What would you do?

[thisnurse]

79 year old male.

admitted for bleeding avfistula.

hx of bleeding

on heparin for mitral valve regurgitation.

fistula repair post one day.

temporary tesio inserted at same time.

pt dialyzed through new tesio. bleeding at site reported by dialysis.

gauze applied to insert site, pt returned to room.

Half hour after return to unit, pt has soaked through the gauze and has blood running down from the site, onto his chest and through his gown.

md notified.

pressure dsg applied to wound. pt instructed to lie flat

heparin held for PTT of 166.(thats right...166)per proticol.

PTT redrawn-same result.

md arrives.

pressure dsg removed and site inspected forty five minutes after bleeding began.

constant pressure has been applied to the site for an hour and the patient is still seeping blood. (soaked thru 4 drain sponges with the pressure dressing)

bleeding has slowed down but still active. pt is stable.

site inspected and another pressure dressing is applied. this dressing will be intact until rounds in the morning.

MD orders heparin to be restarted at a slightly lower rate with coumadin to follow in two hours.

you are his nurse...what would you do?

[kids]

Originally posted by thisnurse

when the renal doc got wind of this in the am he was not too happy with the surgical residents.

I'll bet...I don't think I have ever taken care of a dialysis patient that did not have a high PTT and a normal INR. This guys renal doc should have been advised of the bleeding by the dialysis center.

It would have been a huge help to him had he advocated for himself and said..."I want to talk to my Nephrologist; NOW!"

Amemia is also one of the unfortunate side effects of dialysis...wonder if he was getting any erythropoiten?

Those 2 units of PRBCs may have made him feel pretty good or a week or two tho...if they didn't screw up his dialysis program to badly.

[thisnurse]

no erythropoetin.

pt is still on our unit. still dealing with the anticoagulation problems tho i noticed they have ditched the protocol.

what i didnt tell you is that when the resident came down to assess the patients bleeding that night i told her over and over about the pts history with anticoagulation therapy. i discussed my concern regarding DIC.

i told her that i wasnt sure exactly what the protocol was for restarting. it had been held since i picked up the patient and i was told it would restart at 1000, but i myself hadnt actually looked it up. however i would before i restarted it and after i got a new PTT.

she wanted me to draw from the bleeding tesio. i

told her that probably wasnt a good idea since it had taken so long to slow the bleeding down i didnt want to take a chance of making it worse but moving the ports. i suggested we draw from the marhurkar but i needed an order. she said that would be fine but i didnt need an order to draw from there. i tactfully suggested she was wrong. but to be on the safe side id prefer to have one.

she called the senior surgeon to ask him about the heparin. he told her that i didnt know how to read protocol. i didnt know what i was doing.

she then asked him if i needed an order to draw blood from a marhurkar. he told her no and then ordered the patient to be moved to the surgical floor because i didnt know what i was doing.

i was so mad!

not only were they over anticoagulating this guy, now they were going to uproot him to prove some stupid egotistical point.

the patient was pretty upset about being moved. he refused the transfer and it was finally rescinded. the charge nurse convinced the resident to let the pt stay.he stated he liked it just fine where he was and that his nurses were great.

i spent the next night looking through our policy and procedures book. not only do you need an order to draw from a marharkur, you need a RENAL docs order to draw from ANY port used for dialysis.

yes the surgeons came down and apologized about all of this the next morning AFTER the renal doc let them have it. of course i wasnt there but i was told. they neednt have apologized to me...they needed to apologize to the patient. their little ego trip cost him a few extra days in the hospital.

i cant even feel good about being right because i feel so bad about the consequences to this patient. he is soooo nice.

[Mijourney]

Hi thisnurse. I'm glad that your responsible internist was able to come through for the patient. Your recommendations were vindicated. I'm glad that no fatal iatrogenic effects were experienced by the patient as a result of the surgery residents arrogant actions.

[thisnurse]

feisty

"throw yourself on top of the patient if you have to, in order to keep him from harm."

thank you...i swear i will never forget this saying

[ageless]

Just came across this post and thought I would comment about dialysis catheters..permanent and temporary. Accurate coagulation labs cannot be drawn from these catheters if heparin is ever used to fill the lumen to keep it patent. Heparin is absorbed by the polymers in the catheter rendering the test inaccurate.

[ArenRN, BSN, RN]

As a rule dialysis catheters are not to be used for any other purpose but for dialysis.

You need a nephrologist order to use it as IV line, and generally they only allow it in emergency situations.

Coags will be innacurate if drawn from those caths as already explained.

And you would need to know the procedure for plugging the lumen of the catheter with the exact amount of heparin after use,

if it is used in an emergency situation.

[frann]

79 year old male.

admitted for bleeding avfistula.

hx of bleeding

I'm confused was the guy admitted to bleed him?

Why did he even need heparin restarted. He seems pretty anticoagulated inthe first place

We have a Heparin scale/protocol. If the ptt is > 100, hep. is turned off x 1 hr, reduce gtt by such and such units based on pt weight, and must call doc.