I'm an RN orienting on a medical/telemetry floor. Yesterday, I helped care for a patient w/ESRD (dialysis 2-3x per week). He was admitted to the hospital for cellulitis in the arm with a new A/V fistula (not healed enough to use).
This patient has no IV access-even if a peripheral line is inserted (very hard), it blows with the first dose of IV Dilaudid. He's had too many PICCs in the past and IV therapy refused to even try to start a line on him. He had a permacath placed about 3 days ago and it looks like an abscess has developed.
The docs keep ordering IV medication-specifically Vanc and Gent. My preceptor and I spent nearly all day trying to straighten out this IV access issue (on top of dealing w/a chest pain patient, a GI bleed patient, the list goes on).
Basically, a doc ordered another PICC and the folks in special procedures said one cannot be inserted. IV therapy again refused to try to get another line into him. The doctors told us to run the antibiotics through the permacath as it is his only access and we need to keep that access (hence abx for the abscess).
My preceptor refused to run the abx. I believe that this refusal iwas based on our understanding that it shouldn't be done. The permacath should only be used for dialysis. The docs kept insisting to run the abx in through the permacath.
We ended up calling a dialysis nurse that ran the abx.
Can anyone tell me if this was the right/wrong thing to do or what else could have been done to get the abx into this patient?
Aug 22, '06
In my experience if a Permacath must be used for antibiotics or blood transfusions it is done at the end of dialysis. The problem with a med/surg nurse using the Permacath for infusions is the large amount Heparin that is placed in the cath after dialysis. If you do not withdraw the Heparin before using the cath you are placing the pt at risk for bleeding. These docs need to get a clue about the risks involved for the pt. Can't they place a femoral line if all upper extermity access is ruined? I agree with your instructor, she was protecting the pt and her license.
I did have one pt who had terrible venous access and once his AV shunt healed enough for dialysis we kept NS going on his Permacath and used it for infusions.
Aug 22, '06
Thanks for the reply! Very helpful for the future. I think this gentleman had a femoral line before but he has bilateral bka now--maybe not possible anymore?
Anyway, thanks so much. I couldn't help feeling like we dumped on the dialysis nurse.
Aug 23, '06
With an order from the nephrologist any IV maybe run into a dialysis catheter. A minimum flow rate of 30ml/hr on an infusion pump is required. The Heparin; usually 5000 units/ml; MUST be aspirated before starting the infusion. If you have questions you can call the dialysis staff and they should talk you through accessing the catheter. Dialysis pt's are considered to be immune compromised. Delaying antibiotics with a known infection is placing the pt at risk. If another option exist it is better to not use the dialysis access. If no other option exist you do what you have to do. It is a very real possibility that the pt could have developed or may yet develop life threatening sepsis. If the pt were coding would you still have refused to access the catheter? Your preceptor was in no way risking her nursing license by following the docs orders. Why didn't she check the hospital policy? Why was the pt put at risk over this? Why not call the dialysis staff and ask them how to handle the situation?
Aug 24, '06
Thanks for the info. I think the issue boiled down to not being comfortable or knowledgeable enough about accessing or running abx through the permacath.
I think it would have been far more detrimental to the patient to just wing it (not knowing about aspirating the Heparin) without taking a few minutes to find out what the correct procedure was or get someone (thank god-the dialysis nurse) to help us. I would have refused to run the abx also without more information. We worked very hard to find a solution to the problem.
I'm very grateful for the input as now I know what to do if this situation arises again and I can share the info with other nurses should they run into the same problem.
Aug 24, '06
"My preceptor and I spent nearly all day trying to straighten out this IV access issue"
The impression I had from the original post was that several hours had past while trying to establish another access in this pt rather then use the dialysis catheter. Time the pt may not have had. I am in NO way recommending that someone "wing it" with an unfamiliar procedure. However, while preceptors are not expected to know everything they are expected to know where to find the answers and that includes timely accessing of the experts; in this case the dialysis staff. While on call I routinely answer this type of question including those that call at 0'dark thirty. It is part of the job and why I get a whole $1.50/hour for carrying the pager.
"The docs kept insisting to run the abx in through the permacath"
I read this as meaning there were multiple phone calls to the physician after the order to give the med through the dialysis line. Again, that takes time. One phone call to the doc then a call to the dialysis nurse. If the dialysis nurse says "NO" or more likely "H*%% NO" then you can call the doc back and shift the blame. "The dialysis nurse (the expert/higher authority) said that is against hospital policy" or "You (doctor) have to call the nephrologist for the OK to access the catheter." Above all take yourself out of the hot seat.
If there is ever any question about a dialysis pt do not hesistate to call the dialysis staff. This includes diet questions, what meds to give or hold, where to take a b/p lab draws ect. All dialysis nurses I know would rather answer the same question from the same person every day then have a mistake made to a pt.
Sep 9, '06
If the permacath itself is infected it must come out. Nothing wil fix it.
Sep 10, '06
There will sometimes be emergencies where the catheter must be accessed. Sometimes they are accessed in the ambulance, or during a code, or in the ER. Had one today in ICU; 24 year old sickle cell, seizure precautions, high fever, combative (pulled her IV out after eight tries), IV access a must. The doctor ordered NS at KVO to run contuously via the blue port. (we use 10cc/hr for our non pee ers) Sometimes you need both the blue and the red if the meds are not compatible The key is a nephrologist order. Otherwise some nurses will cry to the other doctors that they can't get an IV started, when in reality they would find a way were it not for the permacath.
Sep 30, '06
the antibiotics should be given by the dialysis nurse when the patient goes to dialysis
Oct 20, '06
I work on a hem/onc floor and our pts. have permacaths place for stem cell collection. We are allowed to use them just as we would any other IV. Most of them do not get hep. locked....we run tko@ 20 cc's. Only hep.locked upon discharge.