Why would an anesthesia provider do this?

  1. At work the other day, I was caring for an extremely critical patient who had become septic after a bowel surgery. She had a leak and needed to go to the OR for repair. I sent the patient to the OR on levophed at 75 mcg/min, vasopressin at .04 u/min, bicarb gtt, sedation, and a fluid bolus hanging. The patient had a QLC in the right subclavian that was functioning well. During the case, the surgeons had agreed to put in a quinton for dialysis access so we could begin CRRT when the patient returned from the OR. I told this to the anesthesia provider (I will not say whether it was an MD or CRNA b/c I don't want to go there) when giving report. Well, the patient came back from the OR with her new quinton and a new DLC in the left IJ. When I asked anesthesia were my QLC had gone, she said she took it out and put in the double lumen b/c the lumens were larger and she could give more volume. When I looked at the anesthesia record, she had only given one bolus of albumin and one bag of crystalloid during the case (no blood, nothing). When I asked her where in the world I was supposed to run my pressors, sedation, bicarb gtt, calcium gluconate gtt, xigris, insulin, and multiple piggybacks, she just looked at me blankly and said, "I guess you should call the surgeons to put in a new line." Now, granted the xigris and insulin were new orders she didn't know about, but come on! Why in the world would you take out a quad lumen and replace it with a double on a critical patient? I know I am venting and this is long, but I would really like to know if there is a logical explanation or if any of you that are practicing anesthesia would do this. Yes, I did get a new quad lumen but it took over 2 1/2 hours to get someone to do it and my CRRT wasn't started until almost 6PM, even though the patient returned at 1:30.
    •  
  2. 15 Comments

  3. by   TracyB,RN
    my guess is that the anesthesia provider was a pompous *** anesthesiologist & wasn't thinking of all of the potential meds for this pt, or that his/her laziness was really causing more work for this pt's direct care givers...They don't care for the pt on the floor, so why should they "care"... & it was just easier for him/her to put in double lumen, instead of untangling tubing.... lazy, IMHO... Either that, or a fairly new CRNA, lacking the critical, thinking for future needs.

    To avoid flaming, NOT all anesthesia providers are this inconsiderate.... the ones I work with are TOTALLY flippin awesome & 150% aware of direct staff & pt care needs.
    Last edit by TracyB,RN on Dec 29, '04
  4. by   pasgasser
    The reason the provider changed the line is because at the onset of the case the pt descibed could easily need large bore access. A 4 lumen CVL is great for infusions but is a horrible volume line. If the 4 lumen line were new I would have likely left and it and also inserted the larger CVL. I can't imagine any provider not getting more access.


    [QUOTE=TracyB,RN]my guess is that the anesthesia provider was a pompous *** anesthesiologist & wasn't thinking of all of the potential meds for this pt, or that his/her laziness was really causing more work for this pt's direct care givers...They don't care for the pt on the floor, so why should they "care"... & it was just easier for him/her to put in double lumen, instead of untangling tubing.... lazy, IMHO... Either that, or a fairly new CRNA, lacking the critical, thinking for future needs.

    This statement is uncalled for.
    Last edit by VickyRN on Dec 30, '04 : Reason: Attacking statement removed...
  5. by   AmiK25
    I understand that the anesthesia provider might have wanted more access, like an introducer. What I did not understand was why she took out my quad lumen that was not even 24 hours old and only left me with two lumens to run my many gtts.
  6. by   jwk
    Quote from AmiK25
    I understand that the anesthesia provider might have wanted more access, like an introducer. What I did not understand was why she took out my quad lumen that was not even 24 hours old and only left me with two lumens to run my many gtts.
    There's only so many lines you can run through one vein. Perhaps they expected some significant volume shifts and felt they needed big lumens. It's not necessary to have a separate lumen for every different infusion.
    Last edit by VickyRN on Dec 30, '04 : Reason: Possible inflammatory comment deleted...
  7. by   jewelcutt
    In most cases, people don't do things to make it harder on others. There may have been other circumstances, perhaps the anesthesia provider thought it was old, or perhaps they just weren't thinking about the future care but rather the present care. Try not to think about things so bitterly because we've all done things not realizing how it affects other providers. Maybe the anesthesia provider thought your tangled lines made his job more difficult. There are two sides to every story, I often find it amazing how some nurses y-together three separate drips to one IV line instead of using stopcocks and have things running together that shouldn't be. I probably wouldn't have taken out the QLC but maybe the doc said the patient didn't need it or the anesthesia provider didn't want two sites for infection. In the future you may need to ask them to preserve your line.
  8. by   AmiK25
    Give me a break, you know exactly what I meant by saying my quad lumen. If I were not concerned for the patient, it would not have bothered me that I had to wait 2 1/2 hours for a new central line to start her xigris, insulin, and CRRT. After all, that is just more work for me so if I weren't concerned for the patient, I would have been happy. As an ICU nurse, I know very well that each gtt does not need its own lumen. However, if you can tell me a way to combine levophed, vasopression, sodium bicarb, ativan, xigris, insulin, and calcium gluconate into two lumens, plus has enough left to give fluid boluses (due every hour, depending on pts. CVP) and piggybacks (a minimum of 2-3 every 4-6 hours, depending on labs) let me know! Once again, my question was, why would she feel the need to d/c the existing QLC when the DLC that was inserted was on the other side? When the patient returned, I did ask her why (in a very polite, professional manner) but she had no answer.
  9. by   stklgs
    It is my opinion that the anesthesia provider didnt have an answer because she probably realized that the Quad should not have come out.. Typically if someone doesnt have an answer its because they realize they made a mistake. Although, I wasnt there and didnt here both sides. I just know from experience, if theres no explanation, they know their wrong..
  10. by   Tenesma
    Explanations:

    1) the change was made without anticipating future ICU needs

    2) the change was made for volume reasons and the QLC was either in the way or abutting the Quinton and needed to be removed, with a plan for a TLC/QLC down the line, but for OR management reasons that last line was delayed for ICU placement.

    Most of my MD anesthesia colleagues are attendings in the SICU as well - so we are acutely aware of line/drip/etc... needs of the patients. However, if it is a line that can be placed in the SICU then there is absolutely NO reason to prolong an OR visit for that.

    3) drips: levophed and vasopressin can be run together... If you are going on to CRRT then you no longer need a Bicarb infusion since that will be managed through the CRRT (unless you have really old machines), and you no longer need a Calcium port either since that will be managed via a sideport for the CRRT (unless you have really old machines and old tubing..) And ativan can be administered via boluses. Insulin can be infused with most solutions (except for a small handful). So the only dedicated line you need is for Xigris - however it can be administered via peripheral IV as well. So the only true CENTRAL line drugs you have here are levophed and vasopressin - which by all means should do fine with a Double lumen.

    My solution: instead of putting in the double lumen for volume, i would have placed a cordis for volume, and then placed a TRIC line through the cordis that gives you 3 individual ports...
    Last edit by VickyRN on Dec 30, '04 : Reason: Attacking statement removed...
  11. by   AmiK25
    Tenesma,

    Thank you for the thoughtful reply. The only real problem I had with the whole ordeal was that after the OR, the anesthesia provider basically said, "It is not my problem, find someone to deal with it." Well, the ICU team said they were too busy and the surgery team said they were too busy and I was stuck without a line. Finally, the attending surgeon sent a surgery intern up to the unit to put it in after a 2 hour wait. It really wasn't that big of a deal, I just wondered what the rationale behind the whole thing could possibly have been. BTW, our CRRT machines are new but we still run additional bicarb gtts for patients who are extremely acidotic and we are "discouraged" from running our calcium in the side ports of our new machines b/c we have had huge problems with them alarming for air in the tubing (even if there is no air). I was running the levo and vasopressin together but still needed a port for the xigris. The other problem was the calcium b/c it cannot run with vasopressin or bicarb according to our pharmacy policy. I actually did try a peripheral, as did a couple of my colleagues and a member of the IV team but this particular patient was extremely obese, as well as edematous.
  12. by   pigtails
    75 mcg/min of levophed!?
    Its sounds as though some other pressor, in addition to vasopressin, should have been tried. Does the patient still have their extremities?
  13. by   AmiK25
    Pigtails,

    We could not use dopamine b/c her heart rate was already in the 140-150 range. I pushed for neo but no one really thought it would do any good b/c she was so vasodilated, it was pretty much too late. Unfortunately, she does not have her extremities b/c she passed away. It was actually very sad b/c she came in for an elective procedure.
  14. by   OC_An Khe
    Nice thread and intersting responses. It does remind us that it is the needs of the patient over the long term and not our immediate needs that have to be taken into consideration when solving a short term problem. i.e. the valid anesthesia need for access.

close