What would you do? -long-

Nurses General Nursing

Published

Specializes in Pediatrics.

The other night at work I had a baby going to surgery the next am. She has a blood clotting condition in which her body does not make enough platelets so clearly the risk of intra or post-op hemorrhage is a big risk. She had a PT/PTT/INR and a type and cross ordered, as days already did the BMP and CBC.

Well, the baby was less than a year old and weighed 9 kg... VERY difficult to feel and see what veins she had. I tried x1, another nurse on the floor tried x1. we called PICU who is our standby and 2 nurses came over, each tried x2. At the end of that, i started filling the vacutainer for the PT/PTT/INR to where it stopped pulling in the blood. I have had issues with the lab where if it isn't a full 2 ml they call back and say they don't have enough, although PICU said they never have that problem they just send what they have when it stops pulling. When it was done pulling, the leftover 1 ml required for the type & cross was sent to the blood bank.

Naturally the lab called, and she said they didn't have enough and would not run the sample. I explained to the woman that this baby does NOT bleed and the blood is very viscous and clots almost immediately (although with the condition, should be the opposite). So she is very rude to me and in turn, I got very frustrated.

I called her doctor and explained the situation to just keep him updated that I am having difficulty with this. He gave me a telephone order to send to the lab that said to run what they could with the sample. My charge nurse tried x2. I also called the STAT team, which they do the difficult sticks. 2 nurses came and each tried x 2, and could not get a sample. I called the lab back and asked them to run the sample with what they could, and I spoke with the same technician and she told me she discarded the sample because it wasn't enough! So, here I am, having exhausted all of my resources, explained to the parents numerous times why I have to keep sticking and torturing the baby, had the baby stuck 12 times during my shift, not counting the IV inserted earlier (doesn't bleed back) and the labs done earlier... the baby's surgery was pushed back because they didn't have the PT/PTT/INR.

My question is, would you write up the lab? In understand they have their own guidelines but if they can run things for the PICU not full why can't they do it for the regular floor? The PICU nurse that told me this was my preceptor my last semester of school and has been practicing at this facility for more than 10 years.

Up Vote Up Vote ×

The lab is probably in the clear as long as they are following established guidelines for running that test.

I know it's odd that sometimes they've followed one procedure and sometimes another, but I can't imagine that the lab could be faulted in your specific instance (doing it right) just because they haven't done it right in the past.

Up Vote Up Vote ×
Specializes in Trauma ICU,ER,ACLS/BLS instructor.
The other night at work I had a baby going to surgery the next am. She has a blood clotting condition in which her body does not make enough platelets so clearly the risk of intra or post-op hemorrhage is a big risk. She had a PT/PTT/INR and a type and cross ordered, as days already did the BMP and CBC.

Well, the baby was less than a year old and weighed 9 kg... VERY difficult to feel and see what veins she had. I tried x1, another nurse on the floor tried x1. we called PICU who is our standby and 2 nurses came over, each tried x2. At the end of that, i started filling the vacutainer for the PT/PTT/INR to where it stopped pulling in the blood. I have had issues with the lab where if it isn't a full 2 ml they call back and say they don't have enough, although PICU said they never have that problem they just send what they have when it stops pulling. When it was done pulling, the leftover 1 ml required for the type & cross was sent to the blood bank.

Naturally the lab called, and she said they didn't have enough and would not run the sample. I explained to the woman that this baby does NOT bleed and the blood is very viscous and clots almost immediately (although with the condition, should be the opposite). So she is very rude to me and in turn, I got very frustrated.

I called her doctor and explained the situation to just keep him updated that I am having difficulty with this. He gave me a telephone order to send to the lab that said to run what they could with the sample. My charge nurse tried x2. I also called the STAT team, which they do the difficult sticks. 2 nurses came and each tried x 2, and could not get a sample. I called the lab back and asked them to run the sample with what they could, and I spoke with the same technician and she told me she discarded the sample because it wasn't enough! So, here I am, having exhausted all of my resources, explained to the parents numerous times why I have to keep sticking and torturing the baby, had the baby stuck 12 times during my shift, not counting the IV inserted earlier (doesn't bleed back) and the labs done earlier... the baby's surgery was pushed back because they didn't have the PT/PTT/INR.

My question is, would you write up the lab? In understand they have their own guidelines but if they can run things for the PICU not full why can't they do it for the regular floor? The PICU nurse that told me this was my preceptor my last semester of school and has been practicing at this facility for more than 10 years.

Wow, unacceptable huh? But I bet for ever nurse there is at least 10 labs horror stories! Can I ask why no one put a line in this child so they could draw? Why not a pre op aline( I know,needs icu) or just an arterial stick? Better then sticking a kid a million times. When my son was one week old he became very ill from beta strep complications. He lost his IV one night and they took him in this back room. After an hour I could stand it no more and went and took him from them. They ended up giving him IM injections twice daily. Apples and oranges, I know, but as a mom, I could not bear the screaming anymore. He had fat chubby arms and legs,even scalp IV was impossible then. I would check with ur manager and see what can be done to resolve this and future situations .

Up Vote Up Vote ×
Specializes in Pediatrics.

I put a note on the front of the chart requesting a CVL or PICC for the pt, since it was known the baby would need platelets following the surgery, and probably abx tx for a few days too

The only other thing I could have thought of was the MD coming to do a femoral stick on the baby, however, although on call, was at home.

The kid was a direct admission from her pediatricians office.

I agree, something should have been done previously to this, but since the shift before me got labs and and IV in they could not have foreseen the difficulty I would have... the PT/PTT/INR was ordered a few hours following the labs obtained beforehand.

OH just so frustrating!

Up Vote Up Vote ×

it's a little late now, but i would have spoken with the mgr of the lab.

i've had instances where i was told i didn't obtain enough, and the mgr worked around it, once i explained the reasons.

poor baby...

leslie

Up Vote Up Vote ×

We have the standard size blue-tops, but also a much smaller one for those who are difficult to draw (I can't remember the amount; a cc or less. next time I work I'll check on that). Perhaps you can get the lab to send a supply of those for next time you run into this issue.

The lab was right in rejecting the specimen. There has to be adequate dilution of the blood with the citrate in the tube in order to get an accurate result.

Up Vote Up Vote ×
Specializes in ER/Trauma.

I was told that the reason PT/PTT tubes have to be filled completely is due to the fact that theres an anticoagulant in the tube so if it isn't filled then the values could be off? But I would definitely ask for a central line or PICC...

Up Vote Up Vote ×

Couldn't the lab have sent up a phlebotomist to draw it? Or don't they do that?

Up Vote Up Vote ×
+ Add a Comment