post op patients w/o TLC line placement confirmation

[elizadream]

We receive many post op patients directly from the OR (PACU bypassed) who receive TLC's from the anesthesiologist right before induction. Recently, a case came over on a vent and the nurse refused to give the ordered rbc's because there was no mention of CXR performed to confirm placement although there was IVF running to the TLC upon arrival . In the OR-they don't usually do confirmation of ETT placement either. A big ordeal was made of the incident-should she have just gotten an order from the surgeon or the anesthesiologist to use the line or demanded (like she did) a CXR to confirm placement?

I'm thinking from a liability stand point.

Thank you for any responses.

[Corey Narry, MSN, RN, NP]

We receive many post op patients directly from the OR (PACU bypassed) who receive TLC's from the anesthesiologist right before induction. Recently, a case came over on a vent and the nurse refused to give the ordered rbc's because there was no mention of CXR performed to confirm placement although there was IVF running to the TLC upon arrival . In the OR-they don't usually do confirmation of ETT placement either. A big ordeal was made of the incident-should she have just gotten an order from the surgeon or the anesthesiologist to use the line or demanded (like she did) a CXR to confirm placement?

I'm thinking from a liability stand point.

Thank you for any responses.

Good question! I work as an NP in CTSICU where we receive patients straight from the OR following heart surgery and on some occasions, the Swan-Ganz needed to be repositioned or the ET tube was either to deep or needed to be advanced after looking at the immediate post-op CXR. While an order from the surgeon or anesthesiologist to use the line is sufficient, I am all for checking placement with a CXR.

[Nursonegreat]

i have seen many pts coming to PACU with a TLC in place, fluids running. i always got a stat cxr, it was standing, didnt need to get a verbal, altho i believe that the orders from mds for the floor included a cxr on arrival to the PACU. i never started a gtt into a TLC until confirmation, altho i would allow previously infusing fluids/blood from the OR into the unconfirmed TLC, would just get a portable on it.

[Bubbles_RN]

We get this a lot in the ICU where I work too...no CXR and fluids running. We have a policy that states we (the ICU RN's) are not allowed to run fluids until CXR confirms placement. This came about because we had an incident of vessel perforation. So I agree with the nurse who wanted to get an x-ray.....it's her license on the line.

[sunshineCCRN]

our open hearts have closing films just before they come to ICU. we confirm swan placement by waveforms and CXR if there is a question (usually anesthesia is right there anyway). every patient receiving a central line (IJ or SC) should have an immediate confirmation of placement--why isn't this done in the OR prior to surgery? Scary!

our central lines from the cath lab or radiology are confirmed with fluoro, all others get a CXR.

our nursing policy covers CXRs for line placement-no order needed.

if you can draw blood and flush from all ports, and the med is stat, i would not hold a treatment. i agree with pinoy: an order would have covered her, but CXRs are always good.

[cvicugirl, BSN, RN]

Wow. Never thought about it. We get stat CXR upon arrival (post-cabg) and I check ETT placement, IABP placement, SG, and TLC placement myself. Fluids are almost always already running via CLs. (Takes at least 30 minutes for a preliminary CXR report from Radiologist, and the MDA and surgeon never stick around to look at films.) I won't let the MDA leave the bedside until I have a decent PA/PCWP waveform though. I won't float SGs anymore for lazy docs.

[sunshineCCRN]

I won't let the MDA leave the bedside until I have a decent PA/PCWP waveform though. I won't float SGs anymore for lazy docs.

darn right! :angryfire