, and end up in the brachiocephalic (innominate) vein. (pathway to the svc is longer from the left side of the body in almost everyone)
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    [color=#483d8b]in either of the above cases, the line is not considered to be a "central line," since the tip of a line must be in the svc (or ivc for femoral placement) to be considered centrally placed.
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    [color=#483d8b]would i use the line? depends on how emergent the situation was, where the line was, and what was being infused through it.
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    [color=#483d8b]the biggest risk in using a line that has not reached the svc is thrombus formation. the more irritating the iv med, the more likely it is to cause intraluminal irritation, leading to thrombus formation.
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    [color=#483d8b]there is also a risk of causing too much fluid getting into the brain if fluid boluses are being rapidly administered and the tip of the line is in the jugular vein.
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    [color=#483d8b]blood probably wouldn't be a big deal, though i wouldn't give it through a rapid infuser. tpn, no way. vanc, no way.
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    [color=#483d8b]there are, however, other ways of checking line placement. bedside ultrasound can be used to exclude jugular placement at the very least. depending on how good the equipment is and how skilled the user is, it may even be possible to confirm svc placement.
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    [color=#483d8b]it is always best to get a cxr to be certain.
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    [color=#483d8b]when you get these patients from surgery, does the anesthesiologist come with them from or? any time i have worked icu where the or bypasses pacu and goes straight to icu, the anesthesiologist comes with the patient. ask him/her what method they used to confirm placement, and if a chest xray is needed. if the tell you one isn't needed, get them to write an order that the line is ok to use.
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    [color=#483d8b]as far as who reads the xray, that depends on the hospital's/radiology's policy. if there is no radiologist there (either staff or resident) and they don't read remotely, then anesthesia (or whomever placed the line) really needs to check the xray. at the teaching hospitals where i have worked, the residents always had to look at the xrays of lines they placed. the radiologist (staff or resident) would read them for other staff physicians, either surgeon, anesthesia, or medical.
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    [color=#483d8b]by the way, placement isn't the only issue. pneumothorax can result from central line placement, and excluding that possibilty is an important reason for having the line xrayd.
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  6. 0
    As stated previously, ETT placement is not routinely checked via x-ray. At most institutions that I rotate thru, if central lines are placed prior to induction, an x-ray is obtained after the case before we leave the room. Mainly to r/o pneumothorax. The central lines are used in the OR for fluids, blood, vasopressors w/o checking placement with CXR. Good blood aspirate after placement is adequate for verifying placement for the OR.
  7. 0
    Quote from elizadream
    I posted this in the ICU forum but could you guys help? Do you use a c-arm to confirm the placement of a TLC- and if so do you write orders to confirm placement so that the ICU nurse doesn't have to worry upon assuming care? If not, than who assumes the responsibility of reading the cxr afterwards?
    Thank you for any responses!

    ***********************************************
    We receive many post op patients directly from the OR (PACU bypassed) who receive TLC's from the anesthesiologist right before induction. Recently, a case came over on a vent and the nurse refused to give the ordered rbc's because there was no mention of CXR performed to confirm placement although there was IVF running to the TLC upon arrival . In the OR-they don't usually do confirmation of ETT placement either. A big ordeal was made of the incident-should she have just gotten an order from the surgeon or the anesthesiologist to use the line or demanded (like she did) a CXR to confirm placement?
    I'm thinking from a liability stand point.
    Thank you for any responses.
    If the line was placed and used in the OR, even without a CXR, there's no reason not to keep using it in the ICU. Of course a CXR is appropriate, but the primary reason for that is checking for a pneumothorax.


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