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ted
vanco via midline

Scenerio:  Attending MD orders midline for a patient who will need 2wks of Vancomycin IV at home.  Patient recently had a right sided chest port removed d/t infection.  Positive blood cultures were drawn both peripherally and from port.  Also has pocket infection.  Has left chest pacemaker with recently confirmed DVT of left subclavian vein.  Patient has CKD.  Blood cultures have been neg X48hrs by the time midline order is received.  PICC RN tells APN (we don't talk to attendings unless they are hospitalists) that Vancomycin should not be infused through a midline catheter for reasons we all know.  Conflict ensues.  Attending MD does not want ANY type of central venous access device because he does not want any risk of DVT  that would preclude dialysis access.  Not even an IJ picc as I suggested.  Interventional radiology medical director (picc team based out of IR) orders picc nurse to place midline.  States attending MD weighed the risk of vancomycin thru midline vs CVL placement be it PICC or IJ or any other CVL and it is his opinion that the risk of vanc thru midline is less than risk of thrombus formation from CVL. IR clinical nurse specialist informs me that it's not my place to say no to midline placement....it's not my place because I am not assuming the risk.  The attending MD has made the decision and he is assuming all risk.  By this time I've put in seven picc's for the day and I am developing a headache.  Ultimately I did not place the midline because IR called the patient down at the end of the day.  Any thoughts?

lynncrni
First, foremost, always and

First, foremost, always and forever, no professional can assume the liability for another professional. This is impossible although many physicians think they can, it simply is not true. A nurse practices under an indivdiual license issued to that person. So all patient care decisions you make are your responsibility, good, bad or neutral.

This is a very bad situation when you are not allowed to discuss patient care issues with the attending directly. It can easily create a situation for a bad outcome. Now with that being said, I can understand why the attending had so much reservation about another CVC in this patient due to his history. I have serious reservations about whether the attending truly weighed the risks of vanco through a midline based on my knowledge of most physicians understanding of tissue damage from a vanco extravasation. Maybe I am not giving enough credit to this attending and that is why it would be so much better if you and this attending had a direct conversation about the patient. I think your idea of an IJ inserted line was good and one that is often used in such situations to prevent DVTs. I would also have concerns about whether a home care company would accept a patient with a midline receiving vanco for 2 weeks. If the patient had sufficient peripheral veins, there may be less risk of serious harm with short peripheral catheters. This would mean more venipunctures but extravasation could be recognized much faster with a peripheral than a midline. This would mean less tissue damage. Just my opinion though, Lynn

 

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

mary ann ferrannini
  I would not have placed it

  I would not have placed it either..... Luckily we have nursing policies and procedures in place to support us....Guess what you place the ML..pt has some problem b/c of the Ph of Vancomycin ...you can bet they would come looking for the nurse insertor

ted
vancomycin via midline

Thanks for your reply Lynn.  I was being pressured to place this midline for vancomycin by my clinical nurse specialist and the medical director of IR.  The IR medical director spoke to the attending and decided that a midline would be "best" for the patient.  Apparently they are of the the belief that I cannot refuse to place this line.   IR placed the midline.  It's difficult to work in an environment where there is no support for the vascular access specialist.

Greg Scott
I was faced with a similar

I was faced with a similar situation this week.  The patient had a right mastectomy and a left pacer.  We can't use the right extremity - industry standards, thus leaving the left extremity as our only option.  Problem was the catheter would not pass through the subclavian.  Probably stenosed from the pacer that has been in place since 2003.  The line was left as a midline, and I informed the MD's that infusing vanc through it was not advised.  I suggested sending the patient to IR for another try at placing the PICC.  The patient was already complaining of the peripheral access that the bedside nurses were placing - on a daily bases.  These are the situations that need to be discussed at conference.  We need alternatives.  We don't do IJ PICC's.  Any thoughts to this situation.

lynncrni
All PIVs for vancomycin must

All PIVs for vancomycin must be the smallest gauge, not in an area of joint flexion and properly stabilized. This may require an infusion nurse to insert during the interim while waiting for another attempt at a PICC. You could also discuss the mastectomy surgery with her physician and possibly use that side since there were other issues. How long ago was the surgery? Level of node dissection or simple mastectomy? Any history of lymphedema? These are situations where the knowledge and skill of infusion nurse specialist are required. Those facilities that try to manage with a PICC or vascular access team limited to insertion only are not meeting the needs of all patients. This is another example of staff nurses being overloaded with the tasks that no one else wants to claim. And my strong bias for full service infusion therapy teams instead of the limited services of catheter insertion teams. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

swiftymartin
 I agree with you, Lynn. As

 I agree with you, Lynn. As well as the vascular access clinician (VAC) which will be designated by the certification authored by AVA by the end of the year. Someone needs to bridge the gap and be the advocate for these patients with complicated histories who have limited options.

mary ann ferrannini
   I just DO NOT want to

   I just DO NOT want to practice as an insertion only PICC/IV team. I have seen too many things happene over the last 27 years aand have come to know that the average nurse does have the IV Therapy knowledge to make a well infromed decision about the best course of action. Some of us that can see the "BIG PICTURE" have fought over the years to keep doing our dressing changes and assessments.

Susan S
how about another drug?

Daptomycin is not as irritating to the vein....Did anyone think of changing the drug????  I have seen DVT  due to Midlines being used to infuse Vancomycin.  I mean I personally visualized it using ultrasound when the patient had pulled the midline and I was called to replace it.  The thought process of both MD that the midline was the least risk...was an ill informed decision...Perhaps they should have consulted with the friendly neighborhood PharmD for their opinions too!.....Sometimes a multidisciplinary approach is BEST PRACTICE too.

     Felt like this discussion need a little push "outside the Vanco box"

 

Thanks for reading my post!

Susan S CRNI

Susan Schuetrumpf, RN, CRNI, VA-BC
Atlanta GA

JackDCD
Vanco through a Midline

Vanco ph 2.4...blood ph 7.45...that's the story. You CAN give Vanco through anything, but should you?. I have always found myself in a courtroom in my mind. Always put yourself in that room. You take the stand...the prosecuter states: Nurse Smith the ph of Vanco is 2.4, therefore caustic to the vein. Your are an "expert" in venous access, inserting Picc's and Midlines?...so you are aware of the damage that an acidotic medication can cause to the vein...yet you inserted a Midline knowing the vein is not large enough to sustain Vanco for 2 whole weeks and now my client Mr. X developed and deep phlebitis that was not detected right away, allowing it to fester and cause a puralent pocket that needed to be excised and a drain inserted....Not to mention my client  uses his arm for work and now may be severley disabled...So, Nurse Smith...why did you feel is was right to ruin my clients life??

There you go...how do you answer that in order to show that was the best solution?..oh and 12 jurors breathing down your neck.

Just say NO!

JD 

lynncrni
Please do not think that JD

Please do not think that JD is exaggerating. An attorney could even be more aggresive that that! So just say NO as he said. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

momdogz
we have often had these disagreements

 with our IR Medical Director and providers (our nursing vascular access team is part of Radiology Dept.).  We stick to our practice beliefs, and - sometimes it has not been pretty!  One of the IR MDs told one of our PICC RNs, when she was advocating for a patient when he told her the PICC tip could stay in the axillary vein and said "that is not part of our practice" - "You don't have a practice!".  

Another case - an intensivist told one of our PICC RNs (who should have known better) and the ICU nurses that it was fine to leave a power injectable PICC tip in the axillary region. The PICC RN could not advance the PICC any further, and the MD told him to leave it (should have known better).  The vein was probably stenosed at that point, which is why catheter couldn't be advanced.  Before I found out about it and could remedy it, this stroke patient who already had RUE deficits had a power injected CT into her brachial plexus area, and it extravasated.  Fortunately - nothing happened (she was followed over time), but it could have been disastrous.

When catheters are not able to be advanced, it is usually because the vein is already in trouble.  Power injecting or infusing vesicants/irritants/Vancomycin as a midline near these already troubled areas is a horrible idea.  I agree that if central access of some kind is absolutely not possible, then peripheral would be next choice.

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

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