maloneys

Thank you for the very helpful feedback and information. We know the 16 gauge is not a central line, in this case, but there was no consistent documentation on when it was inserted, nor on its care. Again, thank you for your help!

Hi Sallyrnrrt, thank you for your thoughtful feedback. Do you trendelenburg the pt when d/c'ing the IJ or EJ IV, you mean? How does this prevent air embolus? Thank you for helping me learn!

Thank you for comments, ArmaniX. Yes, you can have EJ or IJ cannulation. Basically, when protocols are not in place, we want to ensure best practice. Because the 16 gauge periph IV was used, and not a tunneled cath or central line, which we sometimes see on the wards, we want to make sure the IV is flushed to maintain patency. I'm just wondering what everyone is doing in terms of catheter care. Thank you!

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

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!

Hi everyone! I could really use some help here. 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!

After about 90 minutes, he went 130-180 and continued til the end of my shift, with me documenting like a madwoman. It was certainly stressful because of , as you stated, I was worried about him really going sour. I would have loved to see his labs, and maybe give him more fluid, if not a little amio.

I agree about not anticoagulating someone who is fresh, post-op. We're talking 6+ hours. However, I mentioned that because of the fast afib. The patient is under cardiology which is why the cardiologist was paged, and not the surgeon. My concern is the fast afib. 160-200 bpm for 90 minutes seems a bit much, no? In the ICU, we would have started an amio drip stat...not to mention a bit of fluid too. Bloods were done but I wasn't made aware of the results as the patient wasn't on my unit. I was just monitoring him on telemetry.

Hello! I wonder if someone might help here. I work in a med/surg ICU and we monitor telemetries in the hospital as there is no CCU. A post-op cholectomy, 84 years old, not on anticoagulants, with a history of HTN, was on telemetry immediately post-op. He went into fast afib, as he had done briefly and previously pre-op. When the cardiologist on-call was paged, he prescribed 50 metoprolol po. Of course the patient stayed in fast afib, 160-200, since po takes a while to work. After one hour being that fast, I paged the cardiologist and informed him of the rate, and that he was otherwise asymptomatic, with a drop in BP to 100/45, from 130/70. The cardiologist said it was fine. When I expressed my concern that the patient wasn't putting out much urine and was only getting Ringer's at 75/hr, and that I was worried about a clot, he said a patient needs to be going fast like that for about 48 hours to throw a clot. REALLY? I was shocked, but that came from the cardiologist. I documented what I said and left it to that. What do you all think? Is that correct?? Thank you!

I hope so, Ruby, thank you!

Thank you, detroitdano. I'll call them tomorrow. So intimidating.

This is an old story, I know, but only now am I experiencing it. I work in a small ICU and only at night when the staff is minimal. 4 nurses for 11 patients and telemetry monitoring. No orderly or extra support staff. We must rely on each other. About 2 months ago, a nurse that is usually in charge started ignoring me. We had no altercation. When I tried to ask her directly, "is every thing okay?", she barked, "FINE" and walked away from me. Very childish. It progressively got worse. She wasn't telling me about admissions I was getting; she nearly shoved me when passing by me to get to a patient's room; and now more recently, is accusing me (all behind my back) of administering an antibx to her patient. Before the last incident, I called our nurse manager and informed her of my concerns. She said she would try to talk to the nurse but this nurse is known for having personality problems and we should let this just 'ride out'. But now, with accusations, it's getting worse. We are unionized. Should I wait for my manager to tell me how to proceed, or should I go to the union? I'm completely stressed out. Working with her is a nightmare. Help!

Hesitation to do a scan was lack of docs to read the scan at night, due to absence of docs. Thank you very much for taking the time to do this teaching! I'm very appreciative.

I agree, prep8611, and I wasn't using the d-dimer to try to diagnose PE, but without a doc available, it is typical for us to do labs following the physical assessment. That way, if we do need to call the doc, he/she has all the stats. I wonder if, in an ICU setting, the d-dimer is at all necessary then, particularly following surgery or trauma or in the presence of liver disease?

Thank you, Juan de la Cruz, for taking the time to answer my questions and for citing those sources. I'm afraid my continued learning is going down the tubes working in a small, peripheral hospital where there are no docs on at night. I appreciate your input!

Hmm, thanks for all the wonderful feedback. So in these cases, both patients should have been scanned then! How many days post-op would I expect to see an elevated D-dimer in the absence of liver diseases?

Really, prep8611? I didn't know d-dimers weren't' used anymore! Both patients had pneumatic boots on.

Where I work, it's always 3:1, unfortunately

I wonder if someone might help shed some light here. Post-op day 4, abdo abcess drainage patient who went from room air to tachypneic 30-40 and 100% FiO2 over a couple of hours. I did a D-dimer as I suspected a possible PE. Came back 6000. Doc said it would be elevated since the patient is 4 days post-op, and you need a result of 10 000 for it to indicate PE. Then a few days later, 3 day post-op cystectomy, same symptoms as patient above, D-dimer 3120, but ultrasound showed PE. I don't understand! Please help! Many thanks in advance.

In my case, my only access was the CVC so that's why I used that. No docs at night in the ICU so fem stick would have been out of the question. I appreciate the feedback. Thank you so much! So if anything, the culture from the TLC might have at least shown line sepsis?

Where I work, we have 11 ICU beds, plus we monitor telemetry for the hospital. On the night shift, we are 4 nurses, no orderly, no managers, no secretaries, no body! Plus, if there's a code on one of the other units, ICU answers the code, so 2 nurses leave the unit leaving only 2 nurses for 11 patients and all telemetry monitoring. Now THAT is unsafe practice ;-)

I had a patient last week who spiked a temp, had a 2 week old triple lumen in her SC. Horrible peripheral access so I took one set of blood cultures from her central line. A colleague said it was invalid (even for query line sepsis) and that we should continue poking til we get a set from a peripheral poke. What do you think? What would you have done? Thanks for your advice and feedback!

Esme, you're a star! Thanks for the teaching/learning, yet again ;-)

Hmmm, perhaps an undiagnosed Ca. Thanks for thinking!

Hi everyone, can I pick your brain? Last weekend had a post cardiac arrest patient, 59 y.o.man , hx of HTN, afib, back pain, ETOH abuse, cocaine abuse, who arrested at home. When ambulance arrrived he was asystole. Arrived to ER, asystole, CPR done for 45 minutes. He somehow got a pulse again. He came to our ICU in SR, copious melena q1h, on levo, of course. So I did a CBC. Hgb was 17.8 on first take. After 2 hours and more melena, I repeated and it went up to 19.3. I thought that was strange as his Na was 140, so there was no hyperconcentration and volume depletion. Any thoughts on why his hgb would be so high? Thank you for any ideas :-)