TLC clotted over...

[muscledriver]

It's been one of those weekends...

Short story...Due to past hx of drug use, pt had a TLC installed to receive abx r/t a chronic LE infection. While wrapping up my shift, I disconnected the IV line from the lumen, clamped the line and as I was going to put a cap on the lumen, the patient pulled away, the alcohol from the cap mixed with some blood at the lumen and it splashed on her gown. So, pt starts screaming I tried to pull out her line...etc. I calmly clamp her line, place the cap, change all her linens, her gown, and did my best to bow out for the night while trying to find my quiet spot.

Come back on the unit this morning, to find that the entire line had clotted. It appeared as there was a backflow and it had clotted all the way to the lumen opening (making me very worried about a clot breaking off or infection). Interestingly enough, the night shift had the same issue with a separate line and now the pt's TLC is down to one working line.

Apparently there were no MD's in the hospital today that could deal with this in order to fix it. So my question is - how can this be fixed? I would think you should just be able to put TPA in the line to dissolve the clot but one of the nurses told me that the clot may be too large for this method. I also find it very strange that another RN ended their shift with the same issue.

I work on a run of the mill MedSurg floor and I do not have a ton of experience with the TLC, so I apologize if this sounds like a simple fix. I feel terrible that this happened, and take it very personally, I just don't understand how it came about when the line was clamped and capped.

[icuRNmaggie, BSN, RN]

I would inform the MD. He can order cathflo or place a new one over a guidewire if absolutely necessary. It is very strange that you have had a back flow of blood in two lumens on two different shifts.

[IVRUS, BSN, RN]

My question to you is this: Once you removed the IV that was infusing into the line, was the lumen clamped off prior to removing the tubing? And once the needleless connector was applied, didn't you flush with the appropriate solution ie. Normal Saline, and then heparinize the line if needed? Not flushing the line post disconnection will cause you to have a clotted lumen. I would definitely have the IV team, or the RN instill Cathflo once it was ordered into each lumen which was occluded.

[SierraBravo]

First of all, what is a TLC? I work with central lines all day, every day and have never heard of that term. How many lumens if this is a central line?

As someone else said, why didn't you flush the line when the infusion was complete? You should be flushing and as the flush gets to the end, clamp the line so that you are using positive pressure and there is no "backflow". Depending on what type of line it is, you can ask the provider for alteplase which will usually fix the issue. If the first dose doesn't work, sometimes a second dose is needed. If that doesn't work then you obviously need to notify the provider and they will determine how best to fix the issue.

[IVRUS, BSN, RN]

A TLC is a Triple Lumen Catheter

[muscledriver]

Yes, the line was flushed, this is why it's so odd. I am starting to wonder, since the patient is an inmate, and has been in and out of hospitals for years with numerous central lines, with a long track record of abusive/agitated behavior while in the hospital, if they somehow tampered with the line? I mean why would there be two lines out of service with the same issue? Doesn't make any sense.

Thank you for offering solutions, I work on a med-surg unit but we rarely get triple lumens so I was not sure how these types of issues are dealt with.

[icuRNmaggie, BSN, RN]

I would be highly suspicious of this inmate trying to do something self destructive such as faking blood loss or giving herself a clot or even a line infection in order to stay in the hospital or file a lawsuit. Refer this to your risk management and ask administration for a guard and a room search. Remove all syringes and flushes if you have not already done so.

[icuRNmaggie, BSN, RN]

She could even be putting the lumens in her mouth. I have seen crazier things.

[nurseprnRN, BSN, RN]

I had a junkie once who loved him his central line. Nice big line, all right there, no screwing around with a tourniquet and arm veins.

[muscledriver]

That is what I was thinking as well, thinking that the inmate may have fiddled with the line seeing that she has had so many over the years and will do whatever she can to delay going back to prison. My concern now is that this doesn't get me fired! As a new RN coming up on completion of my first year working (with a very Type A personality), I am always on alert that any problem might get me canned.

[OneDuckyRN]

Maybe it's irrelevant, but doesn't your facility REQUIRE that inmates have a corrections officer with them at all times? I'm not sure what state you're in, but it seems like your state's department of corrections would have some sort of provision for that. Unless the CO just doesn't care, I would think that being watched all the time would sort of deter her from messing with her TLC (I think this might be the same thing as a triple lumen PICC). This sort of behavior should buy even a non-inmate patient a 1:1 sitter.

Even jail inmates in my facility are required to have some sort of law enforcement supervision at all times. You might want to look into this.