Discontinuing IJ turned into a Rapid Response

[Manatee111]

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 was s/p day #4 fem-pop. First, I checked that labs were all WDL. I prepared everything according to sterile technique. The patient was in a sitting position in a chair (which seems to be the only questionable thing I can find with the removal). Per sterile tech. I clipped the two sutures holding the central line in place. I had the patient take a breath in, exhale & inhale again then hold it while I drew out the line. The line was intact. The pateitn commented that the removal wasn't so bad at all. She then coughed really hard. With in seconds her breathing pattern changed, she became flushed in the face and she stop responding to me. I called for help & had a Rapid Response called. Initially, MD thought she had an air emboli & the ICU Hospitalist flipped that the patient wasn't in Trendelenburg when I pulled, but that isn't required as part of our Policy & Procedure. The patient being in a chair seems to be of issue, but I have seen central line (IJs too) pulled while the patient is in a seated position before as well as pulling them in a seated position myself. They did an u/s of the jugular at the bedside & there was a large clot. The on-call MD's all seemed so worried to take an further steps as instructed by the vascular surgeon and the cardiogist. I'm really worried because I've already been told that this is going to be a risk mang. issue. All because she was in the chair???

[catshowlady]

OMG, you could be talking about a pt I took care of when I was a new ICU nurse. I was not the nurse who pulled the line (I was off that day). Regular TLCVC (not a cordis) pulled with pt up in recliner chair that was laid back, pt crumped, got re-intubated (& a new TLC). Lots of investigation, paperwork, nurse questioned about why line was pulled w/ the pt up in the chair. Pt improves, TLC pulled (pt flat this time!), pt crumps again. Went back to OR (can't remember why), pt died on the OR table.

Guess what they found? IIRC, there was a surgical staple missing from his pulmonary artery. The surgeon thought that was the cause of the pt's complications.

Obviously, that doesn't mean that's what's wrong with your pt, but that is what happened to our pt.

:paw:

[nrsnic, BSN, RN]

i haven't been a nurse long, but i have been involved in a very significant medical error (please understand that this is not me saying you made a mistake...i have no way of knowing that from where i sit). during my preceptorship in the last term of nursing school, a baby i was working with had to have his lipids and tpn switched out d/t expiration dates (they were changed every 24 hours). i was being instructed in how to change lines for babies that have picc lines. you have to be quick and get it done because these lines can clot off very quickly.

unfortunately, a few things occurred during this time that caused the lines to become switched in their respective pump channels. the tpn and lipids were now running at completely the wrong rates. this was not discovered for almost 24 hours, and then the only reason it was caught was because a triglyceride test was miraculously drawn that day and came back very critically high.

now technically speaking i was working directly under the license of the nurse i was working with, and she didn't check my work entirely. however, i was still the one who put it together wrong. devastating, to say the least. i will say one thing though...i effected a hospital-wide process change. risk management and quality improvement got involved, did interviews and decided that a couple of policies were inadequate or missing.

moral of this completely different story is that even if you are by some chance in the wrong, you have stated that you followed your policy and procedure. you were only doing what you knew how to do based on what the organization told you was right. one of the most unfortunate things about healthcare (that i am not even sure how to improve) is that mistakes sometimes have to be made before improvements can be made. i know this is a small consolation when you are sitting there tearing your hair out trying to understand how you could have done it differently...but know that you have probably effected a change that will help more people than you will ever be able to touch.

[JulieCVICURN, BSN, RN]

The only thing I see that you missed is that you didn't draw back on the line before you pulled it. We always do that because large clots can get stuck on the end of the cordis. I once pulled on that I actually had aspirated and when I pulled it a clot approximately a quarter of an inch long came with it. I was lucky that the whole thing came out attached to the cordis. If I'd held any pressure at all on the site while I was pulling instead of waiting until I pulled it to put pressure on the site then I would have probably had exactly the same thing happen.

I'm not sure there's fault to be had here. It was just a freaky thing maybe.

ETA: We pull cordis' frequently with patients in sitting position. It doesn't seem to be a factor.

[Da_Milk_of_Amnesia, MSN]

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 .

[SharonH, RN]

Manatee, sometimes there are adverse outcomes it doesn't mean you did anything wrong. As for a risk management issue, anytime there is an unexpected event it will be a risk management issue, it's not about you per se. This isn't the last time you will write an incident report, trust me. Don't worry.

[CathyLew]

Thats what I was thinking.... your hospital may have a procedure where any Rapid Responce goes to Risk managment.

in addition to documenting well in the chart, you can keep a personal log of the incident. (don't use patient names) but doccuement the situation, and all staff members that were on that day. (or other things that you may not put in the patient chart) like patient acuity, census, etc...

Sometimes if you are questioned about something weeks or months later, it is good to have your own notes to refresh your memory.

[PostOpPrincess, BSN, RN]

Never pull a line when a patient is in a chair.

[WindwardOahuRN, RN]

Never pull a line when a patient is in a chair.

I totally agree. If the patient crumps you not only have to respond to the crump you also have to get that patient back to bed or even on the floor if getting him back to bed is not possible.

It's just a bit of common sense. There can be complications with the removal of any line---air emboli, clots, breakage of the cath, runs of VT, knotting of the catheter. Best to have the patient in a place where you can initiate emergency measures quickly if needed.

And about that "policy" thing? There simply is not enough paper in the world to have a policy that covers every single thing that we as nurses have to do. Although we are mandated to do at least what the policy requires we are not restricted from practicing even more safely.

I think they call that critical thinking? I've seen hospital policies that have me shaking my head and wondering just who the hell wrote them. Although we should be able to go to them and think of them as a work procedure "bible" it is often not the case. Think of how many times policies are revised and think about why they are revised---because they were not quite right in the first place. A bit scary, I guess, especially for those who are new to the game and relying on those policies to steer them in the right direction.

We all make mistakes and most of us learn valuable lessons from them. Learn from your mistakes, forgive yourself for being human, and go on. :hug:

[questionsforall]

The patient should be laying in as flat a position (preferably slight trendelenburg) as they can tolerate and they should be holding breath in order to prevent air embolis.

Just to add that I was present for a code last week were an inexperienced nurse pulled a cordis out while the patient was sitting up in the bed and the patient decompensated in seconds and needed to be reintubated for suspected air emoblis.

[guest239592]

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.

[WindwardOahuRN, RN]

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. :)