[ddoosier]

I work in a level one hospital in the SICU with two years experience. I would like some feed back. Here is the big picture...I recently admitted a twentyish male with GSW x3. His injuries are an aortic transection, DIC (which was corrected) SBI (r hemicolectomy) Abd and BLE compartment syndrome and has an open abd with heimlich to hws and BLE fasciotomies to multiple WV's. BP very labile, fluid dependent, on pressors , and many boluses and various transfusions required. Major resucs was applied intra op and post op. Post op < 24hr.. Pt is acidotic, Mech vent, on vec (TOF 0/4) very low dose of versed and morph gtts. He experienced an accute episode of desat from 90 to 70's and despite bagging was unable to achieve a SPO2 of 85 @ 0200. (His PI was .5 consistantly with Sats in the 90/s prior) Suspected PE (xray not definitive and unable to travel to CT). ABG's revealed severe acidosis (7.0) and his vent settings were set @ 100-22-20-22 and was SWANed. He eventually coded at shift change (no surprise). CPR was successful and lasted approx 5-8min. CRRT was started during day shift and his metabolic imbalances improved but was still hypotensive and third spacing. Pt became majorily anasarcic, the a-line crapped out and many attempts to insert another and obtain an ABG were unsuccessful. My vascular access was 2 PIV and a MAC cordis with side port and VIP. I was infusing Normal saline,epi, vasopressin, versed, vec, NaHco3 and various transfusions and boluses. I frequently warned the resident that my R PIV was crapping out and was pushing for extra access along with an a-line. My r PIV did crap out and the team inserted a femoral TLC. That morning during rounds the attendings were very upset about the central line placement. The residents were reprimanded and the attending complained to my assistant NM. Thankfully, I frequently kept my AN updated (I was very frustrated about my limited access and no a-line) throughout the shift. As a result, I feel that the resident threw me under the bus because the the attending felt that I was putting too much pressure to gain more access. Also during rounds, they decided to d/c the swan and rewire to a TLC. The R3 and the 2 R2's didn't catch this contraindication. Feedback from different levels of experiences is appreciated.

[starcandy]

I understand you needed more IV access for your patient, but why was the Dr. upset??

[sarahrain]

Normally, such a critically ill patient, we would keep a Rt CVL so that we won't have to rush to insert one when the patient is coded. If it is so urgent, why not you temporarily disconnect the sedation first. One lumen for the vasopressin and epi. The other for fluid challenge. One for monitoring the CVP and other bolus assesses.

[Conrad283]

IMO, I think that you did the right thing ...

[ddoosier]

They were upset because of the femoral CL insertion d/t to his IVC injury. i.e. it could clot ect. But I am glad that you asked this question. I didn't think of this contraindication at the time. I thought I would share. It is something that I will never forget. I did temporarily disconnect meds at different times (Insulin, Morph and versed). But I did need more access...Both of my PIV's were crapping out. I was infusing THAM at times and I had the BiCarb gtt. They both need dedicated lines. It was a good learning experience. I appreciate the responses. It is always interesting to hear how other RN's would handle this situation. Did you guys pick up the contraindication? Next time, instead of pushing for more access, I will just present the situation i.e...I have this many meds, this type of access and ask the MD what they want. The residents should have realized this contraindication. A more experienced RN may have. As for myself, I wish that I would have...but now I know.

[starcandy]

Originally Posted by ddoosier

They were upset because of the femoral CL insertion d/t to his IVC injury. i.e. it could clot ect. But I am glad that you asked this question. I didn't think of this contraindication at the time. I thought I would share. It is something that I will never forget. I did temporarily disconnect meds at different times (Insulin, Morph and versed). But I did need more access...Both of my PIV's were crapping out. I was infusing THAM at times and I had the BiCarb gtt. They both need dedicated lines. It was a good learning experience. I appreciate the responses. It is always interesting to hear how other RN's would handle this situation. Did you guys pick up the contraindication? Next time, instead of pushing for more access, I will just present the situation i.e...I have this many meds, this type of access and ask the MD what they want. The residents should have realized this contraindication. A more experienced RN may have. As for myself, I wish that I would have...but now I know.

I would have done the same as you and tried to get more IV access. No, I did not catch the contraindication, but we learn something everyday.

[gradcare]

contraindication purely relative. No access = dead. Hey you get it where you can. Very poor chest so sub clav line probably out, IJ perhaps but sounds like the vena cava was getting a little crowded. Besides you didn't choose where to put the lines, you just asked for more access.