central lines

  1. We have a thoracic surgeon who will put in a subclavian line. He orders a chest X-ray (per policy) then insists if he writes the order to use it we should, without waiting for xray results. Also he recently had a triple lumen that ws found to be coursing upward toward head. He also insisted this is Ok to use as there is no documentation to prove it's harmful. Please advise. We have been arguing with this Dr for years.


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  2. 12 Comments

  3. by   LRichardson
    << insists if he writes the order to use it we should, without waiting for xray results. Also he recently had a triple lumen that ws found to be coursing upward toward head. He also insisted this is Ok to use as there
    is no documentation to prove it's harmful. >>

    Your doctor is out of line on several fronts.. first.. he's going against hospital policy which states you must have xray results (and DUH I bet they came up with that protocol for a REASON!).. second.. just because he writes it.. doesn't remove us as RNs from culpability.. if there is a patient complicaton our license.. uhmm and our butts would be yanked into court right along with his! He needs to get over his "nurse as handmaiden" mentality and come into the 90s <grin>

    As for the proper placement and research showing the danger when not placed as intended.. well.. I havent' seen any. but I haven't looked.. next time I go to the library I WILL look it up.. off the top of my head though I can think of some drugs I sure wouldn't want to give unless the catheter was in proper placement..

    PRESS ON!!! Fight his irrational thinking with Facts.. and you'll win everytime.. promise
  4. by   Cindy Johnston
    Did that doc mean that it was in the internal jugular vs. the subclavian? I have, in previous years, in Texas , cared for many that were in the IJ, some docs preferred it. Don't know about any studies, tho...And I absolutely concur about the xray bit...He was just probably wanting to assert his "authority" or compensate for a small you-know-what... grin
  5. by   LRichardson
    When referring to internal jugular vs subclavian .. you're referring to place of origin, correct?? I think the problem is when the origin is the subclavian and the catheter winds up into the internal jugular.. hence any drugs given through it would be directed toward the head rather than the heart.. and it's been a while.. but if I remember correctly the length of the IJ prior to branching into smaller veins is not that long.. therefore, if you're giving some especially caustic medications (especially if going at a fast rate) there would be a greater opportunity for damage to the vessels.. and those vessels being in the head.. OUCH.. not good.. but hey.. that's just me trying to be logical..

    Oh.. and I loved your comment about uhmmm compensating <giggle> <grin>
  6. by   nowplayingEDRN
    Well that is one reason why any place I have worked has the protocol.....xray for verification, then MD writes the order to use.....you want it in the appropriate spot which is right above the right atrium.....obviously if it is a swanz then it is going to be advanced farther.....this little black duck would not be using any Central Line that was not in the right spot and if I had heartburn with the doc over it....I'd find me the nearest supervisor and we would clear the air up really fast.
  7. by   renerian
    I would not use till placement was verified despite any irritation the surgeon may display.

    renerian
  8. by   Sue McGann
    The hospital wants to change their policy stating that nurses may initiate IV therapy prior to catheter position confirmation with a chest x-ray. I can see that you are also have sort of the same problem. I do not agree with the practice due to my years as a hemodialysis nurse and a Critical Care nurse. But I have a list of articles that support the practice. Now I want to research the number and typrs of law suits due incorrect line placement.
    I will copy the references below
    Guth, Amber A. M.D., F.A.C.S. Routine chest x-rays after insertion of implantable long term venous catheters: Necessary or Not?" The American Surgeon. January, 2001. Vol. 67, pp. 26-29.

    Riblet, Jeffrey L. M.D., Shillinglaw, William D.O., Goldberg, Amy J. M.D.; Mitchell, Kevin M.D.; Sedani, Khemraj H M.D.; Davis, Frank E. M.D.; Reynolds, Neal M.D., "Utility of the routine chest x-ray after 'over-wire' venous catheter changes." PP. 1064-1065.

    Cullinane, Daniel C. M.D.; Parkus, David E. M.D.; Reddy, V. Sreenath M.D.; Nunn, Craig R. M.D.; Rutherford, Edmund J. M.D. "The Futility of Chest Roentgenograms following routine central venous line changes." The American Journal of Surgery. September, 1998. Vol 176. pp 283-285.

    Sanabria, Alvaro M.D.; Henao, Carlos M.D.; Bonilla, Romulo M.D.;Castrillon, Carlos M.D.; Cruz, Herman M.D.; Ramirez, William M.D.; Navarro, Pablo M.D.; Gonzalez, Mercedes M.D.; Diaz, Abel M.Sc. "Routine chest roentgenogram after central venous catheter insertion is not always necessary." The American Journal of Surgery. 186 (2003) pp. 35-39.

    Lucey, Brian; Varghese, Jose C.; Haslam, Philip; Lee, Michael J. "Routine chest radiographs after central line insertion: mandatory postprocedural evaluation or unnecessary waste of resources?" Cardiovascular and Interventional Radiology. 1999. 22. pp 381-384.

    Gladwin, Mark T. MD; Slonim, Anthony MD, Landucci, Dante L. MD; Gutierrez, Deborah C. BSN; Cunnion, Robert E. MD. "Cannulation of the internal jugular vein: is postprocedural chest radiography always necessary?" Critical Care Medicine. 1999 Vol. 27, No. 9. pp1819-1823.

    Amshel, Craig Edward MD; Palesty, J. Alexander MD; Dudrick, Stanley, MD FACS. "Are chest x-rays mandatory following central venous recatheterization over a wire?" The American Surgeon. June 1998. Vol 64. pp 499-502.
  9. by   nursenatalie
    Ok, if the doc, or anyone else wants to use the line prior to x-ray results then why get the x-ray in the first place?
  10. by   butterphlyrn
    I had a physican tell me once to go ahead and use a patients subclavian central line before getting a chest x-ray. I really didn't need to use the line emergently so I waited til I got the chest x-ray. I was glad that I did because once we got the x-ray results back, we were setting up for a chest tube because the catheter was in the patients lung. We couldn't tell clincally because the patient really wasn't showing sings of a colpased lung. His pulse Ox was lower than it had been.

    So I always practice, teach, and advise Rn's to wait on the x-ray and if a MD wants to use the line before the results are back you tell them to go right on ahead and they need to stay and monitor the patient. Then you tell them that you will write in your nursing notes that MD advised not to use central line without results on placement ect...................
  11. by   ratchit
    The thoracic surgeon is probably used to calling the shots the way he does in the OR. They don't check his lines first there, why should he be restricted by your rules?

    Always cracks me up that they will place lines in the OR, then check an Xray in the PACU or ICU. Had a patient today who had 10 liters of fluid run through his new central line before he got to me. Of course, I had no other access and wasn't supposed to use that line for his dopamine and levophed until I got an xray.

    Dontcha think we would have known if 10 liters of fluid including 6 units of PRBCs were sitting on top of his left lung? <rolling eyes>
  12. by   Rapheal
    I just recently encountered this situation on the floor. Doc told me okay to use the line before the x-ray. I did but after reevaulating my decision decided never to do this again. If it was placed wrong I know the state board isn't going to accept me saying "but he said it was okay", or the guilt I would feel if the patient was harmed and I could have prevented it but didn't because I was afraid of the doctor's disapproval.
  13. by   butterphlyrn
    My situation wasn't a patient from the or to the unit. It was placed on the floor by the intensive care doctor and had I used it I would have bolused her lung.

    I do however use the line that I receive from the or. I agree with you about getting patients from the or and using the line, but when they are in ICU, I wait for the film because I am not going to take that chance having a MD place a cather in the lung before
  14. by   mags-rn
    Originally posted by pjdk9
    We have a thoracic surgeon who will put in a subclavian line. He orders a chest X-ray (per policy) then insists if he writes the order to use it we should, without waiting for xray results. Also he recently had a triple lumen that ws found to be coursing upward toward head. He also insisted this is Ok to use as there is no documentation to prove it's harmful. Please advise. We have been arguing with this Dr for years.
    Referring to this specific question whether a line in the jugular vein could be used, the answer is no for the reasons given below. There may not be evidence in the literature about such things where common sense is needed!

    I would say that a check X-ray is mandatory for all central lines inclusive of peripherally inserted lines. Apart from recognising complications like pneumothorax, you do not want to rely on pressure measured outside thoracic cavity or infuse vasoactive or hypertonic solutions like TPN elsewhere than the desired site. There may be situations where you cannot wait or cannot do a check X-ray (for example perioperative period). In these situations as long as one is able to aspirate blood in all the lumens and there is a convincing pressure trace with appropriate pressures, I do not see any reason to start using the line without an x-ray. If these criteria are not met, I would have a high suspicion and hope a check X-ray was done at the earliest. Regarding line tips migrating to the jugular veins, pressure on the jugulars would cause distortion of the wave form and pressure.

    We recently had a patient who sustained head injury and admitted under the neurosurgeons. On the third day patient had features of acute abdomen. Patient also had left sided pleural effusion. Differential diagnosis including pancreatitis were considered. Before using the central line inserted through the femoral route, the registrar tried to aspirate the line only to get some clear fluid. The line was not used and another access was secured. On reviewing the abdominal X-ray, it was found that the line was coiled in the same side (left) iliac fossa. Patient also had some 3 litre fluid in her pleural space which was of the same colour wh8ch was aspirated out. This patient had received all drugs including Mannitol and fluid through the line inserted in the femoral region for three days. All she needed was removal of the line and throracocentesis!

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