IJ catheter for Dialysis

TRAMA1RN · Jul 16, 2008

By no means should you feel like an idiot. I think that it showed great critical thinking on your part to ask the pysician for an IM or peg med order. ALL dialysis catheters are off limits to anything except dialysis. If you worked with me I would have been very proud of you and honored to know that you had the clarity of mind to think twice about the MD order.:clphnds::urck:

jennjen512 · Jul 16, 2008

You are not dumb at all; you have just never been exposed to that particular line. In my facitily we are not to use dialysis catheters for meds unless there is a doctors order stating that it is OK to do so or it is an emergency situation (code). There is too much of a risk of clotting off one or both of the ports if they are not flushed properly and the ports are usually locked with heparin and must be pulled back so the heparin is not administered to the patient. Dialysis is much more important in most cases, especially if the drugs can be given IM or PO.

Burnt Out, ASN, RN · Jul 16, 2008

Well first you did a wonderful job so don't feel dumb. It doesn't matter if you are a RN or LPN, we can not know everything.

In my facility, we do not use a dialysis catheter/Vas Cath unless it is an emergent situation or we have no other access and then we get an MD order to use it. Most of ours do have a pigtail port that we use like you would a central line lumen. But if we have to use the other lines, we must deaccess all that heparin and re instill it after our infusions are complete.

Daytonite, BSN, RN · Jul 16, 2008

i was an iv therapist. those ijs for dialysis are never used for anything but dialysis, so no medications are given through them. they are heparinzed to keep them patent. the dialysis nurses would have a hissy fit if our iv team did anything with those catheters. you are correct that one port is arterial and one venous. if the patient manages to pull the cap off of the arterial port, he will spurt arterial blood just as if an artery were severed. if the cap of the venous port comes off he can pull in air by negative pressure and an air embolism can form in his heart. if he pulls the catheter out pressure needs to be held over the exit site until the bleeding stops and then a pressure dressing applied.

as far as your rns giving any iv ativan, i would advise you to defer to your facility policies. i also worked in ltc. if there is ever a question as to what you can or cannot give, check your iv and medication policies and then call your pharmacy service and consult with the pharmacist on call. that's what they are there for. some hospitals won't even let their medical staff nurses give iv ativan and it is a hospital policy.

since this patient was a dnr i would have asked for an order to d/c the ij if dialysis was no longer going to be done since it was a safety risk and i would have charted that the doctor was asked about this even if he did not give the order. he may be reticent to order the d/c and would rather that the renal doctor give the actual order for that because he is probably the one who inserted the ij. at that point, i'd contact the renal doc and explain the situation.

mpccrn, BSN, RN · Jul 16, 2008

ummm some of the above information is correct, some not so accurate. i left ICU and was a dialysis nurse for about 5 years.

First, IJ's are a central line like PICC's, subclavians or femoral lines. yes there are 2 ports marked V and A, but it's in the same vessel. The V and A are more likely indicative of the where the other end of the catheter lumen lie in the vessel itself, distal or proximal. It is used to hook the patient to the machine. 'A' being the line used to withdraw the blood from the patient to feed the machine and 'V' used for its return.

2nd: the lines are heparinized with a more concentrated heparin solution to ensure their patency. Dialysis nurses and docs are EXTREMELY territorial when it comes to their lines. we didn't want people messing with them because they were essentially the patient's lifeline and their only means of dialysis access. Nephrologists don't place lines and must rely on someone else to put them in. that's a pain in the butt and slows us down. a 4 hours treatment is really about 6 hours to the nurse doing it cuz they have to warm up the machine, test it and then disinfected it after the treatment. better no one uses our line.

3rd: a dialysis line CAN be used for med administration, provided you pull the heparin out of it, 10 cc waste is usual, and block it again with heparn when done. we'd prefer if you don't use it for routine med administration but in an emergency or no other options availabe it is a viable route. refer to #2.

4th: a fistula may or may not be accessible depending on it's blood flow and maturity. it's usual to place a line in as the fistula develops and matures. it's not uncommon to try sticking it and see what happens. sometimes it collapses, sometimes it's flow is not enough to sustain the machine, sometimes you pull from it and return to the line. using it will eventually make it stronger.

5th: your suggestion of an alternative route and opening a discussion with the doc should in no way make you feel like an idiot! i'd worry more if you tried to fake it. docs and your co-workers will appreciate your conscientiousness. it show you were thinking and your confidence in your knowledge base to ask in the first place. you were your patient's advocate. good job! :yeah:

6th: nursing is an ongoing learning process. when you are unwilling to continue leaning, it's time to get out!

hope this helps. :heartbeat

Fiona59 · Jul 16, 2008

I used to work dialysis and let's just say territorial is a nice way of describing the view of the lines.

In my hospital we have an acute and chronic renal unit. So if a problem arises or questions we are encouraged to call the unit. I've seen former workmates come down and re-attach dressings and cover the lines that hang.

We're line lines just dangling? We were trained to cover them with gauze and even had little bags with drawstrings to cover them up.

Kinda funny looking back. Those lines really were some of those nurses "babies"

onyx77 · Jul 16, 2008

My community clinical was in dialysis, I know it has been about 6 months now since graduation, but I do remember my mentor telling me that the dialysis catheters were ONLY for dialysis and not for med administration or blood draw. But then again, I only had 28 hours in dialysis!

-MNC_RN- · Jul 16, 2008

Generally speaking, dialysis catheters are used for nothing else. There are always exceptions.

My big question would be if he was admitted to your facility and dialysis was DCd, why leave in the line? It's a route for infection and a risk if pulled (obviously). Unless there was a good chance that he or his family would change minds, it should have been taken out even before he hit your doors.

[in regards to your original post, you did the right thing.]

kstec, LPN · Jul 16, 2008

Thanks for all the replies. Yes the resident was brought to us to pass. He is alert and confused and does pull at this IJ and peg tube. My question also was ,why didn't they pull the port before sending him to us. We are not an acute LTC facility. I did write a request to the house MD to either give the RN's orders to maintain the line, or to have it d/c'd due the the high risk of being pulled out. I obviously know enough to know that he would bleed out if not caught and pressure applied immediately.I realize that I'm not an idiot, but when you have to admit to a MD that you do not know, you feel kind of inadequate, especially being a LPN. I know alot but 1 year of schooling compared to 2 or four gives you a lot less time to be exposed to things. It was almost comforting to know the RN's at the facility were just as confused as me re: the IJ. I assume it's more of a specialty area. I've only been out of LPN school for 2 years, and I have said "I don't know", a lot but prior to becoming a LPN I was a pharmacy technician in a hospital for 14 years, medications are my strongest asset. I'm gaining excellent assessment skills, and I learn something new everyday, if not from a coworker, from the internet. I love to learn, but don't want to go back to school right now. Thanks again, for you information and reassurance. Unfortunately in nursing school you learn a little about everything and a lot about nothing.

TigerGalLE, BSN, RN · Jul 16, 2008

ummm some of the above information is correct, some not so accurate. i left ICU and was a dialysis nurse for about 5 years.
First, IJ's are a central line like PICC's, subclavians or femoral lines. yes there are 2 ports marked V and A, but it's in the same vessel. The V and A are more likely indicative of the where the other end of the catheter lumen lie in the vessel itself, distal or proximal. It is used to hook the patient to the machine. 'A' being the line used to withdraw the blood from the patient to feed the machine and 'V' used for its return.
2nd: the lines are heparinized with a more concentrated heparin solution to ensure their patency. Dialysis nurses and docs are EXTREMELY territorial when it comes to their lines. we didn't want people messing with them because they were essentially the patient's lifeline and their only means of dialysis access. Nephrologists don't place lines and must rely on someone else to put them in. that's a pain in the butt and slows us down. a 4 hours treatment is really about 6 hours to the nurse doing it cuz they have to warm up the machine, test it and then disinfected it after the treatment. better no one uses our line.
3rd: a dialysis line CAN be used for med administration, provided you pull the heparin out of it, 10 cc waste is usual, and block it again with heparn when done. we'd prefer if you don't use it for routine med administration but in an emergency or no other options availabe it is a viable route. refer to #2.
4th: a fistula may or may not be accessible depending on it's blood flow and maturity. it's usual to place a line in as the fistula develops and matures. it's not uncommon to try sticking it and see what happens. sometimes it collapses, sometimes it's flow is not enough to sustain the machine, sometimes you pull from it and return to the line. using it will eventually make it stronger.
5th: your suggestion of an alternative route and opening a discussion with the doc should in no way make you feel like an idiot! i'd worry more if you tried to fake it. docs and your co-workers will appreciate your conscientiousness. it show you were thinking and your confidence in your knowledge base to ask in the first place. you were your patient's advocate. good job!
6th: nursing is an ongoing learning process. when you are unwilling to continue leaning, it's time to get out!
hope this helps. :heartbeat

Well done! I couldn't have said it better myself!

One thing to add... Sometimes these IJ temporary dialysis catheters have a med port attached to them. There will be the 2 lines (with a red and a blue cap) then a smaller 3rd line that is skinnier like a central line. In the hospital we use the small line for meds.

Now that is ONLY in the temporary IJ dialysis catheters. NOT in the chest wall perm catheters. I've never seen a perm cath that had a med port. The perm cath usually sits on the left or right chest area, where the temp IJ cath is up in the neck. I'm not sure which one the OP is talking about.

Tiger

zionic · Aug 21, 2012

i realize this thread was created a long while ago but it is as fresh to me as the conversation is to me and i would appreciate seasoned nurses in the mix to give their inputs. I've been an rn for less than 2yrs and an incident occured at my institution with regards to the usage of a jugular catheter. my patient an ESRD pt went to the OR for the insertion of a new catheter and Av graft, which became a complicated procedure as she bled intensely while still in OT to the point that she bacame quite unstable. Anyways she was taken back in the OT where an exploratory was done and she got drain inserted her hb dropped severely that she had to get ffps and prbcs. when i went to pick her up from the OR, i received her with q unit of PRBC infusing via her newly inserted jugular catheter, i took he backon the unit and recommenced the blood via the access, and on completion i flushed same with saline, i handed over and left for the day while the patient was still receiving the saline flush infusion. on arrival the next day this pt was in severe pain, she complained of pain to her chest area underneath her left breast, assuming it was the impact of the jugular cathether, i assessed her pain medication and realised she got nothing for pain since return from OT, so i chose to give her the prescribed morphine, but as her piv was down and the jugular cathether was still uncapped with aheplock conector still attached i decided to give it via that port (in my institution only med interns put up iv catheters, rns only put them up in emergency situations). this i did with the knowledege that pts receive medications via same during codes or emergency situation and because the port was stil saline locked following the administration of blood from the previous day i didn't think it was contraindicated. unfortunately my pt's pain was not relieved and eventually a CT spiral with contrast was done (the contrast was also passed thru thesame port) which revealed a pneumothorax (the pt had a puncture wound, which according the the surgeons was a very minute one, that will seal on it's own). i discussed this with my coleeagues who are all seniors to me, and explained to them not until we got to radiology department did i wonder if we the A line was the right line to use as opposed to the V line but then, in the same breathe i recalled that UACs are used in babies fro very strong medicines, so i brushed it off with the intent to research more on it (that's my favourite thing and it's howm am on this page today). but to my dismay the next day my colleagues were very much concerned and believed i should write an incident report because that wasn't the right action to have taken because "the jugular cathether isn't a central line" disturbed, i explained i know it wasn't the best access but i went ahead to use it becos i have used it before in a code situation. well long story short i spoke to my area sister and the consultant on that team who like many others have said indicated that the jugular access wasn't the best port to have used but then it's use was restricted for fear of clotting, but in general they don't think i should be worried about it. My concern now is, i was very shocked, because the talk became the fact that i used an arterial line to administer blood, but today am most joyous to read here that not only is the line a "no go area" for floor nurses but it's also a catheter whose tip is single and positioned in the right atrium just like other cvc. Am relieved to a great level and am glad i've learnd another thing cos now i understand why the dialysis nurses protect that line and the anatomy of this line. my colleagues really made me believe the administration of morphine via that port was the cause of the pt's weakness, which in fairness was never an issue afte the pt was encouraged to exercise and utilise her muscles. So , experienced nurses thank you for always sharing your 5cents on this site and providing new nurses lyk myself the opprtunity to advance our career through your knowledge. i know i could have done otherwise like my colleague who started this thread but at thesame time i think it was a huge learning proces for me.