[JiffyGriff]

Have a question, I'm doing my preceptorship in my hospitals ICU right now. I love it by the way. Last night I was taking care of a patient that was on CVVHD (Citrate), LR & NaCL replacement @ 500, CaCl @ 40, TPN @ 75, Insulin gtt, and various antibiotics for some E. Coli and Candida in an abd. surgical wound. She had a R. Fem. Vas Cath for the CVVHD, a triple lumen L. IJ, a L. subclavian quad lumen, and a L. antecubital A-Line. So here's what happened, she had standing orders for a 500cc NS bolus for CVP < 6. Her CVP readings weren't very accurate and we couldn't get the machine to print out, we re-zeroed the transducers and flushed the a-line out real good so that we would have a slightly better reading. A little later she was running about a cvp of 3-6 with pressures in the 90's/30's, previously had a cvp of 6-8 and pressures of 100's/40's. Decided to give her a bolus and found an appropriate lumen on the L. Subclavian, hooked it up and started it at 1000. Wouldn't go in, so I decided to flush, grabbed a flush and flushed it through, it was a little congested. Started the bolus and looked up........ patient's pressures 180s/90s........ ...flipped my lid, stopped the bolus and got my preceptor which was like 2 seconds away. What we decided was that the nurse before us that had been running a Levophed drip for the first half of her shift, D/C'd it without aspirating the drug out of the line... . Pressures came down after about 20 minutes.....a little morphine helped it out some too, and we still ended up giving 2 bolus's from then on out. Everything was peachy.

My question is first of all, does this happen often......cuz that's a little scary? and Second, would it be good practice for me if a patient had been on any hemo drip should I go ahead and draw 10cc's out of those lumens before I give anything through them? What if I don't know what lumen the pressor was in and there are like 4 lumens open, can I draw 40cc's off of an unstable patient? and Do I count aspirates like that as output as well as aspirates prior to blood draws or is that being anal?

[steelcityrn]

First off I would check the policy book there on iv meds and flushing. I have never worked anywhere where it was common to draw back lines before giving another iv. And yes, I do think that you may be a little too concerned about the temporary increased b/p, but I could never fault ya for caring sooo much. Keep up the good work!

[dorimar]

you should be able to count on a clamped line being flushed of any drug (except of course a vas cath for dialysis which will have heparin in it and need to be withdrawn before using).

[JiffyGriff]

First off I would check the policy book there on iv meds and flushing. I have never worked anywhere where it was common to draw back lines before giving another iv. And yes, I do think that you may be a little too concerned about the temporary increased b/p, but I could never fault ya for caring sooo much. Keep up the good work!

Thanks for the sarcasm, I'm rolling on the ground. I guess you missed the part where I said I was doing my preceptorship, my third night EVER in the ICU. And yes, when my patient's pressures jump almost 100 points in about 20 seconds and stay there, yeah, I'm gonna be worried about it, esp. when I had no clue what happened.

I just wanted to know if it was a common problem for people to leave potent pressors in the line like that.

[ZASHAGALKA]

Incidentally leaving drugs in line is not a common practice or problem.

BUT.

I WAS taught to aspirate off a few mils before flushing when securing lines from surgery/other units for the first time.

~faith,
Timothy.

[TennRN2004]

Originally Posted by JiffyGriff

Thanks for the sarcasm, I'm rolling on the ground. I guess you missed the part where I said I was doing my preceptorship, my third night EVER in the ICU. And yes, when my patient's pressures jump almost 100 points in about 20 seconds and stay there, yeah, I'm gonna be worried about it, esp. when I had no clue what happened.

I just wanted to know if it was a common problem for people to leave potent pressors in the line like that.

I would agree that if a gtt like Levo was stopped, the prior nurse should have flushed your line when the gtt was d/c'd. Especially in a patient with a need for so many IV accesses, you don't want to lose one of your ports because it wasn't flushed properly. Personally, in my practice, I don't aspirate before giving a med, unless as another poster stated it is a vas cath access and you pull back the heparin. I've never had a problem like what you saw, or can't think of anyone I know who has in my ICUs, but it is always a possibility. You're better off questioning these types of situations though as a new nurse, rather than assuming it's no big deal.
I'd rather ask and it turn out to not be something rather than not ask and have something bad happen to my patient.

[JiffyGriff]

Originally Posted by TennRN2004

You're better off questioning these types of situations though as a new nurse, rather than assuming it's no big deal.
I'd rather ask and it turn out to not be something rather than not ask and have something bad happen to my patient.

Good point.

[MommyandRN]

I have never aspirated back after giving a med. Always flush. The nurse before you should have flushed the line, yes. But don't think you have to aspirate back after everything you give IV. That would get ridiculous. Flushing with 5cc -10 cc is plenty.
As for counting I's and O's, when I was a new nurse I though that too, that I had to count every flush, every blood draw, and waste. But my preceptor told me all of taht was miniscule, since I's and O's aren't that exact. Makes sense. We probably flush in as much as we take out in blood draws so they cancel each other out. Always count I/O as exact as possible but when you are flushing lines all day you can't be expected to count each cc you put in and take out of them.

[JennInColumbus]

I'm fresh out of my training as an SICU nurse and one of the very first things I was taught was to always aspirate my lines before doing anything if I don't know 100% that they were flushed. It's not usually a problem for patients being handed over at shift change on the unit, but with transfers from the floor it is one of our first tasks.

A lot of people come to us with pressure issues and have had vasoactive drugs running previously. IMHO, you were lucky (yah!) that you learned this lesson with a patient who was unharmed because you will never allow it to happen again. You were right to be freaked. I hate it when I learn something the hard way, after never having been told the right way!

I wouldn't have wished this experience on you, but as long as you walk away having learned from it, I think you should let yourself off the hook.

[nicolentony]

It OCCASSIONALLY happens in my place of work. As you get oriented to your unit more, you'll understand who are the lazy RN's. If you follow them, you know you have to be careful everything is labeled correctly, lines are flushed and clamped appropriately, etc.
I always aspirate back on a lumen after I d/c a vasoactive med and then flush with 10ml NS and clamp.
I also find that if they do get bolused with levo or neo or vasopressin or ntg, if you wait a couple minutes, the pressure will stabilize without intervention. As a new nurse, though, I did what you did. Everything is a learning experience.
Good luck to you!