Central line protocols - page 3

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... Read More

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    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 arse 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.
    Altra likes this.

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    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.
    ~*Stargazer*~ likes this.
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    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 :-)
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    Quote from MunoRN
    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 :-)
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    Sorry- I'm confused here.
    Are anesthesiologists not part of cardiac arrest teams?
    In the socialised healthcare system in the UK they would be the ones to place a central line in a patient in ED if it was required post arrest, or they would go with the patient when they were transferred and do it there.
    A central line would be required if a patient was post-arrest and needing dopamine,least of all to monitor CVP,let alone for admin of the dopamine. What's the likelihood of pt having another arrest and requiring more infusions? Surely best to get the line in ASAP whilst pt is stable.

    I've never heard of having a department that calls itself Intensive care but doesn't have Docs who can insert central lines.
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    A lot depends on the size and type of hospital. In our case, our group has 5 hospitals in our particular region. While they all do elective surgeries, the central, larger hospital does most of the emergency surgeries, has the cath lab, etc. My particular hospital has an ED with 18 main ED rooms + up to five hallway beds, two 'fast track' rooms with a number of chairs where these pts once examined can sit and wait for diagnostic procedures or discharge. Oh, and the main ED also has five other recliner type situations where pts can be pulled from main ED rooms once initial workup is done if the main ED bed is needed for something else. This is a smaller ED than our central, trauma ED (with cath lab) is.

    Our ICU has, I can't remember for sure, 9 or 10 beds.

    I guess my main point is, small hospital with small staff. There is no 24/7 surgery so no 24/7 anesthesiologist. And, our ED is small enough that approx 1/3 of the day we only have 2 ED docs, and 1/3 we only have 1 ED doc. If that one ED doc is swamped...

    DC :-)
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    Goes case by case, if the patient has pipes we feel comfortable to admit with at least 2 large bore IV's. If they have crap for veins, the ED doc will throw in a CVC before admission. Sometimes we have the time to do everything, sometimes not. But our policy is CVC within 12 hours of pressors.

    I wish we had more PICC nurses...
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    No. We don't have this policy. Frankly, if you have someone refusing report, say " ok, if you refusing report, I will contact bed management. If they believe their story, they will stick with it. Otherwise, I don't do drama.

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