Central line protocols

Altra, BSN, RN · Aug 28, 2012

I work in a teaching hospital -- lots of residents willing to put in lines.

And ... if someone in the unit really *had their thinking cap on* ... they might have been more concerned with the lack of an a-line for a patient with pressors being titrated, than a central line ... just saying.

Double-Helix, BSN, RN · Aug 28, 2012

It seems like the priority would be getting the patient to a higher level of care where he can be more closely managed, rather than leaving him in the ER while a central line was put in. No, a PIV is not ideal for running pressors, but if it's all you have, it's all you have. Were you able to find this protocol written anywhere? Seems like a great issue to escalate to your manager, the CCU manager, and higher if need be.

I work in Peds ICU, so our practices may be less applicable to your setting, but we rarely have central lines placed in the ER. ER will stabilize the kid with whatever quick access they can get and bring them to us ASAP. Our intensivists and our residents place the central lines (although a resident never places one without an intensivist at the bedside). In our adult ICU, the doctors there do place central lines as well.

I'd encourage you to take this up with your manager. If indeed it is a correct protocol at your facility, maybe they can give you some insight as to why. If it's not a protocol, the issue should be addressed with both the ER and CCU so that other patients don't have their escalation of care needlessly delayed.

I'm curious, though, what was the resolution?

Music in My Heart · Aug 28, 2012

Well, dopamine should (ultimately) go through a central line (and as Altra pointed out, have an a-line in place for titration) but an 18 in the LAC should suffice for hours.

There's nothing to argue about, though: Either the intensivist accepted or they didn't; either hospital protocol says they must have a CL in place before they move or it doesn't.

Once you know the protocol, don't argue with them, just insist on giving report and send the patient. If they refuse to take report, get their name, call adminstration, and let them fight it out (if need be)... and then file an incident report (not punitively, simply because the system is obviously broken).

Sun0408, ASN, RN · Aug 28, 2012

Rarely do pts come up from the ED with a central line. If one is needed, we ask the MD's or PA's to do it at bedside once the pt has arrived. On occasion the pt will leave us within 30 minutes for the OR, from there we call the OR and have them put in the central line and A-line.

That is strange what you describe, maybe the CCU nurse was correct but mistaken a bit.. Pressors are best in a central line but that doesn't mean she couldn't get a line once the pt arrived. I would talk with the CCU NM and your NM to sort this out.

nuangel1, BSN, RN · Aug 28, 2012

no residents in my community hospital .icu pt in ed on pressors requires central line.our er doc or the 2 intensivists that run our 2 icu's has to place it .it does get to be an issue at times as to who places it and when .they expect the ed doc to do it in the ed.but thats not always possible.i don't know that its a written policy.but it is the expectation.

Anna Flaxis, BSN, RN · Aug 28, 2012

No, we don't have this protocol. If there is time in the ED to place a central line, one of our ED docs will do it. If not, it has to be done in the ICU by the intensivist. "I don't do central lines" is not an acceptable phrase for an intensivist or an ED doc in our facility to utter. If you do not do central lines, then you have no business taking care of critical patients. Period. But, as mentioned above, you need to find out if your facility really has this policy.

Guest343211 · Aug 28, 2012

It seems like the priority would be getting the patient to a higher level of care where he can be more closely managed, rather than leaving him in the ER while a central line was put in. No, a PIV is not ideal for running pressors, but if it's all you have, it's all you have. Were you able to find this protocol written anywhere? Seems like a great issue to escalate to your manager, the CCU manager, and higher if need be.
I work in Peds ICU, so our practices may be less applicable to your setting, but we rarely have central lines placed in the ER. ER will stabilize the kid with whatever quick access they can get and bring them to us ASAP. Our intensivists and our residents place the central lines (although a resident never places one without an intensivist at the bedside). In our adult ICU, the doctors there do place central lines as well.
I'd encourage you to take this up with your manager. If indeed it is a correct protocol at your facility, maybe they can give you some insight as to why. If it's not a protocol, the issue should be addressed with both the ER and CCU so that other patients don't have their escalation of care needlessly delayed.
I'm curious, though, what was the resolution?

I agree. This is generally how it works, whether in peds CICU or adult Cards ICU or ICU.

You just got to love all the passing of the buck.

Dopamine, particularly if higher than renal is typically to be run through central access, but paramedics run through EJ; although, as per hospital and unit policy, what paramedics do doesn't necessarily matter.

Solve the issue by asking the supervisor or manager what the policy indicates. If this is policy, well, ED and ICU department heads need to discuss this. If patients need to be moved, this should be settled and all should be aware and in compliance of policy.

In a teaching facility, residents and the like would be jumping at the opportunity to put in an art line and central line, which is probably the best temporary deal for this patient

BigheartRN · Aug 29, 2012

Hi! As a former trauma SICU nurse we would get numerous patients sent up from the ED or trauma bays without a central line in place and pressors usually infusing. The resident/fellow/attending or whoever was available would place the central line and readjust the pressors and we would continue to stabilize the patient from there. I have never ever heard of us refusing a patient due to the fact they don't have a line in place, they are not intubated, etc... Usually the ED stabilizes them as much as they can and transfers them to us so we can continue the care at a more "intense and focused level".

Asystole RN · Aug 29, 2012

I work at a medium sized community hospital. He have a policy that a central line must be placed within six hours of initiating vasopressors. The ED docs can place CVCs, and the intensivists. We have a vascular access team of nurses that will place PICC lines in any of the units.

We have a patient who had Dopamine running in a 18g in the right medial antebrachial vein, the vein extravasated. Due to the Dopamine and the extent of the extravasation they do not think that the arm will be saved.

The six hour rule is being revised.

Watch the news!

Guest343211 · Aug 29, 2012

We have a patient who had Dopamine running in a 18g in the right medial antebrachial vein, the vein extravasated. Due to the Dopamine and the extent of the extravasation they do not think that the arm will be saved.

This is true. Dopamine can do some very nasty things to tissues. People have to do what is priority, but I say, get the central line ASAP to prevent other problems--b/c they definitely DO happen. I have even seen super nasty damage from diluted K+ infusions.

brainkandy87 · Aug 29, 2012

Well, I did let my director know, who contacted the CCU director. Apparently they had this issue in the past, but not lately. I spoke with quite a few people, including my director and one of the hospitalists, and no, there is no policy in our hospital that says anything that this nurse stated. Thanks for all the input.