Question for the PICU nurses from an ER nurse (mini rant too, sorry!)

[NYCRN16]

I work in and ER that has seperate peds and adults, but I work mostly on the adult side. Recently, we had a child in the peds ER that the resident wanted dobutamine gtt on. He went back and forth on whether or not he wanted it for about an hour and then they decided that they were transferring the patient anyway and they didnt start it. From what I have seen at other hospitals and from what I do with adult patients (our policy) is that you do not start vasopressors on peripheral lines. This child was about a year old, was sitting up in mothers lap, arm bent with a 24g, IMO this is a situation that is really likely to infiltrate. They did not put an arm board and would not start a central line. One of the other nurses told me today that the peds cardiology attending was pissed at me over this, and that he told her so. Well, he never even said ONE WORD to me. Her response was well, didnt you hear him talking in the background? Well actually no, I was busy triaging about 5 patients in a row, and I only spoke with the resident, who only does peds, does not have much experience in PICU. IMO, he doesnt have much business ordering meds like that if he doesnt even know WHAT IT IS or how to give it. On the adult side, the MICU people manage those patients and medicine the patients that arent so sick. If he had something to say then he should have said it to me. Her response is "well they do it all the time in PICU". Fine, but they are not responsible for 15 patients at a time and are able to watch the site more often and avoid infiltrating that IV. At night we are responsible for all the patients that are there, any admissions, and triaging. There are only 2 nurses that night, and there were 20 patients in the peds ER including this child, as well as non-stop ambulences and sign in triages.

My argument was:

I do not run vasopressors in a peripheral line except in an extreme emergency. If this was that situation, than the child should not be sitting up on mom's lap in the chair. Her response was you let the child do what is comfortable. IMO you cant have it both ways. If the child is that sick they should be laying in the bed, or he is well enough to sit up, play and eat. I know how fast an IV can infiltrate in a small child. By the time you realize it half of the upper arm is flooded. Who do you think that lawsuit is going to blame when that happens when the child loses his arm? That's right the nurse.

2) Just because he says that they "do it all the time" doesnt make it right. I could not find a written policy anywhere that spells out the administration of these types of drugs in peripheral IV's in pediatric patients. I am sure that it is approved for code/near code situations, but I know there is no way that it could be approved for long term use. Besides, this kid was going to be transported to another hospital. If that line blows en route, do you think that thier staff are going to take the blame for that? No way jose! I wish I could find some literature on this situation, I looked online and didnt come up with anything. What would be even better is finding literature on lawsuits in this situation.

3) She said that kids dont look very sick until the very end. This kid was newly diagnosed that night, how long do you think he has been going around like this? I am sure not one day. IMO if this kid was so critically ill, than he should have been lying in the crib, attached to the monitor. While he is sitting in moms lap cooing, and taking a bottle, the movement throwing the monitor off, this is hardly good management. She says that if the kid is crying it can make the condition worse so you let them stay with the mom. When I did my rotation in PICU, if the kid was that sick and not able to stay calm by other means that would allow them to monitor them, they were sedated. I dont mean snow the kid, but a little benadryl would have done no harm and not brought down the b/p.

I am sorry about the long question and the rant, but I cant believe this BS that they are trying to pull now. Besides that fact that the attending LIED and said that he spoke to me which he never did, unless you call bitching and yelling out loud 20 feet away from me talking to me! Then he tried to say that well I told the resident. Well that is fine and dandy, but you never told me. All in all the kid turned out OK after all, and they never did start that drip. Thank you all in advance for reading my rant, and appreciate the input you have/what you would do when a situation like this comes up in the future. Thank you again :icon_hug:

[fergus51]

I work NICU and while we prefer to have a central line, we will run pressors through a peripheral. We are required to check the site Q1H and I've had to do it on kids who were almost a year old before with a 24g in the PICU when I floated there. I understand your concerns about the number of patients you had. If the child needed dopamine, perhaps he should have been transfered to the PICU immediately and they could have done it or they could have sent a nurse down to do it rather than just complaining. ER isn't ICU and they shouldn't be expected to function in the same way.

I agree with what the nurse said about allowing the child to stay with mom. That doesn't make them necessarily less sick. We try to avoid sedation if it isn't necessary since it's a great way to mask subtle symptoms. The ability to sit with mom doesn't have anything to do with whether or not he needs dopamine.

[canoehead, BSN, RN]

I would be uneasy as well about that drip. My gut says not to start it peripherally, and if they want it that bad they can expedite the transfer to ICU to someone who is comfortable. Or you can set up the drip and let the resident titrate. In any case I would be putting an armboard on the child if it is your only line in a critically ill baby.

[NYCRN16]

I work NICU and while we prefer to have a central line, we will run pressors through a peripheral. We are required to check the site Q1H and I've had to do it on kids who were almost a year old before with a 24g in the PICU when I floated there. I understand your concerns about the number of patients you had. If the child needed dopamine, perhaps he should have been transfered to the PICU immediately and they could have done it or they could have sent a nurse down to do it rather than just complaining. ER isn't ICU and they shouldn't be expected to function in the same way.

I agree with the fact that the ER is not an ICU and shouldn't be expected to function as such. There is no PICU that I ever heard of that had it's nurses responsible for that many patients in addition to a sick kid. Checking the site every hour was impossible in this situation. They would never send a nurse down from PICU that was not an option, nor would they send the patient to the PICU because he was going to be transferred so that was out. BTW, the transfers here take HOURS, so we would in fact be monitoring this child for a long time.

I agree with what the nurse said about allowing the child to stay with mom. That doesn't make them necessarily less sick. We try to avoid sedation if it isn't necessary since it's a great way to mask subtle symptoms. The ability to sit with mom doesn't have anything to do with whether or not he needs dopamine.

I was not saying to take child away from mom, but if he needs rest and decreased stimuli, he should have been laying in the bed quiet with mom, not on the floor, sitting in lap, playing and such. Sedating a child is not a first line option, but it is not an uncommon occurance in PICU from what I remember seeing there when I was a student. My friends brother was hit by a car and was in an induced coma for weeks due to a head injury. It would seem that they wouldnt want to mask mental status, but they did to benefit him (and thanks to the PICU nurses there, he walked out good as new )

Another question...has anyone had a line actually infiltrate with caustic medications/vasopressors? Have you heard of it happening and what was the result of this?

[fergus51]

Sitting in mom's lap can often result in a lot more rest than in a hospital bed.:) I had an 18 month old on the peds unit a couple of months ago and the second he was put in bed (away from mom), the screaming would start. Ideally he would have laid in bed and slept. But, the care of babies is seldom ideal so in that case being calm in mom's lap was better. I couldn't make that baby lay down and sleep if he didn't want to. I can't say that was the case for your baby because I wasn't there and I don't even know what was wrong with the patient. All I'm saying is that we have good reasons for avoiding the use of sedation if we can and being held by a mother doesn't mean a baby isn't sick, so that may be where the PICU nurse is coming from. I've also noticed that some places are much more sedate happy than others. You obviously trained in such a place, but the doc and nurses in the PICU now may not share that philosophy.

I have seen a few bad infiltrates in my time. I've seen a handful that were really nasty and required plastic surgery later on. They were bad, but better than the alternative. In those cases it came down to having a live baby with a possible infiltrate or a dead baby without infiltrates. Only one was with pressors though and that was the nurse's fault for not checking her site for a couple of hours (long story). You can usually tell when they infiltrate very quickly because you check the site so often and because the BP changes, so it doesn't result in a terrible infiltrate. The worst ones I've seen have all involved TPN (calcium burns are terrible!) and lipids.

[BittyBabyGrower, MSN, RN]

What did they want the Dobut for? If this was a cardiac kid then, yeah, you probably should have started it with the stipulationg that she be transferred to PICU, but I understand why you didn't. Could you have armboarded it so that she couldn't bend it? We use peripherals in our NICU and PICU's since Dobut doesn't run with much of anything else. I have had more infiltrates from HAL/IL than from vasopressors. We use Regitine when vasopressors infiltrate. Sometimes they will get a slough and then we do wet to dry dressings and plastics is consulted.

Also, if the kid was having cardiac issues and needed to be kept quiet, then having mom sit with her was very appropriate. Sure, you could have sedated her, but then you may have ended up with a tubed kid and then your night could have gotten worse.

What do you do with other patients that are being transferred out? If the transport team wasn't coming for a while, then yes, they should have transferred that kid to PICU for monitoring. It sounds like you all need to bring this up and set a policy for it. Sorry for your bad night

[Pedi-ER-RN, RN]

What did they want the Dobut for? If this was a cardiac kid then, yeah, you probably should have started it with the stipulationg that she be transferred to PICU, but I understand why you didn't. Could you have armboarded it so that she couldn't bend it? We use peripherals in our NICU and PICU's since Dobut doesn't run with much of anything else. I have had more infiltrates from HAL/IL than from vasopressors. We use Regitine when vasopressors infiltrate. Sometimes they will get a slough and then we do wet to dry dressings and plastics is consulted.

Also, if the kid was having cardiac issues and needed to be kept quiet, then having mom sit with her was very appropriate. Sure, you could have sedated her, but then you may have ended up with a tubed kid and then your night could have gotten worse.

What do you do with other patients that are being transferred out? If the transport team wasn't coming for a while, then yes, they should have transferred that kid to PICU for monitoring. It sounds like you all need to bring this up and set a policy for it. Sorry for your bad night

I agree 100% Just my 2 cents.... We do hold kids in our peds er that are going to be transferred, but they go to a 1:1. We only transport out things like hearts and organ failure. Sounds like your PICU should have taken the pt and kept them until the transport team arrived.

[Gompers, BSN, RN]

I agree with most of the responses here. It's true that in the NICU (and I assume in the PICU as well) there are situations where vasopressors HAVE to be given via peripheral IV. If we have a cental line on a baby and it gets infected, we almost always have to pull it. Then we are not allowed to start a new central line until the baby has at least one negative blood culture, and in some cases we need three days in a row of negative daily cultures (this is with candida sepsis). In the meantime, we have a very septic baby with only peripheral access. Fergus hit the nail on the head when she said that it comes down to risking a live baby possibly getting an IV infiltrate versus not giving the pressors peripherally and then having a dead baby! You might think that is a pretty harsh statement, but it's one we deal with in PICU and NICU. I'm sure we have a written policy somewhere allowing this. But in the end, this is common practice in most NICUs, and our kids have the most fragile veins of all. As far as being sued - if you properly monitor the IV site per hospital/unit policy and document everything, then you are covered.

The armboard thing - that is a nursing judgement because the nurse is ultimately responsible for the IV site. You should have been able to place an armboard without having to consult anyone. If you didn't think the IV site was acceptable, as a nurse you also had the authority to start a new IV site for the pressors.

[AlabamaBelle]

I work in PICU. While not preferred, we have given dobuta/dopa via PIV, with the STRONG understanding that a CVL will be placed ASAP.

Fergus & BittyBabyGrower are absolutely correct - keeping the child quiet and calm is of utmost importance. Many of our children who are on vasopressors are also receiving some sedation. And usually, if the child is going to be put on pressors, the child is moved quickly from our Peds ED to the PICU. The pressors are generally begun in PICU after the child gets to us - we have the drip(s) ready to go. Generally, our policy is to keep the child quiet & comfortable with parents close by. Usually, once we explain why the armboard has to be on, the parents are fine with it.

As has been stated earlier, a really sick child may not look very sick at all. Children can hold their VS very well - their BP is the last thing to go - and when that happens you are so behind the eight ball. I've seen it time and time again, the child doesn't look that bad, but within a matter of minutes, the fat has really, really hit the fan.

Our policy is also that a child on any pressor must have q15minute VS and be on full monitors - in a Peds ED, given the nature of emergency medicine, I'm not sure that q15's are very feasible/reasonable.

Hope this helps.

Cindy, RN

[AlabamaBelle]

I am a PICU RN. While PIVs aren't first choice, sometimes you start with what you have. Generally, in our facility, pressors are begun in the PICU. The child in the Peds ED who needs pressors would be brought up to us pronto. Also, our facility policy also states that continuous monitoring with q15min VS must be implemented. Once with us in the PICU, a central line would be a priority.

As Fergus, Gompers & BittyBabyGrower have stated, a really sick child may not "look" or "act" sick. Children are great at compensating, but when they've reached the end of their rope, watch out. Their BP is the last thing they lose. Depending on the age of the child, the holding or willingness to be held might be an indication that child just doesn't feel well, especially a usually active, curious toddler/preschooler.

To have a child on any pressor in an ED is not at all a good thing, IMHO. Emergency Medicine is just that - emergency. With your patient load/pace, this is a potential disaster waiting to happen. I hear your concern about the resident, as our whole PICU has had issues with a resident or two. We have a countdown going with one particular one and each nurse knows just how many nights/hours we have left with this one.

Rants are wonderful stress relievers and isn't it great to know that we understand what you went through!

[KJAVRN]

I would have felt uncomfortable running it through a PIV that was as flimsy as it sounds.

We have run inotropes through PIV's, but the site needs to be checked q 1 hour and should have a bllod return.

I probably would not have wanted to start the gtt unless it was an emergency

[UK2USA]

You are absolutely right to have been concerned about starting this drip. I was trained in a unit where NO pressors are run through a peripheral line... and one look at a nasty infiltrate will explain why (see examples here). However since I moved to the USA I see it happening more and more.... it makes me very uncomfortable. IMO Q1 assessments of the site is the absolute minimum I would check. I usually check Q15 minutes for any pressors that run through a peripheral line (also potassium, vanco, gent or any other harsh meds).