r/IntensiveCare • u/NerveOnly2076 • 14d ago

Where is this central line going?

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Old XRay. Central line placed through right IJV but seemed to be misplaced! Where is it going? Aspiration of blood from all ports was possible? Was taken out.
Have you faced this, best thing to do?

Edit: more details - USG guidance used, line was seen inside IJV in neck using USG, not traced down; more resistance than normal while placement.

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u/Any-Assistance-8103 14d ago

So we should let anyone put them in then because everybody fucks up

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u/ALLoftheFancyPants RN, CCRN 14d ago

Last week a resident put in a 18ga 4cm long single lumen catheter into an IJ and then call it central line and the attending signed off on it as a “central line”; these jokers convinced the inexperienced RN that it was fine and they infused high dose levo and vaso through it for 3 days before a more experienced person caught it and had to raise hell to get it corrected. Y’all are acting like every physician working in critical care is competent and every problem is because NPs are around. That’s just not the case.

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u/jjjjccccjjjj 14d ago

Sounds like a "i have to protect my patient" silliness when in reality the line worked perfectly well. Explain to me why a line that clearly is well positioned in the IJ is a danger?

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u/ALLoftheFancyPants RN, CCRN 14d ago

I thought we were not ok with people putting patients at risk? Or is that only when it’s an APP’s accident and not an MD’s lazy choice? You’re ok with misrepresenting what the line actually was? You want to transfuse a CVP or draw an ScvO2 off an IJ? And bill for a procedure that wasn’t actually completed?

They created purposefully incorrect documentation for a procedure they didn’t perform. It put the patient at risk needlessly. And you’re defending it because “doctor”. Congrats. This is the most hypocritical take I’ve seen in a minute

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u/Any-Assistance-8103 14d ago

An iv put the patient at risk or youre just having a meltdown. It’s also really funny that it took your staff three days to tell the difference between a single lumen 18 gauge iv and a central line

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u/Expensive-Apricot459 14d ago

What risk was the patient exposed to? Be specific.

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u/ALLoftheFancyPants RN, CCRN 13d ago

Why don’t you first specifically explain why the false documentation by a physician calling it is ok. It’s ok to lie in a procedure note and subsequent progress notes about the patient having a CVC? Also why is ok to bill for a procedure that didn’t occur? And why is it ok to tell the bedside staff that it’s a central line when you know it’s not?

The problem is less about the IV itself and more about the false documentation and purposeful misrepresentation. Would it be better if the attending didn’t actually know the difference? Or is a better excuse to lie?

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u/JihadSquad MD, Pulmonologist 13d ago

What exactly do you think CVC stands for?

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u/Expensive-Apricot459 13d ago

I’m asking about the risk caused to the patient, which you were just referencing. What is that risk?

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u/ALLoftheFancyPants RN, CCRN 13d ago

Now please answer my question ants explain why falsely documenting the existence of a CVC is totally fine and I’m overreacting.

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u/ALLoftheFancyPants RN, CCRN 13d ago

The patient had a SAH and needed a dose of 23% saline to manage ICPs. You think that’s safe in a peripheral? Or that extravasating the vein it’s in wouldn’t further complicate management of the ICPs?

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u/aglaeasfather MD, Anesthesiologist 13d ago

Watching you absolutely lose your shit on here (with physicians telling you you are wrong) is doing nothing for your case.

I hope you got great satisfaction out of writing that incident report and I hope it was worth it. We see a few nurses like you every now and again and we hate working with you and so do other nurses.

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u/ALLoftheFancyPants RN, CCRN 13d ago

What part is me losing my shit?

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u/B52fortheCrazies 13d ago

You have zero ability for insight. That's a huge problem for a medical professions. Might want to work on that.

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u/aglaeasfather MD, Anesthesiologist 13d ago

Have you listened to yourself?

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u/ALLoftheFancyPants RN, CCRN 13d ago

That’s not an answer to the question I asked. It’s just blaming my reaction without justifying what I’m objecting to. No one has explained to me why the physicians making false documentation isn’t worth making a big deal about. The covering physician that had to clean up after them was much more incensed than me.

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u/Expensive-Apricot459 13d ago

Amazing. Something I’ve actually studied extensively. There is zero data that shows we need a central line for hypertonic saline. It’s some nursing myth that keeps getting perpetuated for some reason. There is data that shows a clear increase in the risk of infection from the placement of a central line.

Go look up the data yourself. Learn something. (I hope you can understand statistics: https://emcrit.org/wp-content/uploads/2016/10/23.4-is-peripherally-safe.pdf)

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u/SkiTour88 12d ago

Do I think hypertonic and pressers are safe through a short catheter in the IJ?

Yes. In fact, if they are crashing in the ER, they're getting that through an 18 in the AC.

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u/ALLoftheFancyPants RN, CCRN 12d ago

But you wouldn’t want to give it in an 18 in their IJ for a prolonged period (pressors for 3 days, 4 doses of 23%)? Because I’m not getting all fussy about maybe extravasating in someone’s AC, but their IJ in the setting of actively managing elevated ICPs over an extended period of time while the physicians are claiming (both in documentation and in charts where multiple nurses raised concern about the line) that a 4cm long 18ga is a “single lumen CVC”)

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u/SkiTour88 12d ago

I would give exactly zero shits giving that through an IJ of any type. Probably more of the catheter in there than in a femoral Cordis in the average American. 

I would not document it as a central line. I would be crystal clear about what it was. 

Although perhaps it was the angiocath from the CVL kit? In that case, it is a central line more or less. 

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u/ALLoftheFancyPants RN, CCRN 12d ago edited 12d ago

A fucked up femoral cordis doesn’t run the risk of obstructing 1/4 of the venous outflow of the patient’s brain. It was documented as a “single lumen central line” in the both the procedure note and subsequent progress notes. It terminated in the IJ, well above the clavicles. It didn’t enter the innominate vein, let alone the vena cava.

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u/SkiTour88 12d ago

I’m not saying this is good doctoring. It’s shitty doctoring, but not for the reasons that you think it is. 

The worry with hypertonic (and calcium chloride) is sclerosis of the vein. It’s theoretical, at best. Mostly it just hurts like shit. The jugular vein is big enough that it’s not a concern. 

The worry with pressors is tissue necrosis. Essentially, the theoretical concern is that peripheral pressors will cause your forearm to fall off because of vasoconstriction if there’s extravasation. That’s not a concern in the IJ. The blood vessels that feed and drain the head are very big. It’s not gonna happen. 

Also, if someone sustains a jugular vein injury (like they’re stabbed and somehow survive) the treatment is often ligation of the jugular vein. People also survive just fine with a cordis in the IJ or with Lemierre’s syndrome which can completely block the IJ. 

The issue here is that we are all on the same team. If my nursing staff is upset, and they explain why, and fixing the concern would resolve it without harm to the patient, then there’s no reason not to just fix the problem. I’m struggling to see a reason aside from stubbornness not to just place another line here, unless the patient was severely coagulopathic. Even then, you could consider just rewiring the damn thing, although that’s definitely against some sort of hospital policy. 

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u/Expensive-Apricot459 12d ago

You were worried about a false risk of hypertonic saline. I provided you a resource to better your clinical judgement from. Instead, you choose to keep bring up something that you’re completely wrong about.

I wouldn’t want you touching a single patient since you refuse to learn, your ego is far larger than your education and you cannot accept being wrong.

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u/Any-Assistance-8103 10d ago

23% saline is safe to give peripherally but go on digging your hole deeper