Discontinuing IJ turned into a Rapid Response - page 2

I work on a Cardiovascular Intervention Unit. I've been on this unit almost 2 year which is the duration of my career. The other night I followed thru with an order to d/c a Rt. IJ (cordis sp?) central line on a patient that... Read More

  1. 1
    I'm an RN in a very large CVICU and we D/C IJ Cordis all the time. I agree with everyone else that you should always have pt lying flat as tolerated for just about any central line removal, esp an IJ. You'll likely be protected if your policy says you can remove while up in the chair. Also of note, to those saying they get clots in their cordis sheaths, I'm surprised your facility doesn't have you running TKO fluids all the time through the cordis to prevent that.
    tcvnurse likes this.

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  2. 4
    Quote from Da_Milk_of_Amnesia
    I worked on a CT step down unit and used to pull cordis with the PTs in a sitting position, usually in a chair. Never had a problem. However, ALOT of the cordis' that were pulled would always have large clots on the end of them if they were not properly maintained. **** happens, I wouldn't sweat it .
    You were just lucky. You'll have to admit that your experience is very limited. Give it time...
    Curious, I took a quick look on the internet just to see what the general consensus was on line removal. I know what I always do but I wondered if there was an accepted variation on the theme.
    In a word? No.
    Although clots were mentioned here there is also the possibility of an air embolus. Steps taken to prevent this include having the patient perform a valsalva maneuver during removal and having the patient lie flat or in a slight Trendelenberg angle.
    There is no way I would remove a line while a patient is sitting in a chair. Just because people have done it and nothing has happened doesn't mean it should be done.
    I've been pulling lines for decades and have always done it the recommended way. Even so, I've seen huge runs of VT when pulling PA caths that had me ready to hit the code button. All resolved spontaneously without intervention but I would have hated to have had those patients sitting in chairs if they hadn't come out of that rhythm on their own.
    Yeah, **** happens but some of it is avoidable. It even happens when we do all the right things but when we knowingly take shortcuts and do things wrong and it happens it's unforgiveable.
    The OP didn't realize that pulling lines while the patient is upright is poor practice. But I think she's learned a good lesson and she'll do better next time.
  3. 2
    I help to write policy and the goal not to write too much detail so that nurses hands are tied to do things in one way. Not always the best thing.

    The other take home about pulling lines beyond NEVER sitting that high up, is to always quickly hold pressure and apply an OCCUSIVE dressing to the site. A cordis leaves a coat hanger sized hole in a large vessel and not covering QUICKLY further increases risk of air embolism.
    tcvnurse and sevensonnets like this.
  4. 2
    A part of a problem in many units these days is that ones with high turn over, you dont' have staff that have "been there, seen it all, done that". What happens is that proceedures are taught over and over again and they may not be the best evidence based practice.

    It very well may be accepted practice in your unit to do so, especially if the policy lacks positioning the patient flat. So I'd hope that this invokes a policy change to limit complications to future patients. You will never be an expert on everything, but you will always have this experience as a safety tip for those you will mentor in the future... "let me tell you why this is so important....."

    We all have many of these stories to tell.
    sevensonnets and fiveofpeep like this.
  5. 0
    He did not have an air embolus, but a clot. His sitting position did not cause the clot. As someone else posted, improper line maintenance allowed the clot to form. Perhaps the Cordis line maintenance policy should be updated.
  6. 2
    FIRST never take a Central line out of a patient sitting in the chair, i'v seen at least 3 people code and 1 which died...
    sevensonnets and fiveofpeep like this.
  7. 0
    The current standard of care when d/cing any central line is flat in bed..have pt take a deep breath.....hold it (or valsalva maneuver)and then d/c it. If the pt can not cooperate to do this the second best thing is to d/c upon expiration. Next apply a sterile air occlusive dressing. You can use some Vaseline gauze or some betadine ung..just make it air occlusive...yes you can get air sucked in through the skin tract even after the CVC has been removed. If your nursing policy and procedure is not up to date or is incorrect...and you followed it....you can still be held accountable b/c they will say "you should have known better" You should have followed the current standard of care. I know what all of our policies say b/c I wrote them all...BUT sometimes when there is a delay in changing them ...I will follow the new standard. In this case for instance when INS changed it to an air occlusive dressing I started doing that right away. I know of a 7.5 million dollar lawsuit where the nurse followed the hospital policy and lost the case. They said that she should have known better and also she had an obligation to inform the hospital that there policy did not follow the current standard of care. When a nurse is sued that is always the question...did he or she follow the current standard in the situation. Sounds like a thrombus had formed on the end of the cordis and it became dislodged when it was discontinued. Complications do happen BUT you want to be providing safe and prudent care so no one can blame it on your nursing care..so the pt should have been in bed for the procedure.
  8. 0
    thanks everyone for the great information. it's practice on my unit to not d/c the cordis with the patient in trend. we aspirate but we dont do trend. Im going to always be sure to do it though now that Ive heard this nightmare from someone firsthand! how scary!
  9. 0
    Where I work, we call the hospitalist to DC the Central lines. I work ICU. Patient is always laying down.
    The only time we DC a central line is during post-mortem care.

    Do you have a policy and procedure regarding DCing central lines?
  10. 0
    A brief search of policy and procedures for various facilities across the nation indicates most facilities require placing the patient in a slight Trandelenburg position or with the head of the bed flat. Several P&P state the patient may not be in a sitting position during catheter removal. I recommend printing a copy of your facilities P&P for your records as well as writing a detailed summary of the events in case you need this later. Good luck and hopefully nothing more will come of this event.

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