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???

[MedicineCNS]

I help to write policy and the goal not to write too much detail so that nurses hands are tied to do things in one way. Not always the best thing.

The other take home about pulling lines beyond NEVER sitting that high up, is to always quickly hold pressure and apply an OCCUSIVE dressing to the site. A cordis leaves a coat hanger sized hole in a large vessel and not covering QUICKLY further increases risk of air embolism.

[Zookeeper3]

A part of a problem in many units these days is that ones with high turn over, you dont' have staff that have "been there, seen it all, done that". What happens is that proceedures are taught over and over again and they may not be the best evidence based practice.

It very well may be accepted practice in your unit to do so, especially if the policy lacks positioning the patient flat. So I'd hope that this invokes a policy change to limit complications to future patients. You will never be an expert on everything, but you will always have this experience as a safety tip for those you will mentor in the future... "let me tell you why this is so important....."

We all have many of these stories to tell.

[Teresag_CNS]

He did not have an air embolus, but a clot. His sitting position did not cause the clot. As someone else posted, improper line maintenance allowed the clot to form. Perhaps the Cordis line maintenance policy should be updated.

[RNTwin]

FIRST never take a Central line out of a patient sitting in the chair, i'v seen at least 3 people code and 1 which died...

[iluvivt, BSN, RN]

The current standard of care when d/cing any central line is flat in bed..have pt take a deep breath.....hold it (or valsalva maneuver)and then d/c it. If the pt can not cooperate to do this the second best thing is to d/c upon expiration. Next apply a sterile air occlusive dressing. You can use some Vaseline gauze or some betadine ung..just make it air occlusive...yes you can get air sucked in through the skin tract even after the CVC has been removed. If your nursing policy and procedure is not up to date or is incorrect...and you followed it....you can still be held accountable b/c they will say "you should have known better" You should have followed the current standard of care. I know what all of our policies say b/c I wrote them all...BUT sometimes when there is a delay in changing them ...I will follow the new standard. In this case for instance when INS changed it to an air occlusive dressing I started doing that right away. I know of a 7.5 million dollar lawsuit where the nurse followed the hospital policy and lost the case. They said that she should have known better and also she had an obligation to inform the hospital that there policy did not follow the current standard of care. When a nurse is sued that is always the question...did he or she follow the current standard in the situation. Sounds like a thrombus had formed on the end of the cordis and it became dislodged when it was discontinued. Complications do happen BUT you want to be providing safe and prudent care so no one can blame it on your nursing care..so the pt should have been in bed for the procedure.

[fiveofpeep]

thanks everyone for the great information. it's practice on my unit to not d/c the cordis with the patient in trend. we aspirate but we dont do trend. Im going to always be sure to do it though now that Ive heard this nightmare from someone firsthand! how scary!

[MomRN0913]

Where I work, we call the hospitalist to DC the Central lines. I work ICU. Patient is always laying down.

The only time we DC a central line is during post-mortem care.

Do you have a policy and procedure regarding DCing central lines?

[ljeanmarielouise]

A brief search of policy and procedures for various facilities across the nation indicates most facilities require placing the patient in a slight Trandelenburg position or with the head of the bed flat. Several P&P state the patient may not be in a sitting position during catheter removal. I recommend printing a copy of your facilities P&P for your records as well as writing a detailed summary of the events in case you need this later. Good luck and hopefully nothing more will come of this event.