IJs

[maloneys]

Hi everyone! I could really use some help here. I posted in this on another forum and haven't received any replies so I'll try here, if that's ok. Pt had a 16 gauge, jugular IV that was heplocked. In for 4 days, never flushed, nor verified if still venous return. Pt was febrile, and I wanted to d/c it (he had other access). Staff told me I cannot, only the doc can do it, and in trendelenburg. That doesn't make sense to me. I would have the pt in a semi or high fowler's when d/c'ing any IJ access. Can anyone tell me what the best practice guidelines are for care of a peripheral IV put into a jugular be, aside from monitoring the site? thank you for any advice!

[Rose_Queen, BSN, MSN, RN]

Have you checked your facility's policy? Some facilities may allow nurses to remove IJ lines; others may require removal to be done by an advanced practitioner (PA/NP) or physician. This should also detail positioning during removal as well as provide resources for how the policy was written that can guide you to further research.

[maloneys]

RNs can remove them, but there are no set guidelines in place. Thank you for your reply!

[zzbxdo]

I don't understand why one would ask the interwebz regarding specific house practices. Go to the charge or manager what the culture of the setting prefers.

[Mully]

When you're removing a line which is placed above the level of the heart, especially a large gauge line, you want to lower the patient's head to at least the level of the heart. This would be either supine, or preferably trendelenburg. This is to avoid a venous air embolism. When the pressure in the vasculature of the neck is less than atmospheric pressure (such as when the removal site is above the heart), air can be entrained into the venous system and can cause significant respiratory distress and death.

This is a real thing, not just some irrelevant theory in a textbook (which there are plenty of), and I've seen it happen. It's an important thing for all nurses who remove these lines to be aware of. You should not have the patient in semi-fowlers or high fowlers for removal of IJ catheters. Generally, you can keep them in that position while you remove the dressing and prepare to remove the catheter, but should flatten them out when it's time to actually pull it.

I don't think many nurses understand the mechanisms behind this, as I didn't until I took a physics class in anesthesia school. Think of occluding one end of a straw with fluid in it like you did when you were a kid. You put your thumb over one end of the straw, pick it out of the cup, and let your thumb off of it. What happens? Air is entrained around your thumb into the straw and the water dumps onto the floor. Think of how fast that happens. Air RUSHES into the straw and completely fills it basically immediately. This is the same thing that happens when you pull that catheter while a patient is sitting up. Their IJ is the straw.

Now say you flipped the straw so your thumb is on the bottom. When you let your thumb go, fluid flows all around your thumb until it's all gone. This is what happens when you place the patient in Trendelenburg. Pressure is built up in the neck, and blood flows out of the vein onto the skin once the catheter is pulled. This is good! That means no air got in because the pressure gradient from the vein to the atmosphere was positive.

Here's a U of Michigan policy I found online: http://sitemaker.umich.edu/proceduretraining/files/cvcr_line_removal_im_ho_protocol.pdf

And here's more on VAEs:

Medscape: Medscape Access

This is a quote from the second reference: A pressure gradient of 5 cm H2O between air and venous blood across a 14-gauge needle allows the entrance of air into the venous system at a rate of 100 mL per second.^{[1, 2, 9, 11, 16, 17]} Ingress of 300-500 mL of air at this rate can cause lethal effects.^[11]

Hope this helps.

[icuRNmaggie, BSN, RN]

I have never seen a 16g angiocath in the IJ.

Did you mean to say 16g angiocath in the EJ or external jugular? In my experience the RN can d/c those without an order when they are no longer needed.

[iluvivt, BSN, RN]

I think she is referring to a peripheral IV catheter being inserted into the external jugular vein.This is considered a peripheral vein and if the catheter is short (less than 3 inches) it is considered peripheral. I still use caution when discontinuing these snd follow standard anti air embolism precautions. Never use an E fie a power injection either and they do not need to verified by x ray.

[iluvivt, BSN, RN]

That was EJ. Sorry for typo

[whofan, ADN, BSN, RN]

You put them in trendelenburg. Had this issue today. Air embolus happened. Luckily patient was ok after being basically hung upside down for four hours. But this required and extra night stay.