Access while Proning

Specialties MICU


  • Specializes in Intensive Care Unit.

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. 

Specializes in Critical Care.

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.


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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