Place a PICC in those patients. Chances are they can not tolerate Trendelenburg position for subclavian or jugular insertion either. The PICC exit site can more easily be positioned at or below the level of the heart to avoid air emboli. If a PICC was not placed and you must remove another percutaneous CVC, have the patient perform a Valsalva maneuver as you remove the last few cms of catheter length, but there are also patients where this is contraindicated. If Valsalva is not possible, ask them to hold their breath or hum. Have a gauze dressing with your ointment ready to immediately cover the puncture site. That is about all I can think of. Lynn
Of course PICC would be ideal but you are right, sometimes the central line is already in and the patient can not lie flat.
If patient has mental status issues and can not comply, I was told to pull on end of expiration. Do you agree?
And.... If patient is on respirator (positive pressure), the pressure is highest during inspiratory phase, would that then be the best time to pull the IJ or subclavian line?
As far a dressing, I am hearing many variable practices. From several of your comments, it is the petroleum property that is essential for occlusion. Would you say that the 2x2 vaseline gauze with tegaderm would be equivalent to vaseline (sterile packet if available) and regular 2x2 gauze and then tegaderm. Do you need the porous gauze?
During the end of expiration would be the time to pull the last segment of catheter when the patient can not comply with instructions. As far as the respirator or ventilator, I would defer to the respiratory dept for them to tell me when the intrathoracic venous pressures would be at the highest to prevent air from being pulled into the bloodstream. I do not know enough about these machines to provide that answer. RE the type of dressing, it is the ointment that provides the seal to the puncture site. It does not matter about the other dressing characteristics. So either product you listed should be acceptable as long as there is the ointment to seal the site and prevent air from entering the bloodstream. Lynn
Place a PICC in those patients. Chances are they can not tolerate Trendelenburg position for subclavian or jugular insertion either. The PICC exit site can more easily be positioned at or below the level of the heart to avoid air emboli. If a PICC was not placed and you must remove another percutaneous CVC, have the patient perform a Valsalva maneuver as you remove the last few cms of catheter length, but there are also patients where this is contraindicated. If Valsalva is not possible, ask them to hold their breath or hum. Have a gauze dressing with your ointment ready to immediately cover the puncture site. That is about all I can think of. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Of course PICC would be ideal but you are right, sometimes the central line is already in and the patient can not lie flat.
If patient has mental status issues and can not comply, I was told to pull on end of expiration. Do you agree?
And.... If patient is on respirator (positive pressure), the pressure is highest during inspiratory phase, would that then be the best time to pull the IJ or subclavian line?
As far a dressing, I am hearing many variable practices. From several of your comments, it is the petroleum property that is essential for occlusion. Would you say that the 2x2 vaseline gauze with tegaderm would be equivalent to vaseline (sterile packet if available) and regular 2x2 gauze and then tegaderm. Do you need the porous gauze?
Chris Thomas
During the end of expiration would be the time to pull the last segment of catheter when the patient can not comply with instructions. As far as the respirator or ventilator, I would defer to the respiratory dept for them to tell me when the intrathoracic venous pressures would be at the highest to prevent air from being pulled into the bloodstream. I do not know enough about these machines to provide that answer. RE the type of dressing, it is the ointment that provides the seal to the puncture site. It does not matter about the other dressing characteristics. So either product you listed should be acceptable as long as there is the ointment to seal the site and prevent air from entering the bloodstream. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Our policy is to remove the line, in this case, at the start of exhalation.