I have found several ocassions where the physician has placed a central line and was unable to advance catheter to the SVC and left the catheter
in the juglar and wrote orders ; "ok to use line." I have seen in his progress notes where the physician writes , "it is ok to use the line or leave it in the juglar
since he is not giving any TPN. " Worse yet, I have found that many of the nurses didnt even realize the tip was juglar , they thought it was a central line with the tip in
the desired location.
Now, I do not maintain or work with the physician inserted lines, but find this info in notes or xray rsults when the MD does order a PICC line or a staff member may ask me
a question about the line.
I am thinking as a PICC nurse I would not be using a line until the tip is in the desired location, that includes a physician inserted central line ( regardless of what he says) . I have reviewed the INS standards regarding Central vascular access device malposition and found; Infusion through a malpositiioned cathteter should be witheld until proper tip posiition has been established. The nurse should assess the infusion therapy being administered and , if possible, insert a short peripheral catheter to continue therapy. If the infusion therapy is not possible through a peripheral vein, the nurse should assess the potential risk for discontinuing therapy, or seek orders to change the infusion therapy until the proper CVAD tip location can be reestablished.
So, I see no loophole in there saying it is ok to use a line with the tip not being in the desired location, if we are not giving vessicants or drugs of a specific ph range or osmolality. Or...does that statement that says " or seek orders to change the infusion therapy until the proper CVAD tip location can be reestablished" mean change "type " of therapy instead of stopping therapy.
I am thinking I need to address this with the appropriate leaders in our hospital to educate the staff to enforce the correct response to this scenario.
Any input from you? Are there documented risks associated with using a line where the tip resides in the juglar?
thanks, Gina Ward R.N, CPAN PICC nurse at Raulerson Hospital
You bet your bottom dollar there are risks!!! Retrograde infusion into the intracranial venous sinuses is one of the huge risks your staff is taking. This produces neurological complications. Venous thrombosis is another huge risk. I know you probably do not have control over this, but this is one of the problems with being a "PICC nurse" as compared to an infusion nurse with responsibility for all safe infusion through all types of VADs. I have seen these orders and refused to follow them, requiring that the MD change the tip location. That order involved IV Dilantin!! I have had several heated discussions over this, but told the MD I could quote chapter and verse from the published literature of this risks. He asked me if I needed to be educated about blood flow! I have also seen this during a consultation project at another hospital. You must stop this practice. If the MDs will not listen to you, it will be the nurses going down in a lawsuit as well as the MDs. Proper tip location is a risk management strategy to reduce the risk associated with any CVAD. You will have to educate the MD with the evidence. If the therapy cannot be stopped such as a vasopressor, or PN, you can change to 10% dextrose or change the vasopressor to a peripheral line. But something must happen to reduce the risk of the malposition CVAD. 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
Where could I find the literature? I did a quick search on the internet and unable to find info. It wants to point more towards malposition isuues and not issues of infusing into the juglar vein.
thank you, Gina
Gina Ward R.N., VA-BC
Where could I find the literature? I did a quick search on the internet and unable to find info. It wants to point more towards malposition isuues and not issues of infusing into the juglar vein.
thank you, Gina
Gina Ward R.N., VA-BC
Start with the list of references in the INS standards on malposition. That is always the place to begin a lit search. Use those phrases and key words in those studies to refine your search. As you know this takes time and I am swamped for the rest of the week and can not locate them for you. 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
Thank you so much Lynn! Gina
Gina Ward R.N., VA-BC
I actually pulled up the articles as resources for the INS standards and did not fully view/purchase them but looked at the abstracts. I wanted to see what it covered before I purchased it. None of them appear to mention or discuss the complications of leaving a central line with the tip residing in the juglar and infusing medications through it.
We have some pharmacy interns here at the hospital , I will ask the Director if he can put them on a mission for me.
Any info would be great thanks, Gina
Gina Ward R.N., VA-BC
Gina,
Did you find the articles you wanted to support the INS position? Can you share?
We have the same problem at our hospital.
Thanks.
Jan
The INS, AVA, ONS, FDA, Manufacturer's IFU (instructions for use), SIR (Soc of Interv Rad) and others all state that the tip of a central venous catheter must reside in either the SVC or Caval Atrial junction. Each of these postiion papers has reference articles that you can use if the management wants something other than these position statements. Also check the Resources tab here for articles. Google search will turn up some articles as well. Infusing anything in a malpositioned catheter can cause problems and the person doing the infusions will be liable. You stated right from the standards--INFUSION THROUGH A MALPOSITIONED CATHETER SHOUDL BE WITHELD.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC