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Discussion

Access while Proning

So I have a question for some more experienced ICU nurses, I hadn't seen this before but I have only been an ICU nurse for 2 years. 
 

I had a patient who was very fluid overloaded, but not requiring pressors. He had been in our ICU and vented for 2 weeks when his hypoxia and oxygenation status plummeted on my shift. We were having to bag him back up to the 90s, he was desatting without being touched on 100% FiO2, we got a chest X-ray and we're hoping there was a pneumo or something we could fix but of course, it was unremarkable. 
We were maxxed on all sedation including propofol, fentanyl, Precedex and now versed. They considered adding Ketamine but held off for the time being. That morning I started him on Nimbex with the goal to prone him during dayshift. 
My apps had put an order in for a PICC line but it was never done. My APP was tempted to throw a CVL in him during my shift but we were scared to lay him flat. 
I have only proned patients a few times. And when proning, im very much used to having CVL access rather than PIV. Granted, I at least had an arterial line but I felt as if it was pretty important to have a central line considering the amount of sedation, paralytic, and other broad spectrum antibiotics we had the patient on while waiting for cultures to come back. My main concern was that Nimbex is a vesicant and with my patient proned, if my IV is infiltrated, I wouldn't be able to tell until my patient suddenly not paralyzed while being proned. Accessing your IV sites while the patient is proned is next to impossible. I mean, it's possible if you want to play twist arms with your patient. 
Am I overreacting? I kinda assumed a CVL and arterial line would be basics when it came to proning just because you never know if they may require pressors and of course paralytics. 
I tried researching and didn't find much info either. 

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    If they're sick enough to be proned they're sick enough for central access. Mortality at that point is basically a coin toss and I'm not dealing with a patient trying to die while losing a #22 in a wrist while they're on their stomach. It's a recipe for disaster.

    To me, it's non-negotiable.

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    Uff da.... Brings me back to the old COVID ICU days..... I would definitely take the time to advocate for a central line at that point. Thinking even beyond the paralytic, I'm going to want solid access for when this patient eventually codes. I hope it all worked out for both your patient, and yourself. I do not think you are overthinking it, in fact I like where your head is at. While laying the patient flat might be extremely risky, it's less risky than flipping them on their stomach with just a 22g in their hand. If needed, I would bag the patient while the line is placed if that made the providers more agreeable. 

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    I've proned plenty of people over the past few years with PIV access only. Believe me, it's not because us nurses didn't want the central access, but there was a bump in the CLABSI numbers during COVID when everyone was getting central lines so they really cut back on who "needed" one for a while. Unless they were on pressors, we weren't getting it. (I tried many times to get the data and find out was this an increase in the infection rate or just the total numbers because we had more patients with central access at the beginning of COVID than we had ever had before). Our ICU has always been pretty stingy with central access. 

    With proper positioning using pillows and wedges you can actually get reasonable mobility to access arms for sites and for site checks with running infusions. And if you have a team that's skilled in the head turns and repositioning you can keep sites even during large turns. As I said, not ideal, but sometimes it's what you have to do. 

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    I used to be an ICU NP for over 10 years but has since switched to Cardiology in the last 3 years. I don't have access to our proning protocol at the moment but if I were the provider working on that patient, I would have placed a neck CVL prior to proning. There are so much drips being used and they are essential to the point that a PIV infiltration would have been hard to detect (due to the positioning) and would have caused harm to the patient if it does occur. A neck line would be so easy to inspect and to protect during the process of proning. Also, some patients do develop hemodynamic instability with the change in position so I would want to make sure that a pressor can be hooked up easily. PICC line may work but in our institution, the venous access nurses who do PICC lines tend to prefer placing them on floor patients and those ready for discharge (maybe to protect their number of complications). 

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