Central line protocols

[brainkandy87]

Ok, so I ran across something new tonight in a post-code pt I was trying to get to CCU, thought I'd get input from other facilities. Long story short: older male, cardiopulmonary arrest, CPR in progress upon arrival, arrives with 18 g in LAC. In the whole crazy mess that is a code, I put an 18g in his foot and an 18g in his EJ. Got a pulse back, stabilized him, put him on Dopamine. Our CCU is notorious (well let's face it.. any CCU) for being hard to deal with and they enjoy finding any reason to not take a patient. So my CCU patients are always stylin' and profilin' (WOO! /Ric Flair). This guy has 18g IV site x 3, criticore foley, 18 fr OG, all clothing removed, all IV tubing orderly, pressures charted q 5 min, yada yada yada.

So I call report and I get about 5 sentences in to report when I get, in a very angry tone: "That patient can't come up here, he's on pressors and he doesn't have a central line. It's hospital protocol."

Alright, I work 6 days a week and take care of CCU patients on a regular basis. I've never heard of this "protocol" and have never had this issue with a patient on pressors before. Any time I have a pt on pressors, they always have 3 IV sites, code or not. So my question for the great minds of AN.com is this: do any of your facilities have this protocol? Granted, in a perfect world, a patient on pressors will have a central line. We don't always operate in that perfect world though. I assumed 18g x 3 is a very reasonable negotiation with that perfect world, but what do I know?

Also, a further question: does anyone in your facility other than the ER docs do central lines? We proposed that the hospitalist, who is an internal medicine doc, put the central line in when he sees the pt in CCU. No dice. "I don't do central lines." Any time someone in the hospital needs a central line, the ER gets called. I guess I halfway want to vent as well, because we get so much flak for "doing nothing." Grrrrrrr.

Anyway, input on this whole central line protocol would be much appreciated. Just curious to see how other facilities operate. Thanks guys and gals.

[Music in My Heart]

We have a patient who had Dopamine running in a 18g in the right medial antebrachial vein, the vein extravasated. Due to the Dopamine and the extent of the extravasation they do not think that the arm will be saved.

That's the thing... if you're running pressors peripherally, the patient must be assessed frequently. If you catch them right away and initial treatment, you can prevent necrosis.

For sure, though, they should have a central line place ASAP.

[Esme12, ASN, BSN, RN]

I work at a medium sized community hospital. He have a policy that a central line must be placed within six hours of initiating vasopressors. The ED docs can place CVCs, and the intensivists. We have a vascular access team of nurses that will place PICC lines in any of the units.

We have a patient who had Dopamine running in a 18g in the right medial antebrachial vein, the vein extravasated. Due to the Dopamine and the extent of the extravasation they do not think that the arm will be saved.

The six hour rule is being revised.

Watch the news!

This does happen and it does get reported but you would be AMAZED at what really goes on and never makes the paper.......frightening.

[sapphire18]

Very rarely will a pt come to us from the ED with a central line. We don't have anyone in-house to place central lines except the ED docs, though, and they only do them in the ED, before the pt is admitted. We call in the on-call surgeon when we need one, so they usually end up getting passed off to day shift. Boo.

[MunoRN, RN]

It doesn't seem to be all that complicated; patient needs a central line, this ICU doesn't do central lines for whatever reason (yes those ICU's do exist) but the ER doc can place one, so get it in before they go to ICU. I'm not sure why a lack of policy forcing you to do it has anything to do with it. (I'm also not sure how 3 peripherals equals a central line).

[NurseOnAMotorcycle, ASN, RN]

So basically you have a sick, sick, sick patient and the CCU refuses them? Guess you should just discharge them. Geez.

[Guest343211]

Well, I did let my director know, who contacted the CCU director. Apparently they had this issue in the past, but not lately. I spoke with quite a few people, including my director and one of the hospitalists, and no, there is no policy in our hospital that says anything that this nurse stated. Thanks for all the input.

No policy after all that? Wow, typical BS.

Document and send to risk mgt, and other appropriates. Seems like they need a policy one way or the other.

[Guest343211]

That's the thing... if you're running pressors peripherally the patient must be assessed frequently. If you catch them right away and initial treatment, [i']you can prevent necrosis.[/i]

For sure, though, they should have a central line place ASAP.

Not always, I saw a kid's leg go to crap in a matter of seconds--stopped infusion right away! That kid still had a nasty tissue injury--and that was with acceptable amount of K+ in the IV infusion. This kid was super sensitive indeed.

You never know with people.

For dopa extravasation, phentolamine, isn't fun, and neither is being the nurse that has to give it.

Here's a link to a good article:

Infiltration and Extravasation: Update on Prevention and Management

[brainkandy87]

It doesn't seem to be all that complicated; patient needs a central line, this ICU doesn't do central lines for whatever reason (yes those ICU's do exist) but the ER doc can place one, so get it in before they go to ICU. I'm not sure why a lack of policy forcing you to do it has anything to do with it. (I'm also not sure how 3 peripherals equals a central line).

I never said 3 PIV = central line. The whole point is that the CCU was attempting to refuse this patient, a post-code, who we stabilized, over a central line placement. That's not acceptable.

[Guest343211]

I never have worked in any ICU or CCU or SICU, whatever, where anyone refused to take an admission for not having a central line--especially post-code.

They would have had to get someone to put the central line in--usually a resident or fellow--in a decent period of time, but we would have been using the EJ for the dopa. Realistically, I am just saying. Seriously. And, it would have meant we would have had to move some other >guarded (quazi-critical) patient to some step down or tele ASAP. I can't count how many times I have had to bust my orifice doing this, and sometimes the other patient--the one in the bay you must move--has been moved yet, b/c the floor doesn't want to take report.

I am all for being safe with meds and lines, but this is not how it has rolled anywhere I have worked. And I have worked in a ton of units.

With the kiddies, in the kiddy hospitals, well, mostly they'd just roll em up and put lines in up in the unit--only without as many of the delays you see with adults. Biggest realistic difference IMO.

Why so many people are set on being PIAs, I will never know.

[iluvivt, BSN, RN]

NO...We do not have this policy. The only thing that MUST be given centrally with no exceptions is TPN and continuous vesicant chemo...Lipids can be given in a PIV b/c it has an osmolarity similar to blood. Now there are many medications that are optimally given in a central vein b/c they are either chemically irritating or b/c they have a low or high ph, or they are inherently irritating . Then there are those meds that should they get into the tissue can cause mild to severe tissue damage. When this happens it is called " an extravasation" so if Ca chloride gets into the tissue b/c your PIV went bad it extravasated as opposed to some Rochepin that would be infiltrated.

So some of the medications that can cause tissue damage are CaCl,contrast media (esp ionic types)the chemo vesicants,most all of the vasopressors esp Dopamine and Levophed. An eample of a low ph medication is Vancomycin and a high ph medication is Dilantin. Of interest, the worst vesicant known to man is Adriamycin.

So with any patient scenario and treatment options the nurse and MD must look at the risk versus the benefit. Clearly, in you situation the patient needed the vasopressors to sustain life and those needed to get started right away. In most cases a PIV is the fasted way to go. If time permits a central line can be placed when feasible. You had 3 good PIVs in so they even had backup. The goal is to put a small cannula in a large vein that is NOT at an area flexion . You are taking a risk putting a vasopressor in the ACF. The extravastions in these sites can be more difficult to detect early and the sites tend to eventually leak and the med can then back track into the tissue. So that is one thing I would have made certain to do and that is put the vasoprressor(s) in the juicy large soft vein with a 22 gauge and secure it very well and no wrist or ACF or hand sites, Pick a site with good tissue such as a FA site, Since the hand has very little tissue extravasations can be horrid here with tendon damage and loss of function. The ACF extravastions can be horrid too causing nerve and potential loss of limb.

I think if you mandate that a central line must be placed to administer certain medication you hogtie the clinician and this can delay treatment. Better to train all staff to make ggod clinical decisions and detect infiltrations and extravasations early. Then of course, get the central line in place as soon as you can. WE do this every day...ED places PIVs usually then we get a PICC order...the pt goes to one of the ICUs....we come along and place the PICC. Once in awhile we get a break and they put in a percutaneously placed CVC and or Swan so we can delay PICC placement sometimes. The other thing the ICU nurse probably wanted was to get CVP reading. If you do have staff to get a cental line in within 6 hrs that is great. I know that does not always happen where I work esp at night but you have to be careful with policies b/c if you put that in writing it could come back to bite you should anything happen. I like to word things with abit of an out,,I would say something like ," Place a central line when clinically indicated and optimally with in 6-8 hours. That way if is placed 9 hours after the vasopressors are started you have stayed within the policy.

[DC Collins, ASN]

We don't have that protocol at our hospital to my knowledge. At least I haven't heard of it and have never had a pt denied for it. For that matter, I have never heard of our ICU refusing a pt at all.

Aside from that, our hospitalists do Not put in central lines, or intubate patients, or anything else emergent like that. I can't fault them, their pt load is incredible!

Aside from the ED docs, on occasion, we do have an IV nurse around who can put in central lines. Or at least we have. I work nights, so I don't see any of these people often, but I have once.

DC :-)

[DC Collins, ASN]

It doesn't seem to be all that complicated; patient needs a central line, this ICU doesn't do central lines for whatever reason (yes those ICU's do exist) but the ER doc can place one, so get it in before they go to ICU.

I wish it was always that simple. In our hospital, the ED docs do the central lines. On the night shift, sometimes the *one* ED doc has a pile of patients, some of them critical, and they don't have time to do a central line on a pt otherwise ready to go to the ICU when he/she is running a code and overseeing a septic pt plus all the 'normal' pts, etc.

DC :-)