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campriishe
Port tip in R ventricle

Hi all,

Wanted to get input on current issue with a patient. Patient was admitted from another facility with her port accessed. Port was placed at a different facility "several years ago" according to pt. When reviewing her films, catheter tip was noted to be in R ventricle?!  Pt has extensive medical history. Stage 4 cancer, history of L brachiocephalic occlusion with stenting and apparently SVC syndrome with  stenting of the R IJ and SVC.  My question is this.  Is this acceptable due to complicated medical history? Obviously  optimal positioning is lower 3rd SVC/ cavoatrial junction. And yes, I  seen lines placed by radiologists with tips in R atrium. But I have never seen a ventricular placement and quite frankly, very uncomfortable with the tip there and didn't want the bedside RN using it.  Pt was receiveing Cardizem gtt and Vancomycin.--oh, was on the Cardizem for A fib with RVR!!!  I spoke to one of our radiology MD's who didn't understand my concern. However, I finally did get him to concede that it needed a revision. So we stopped using the port and I placed a couple of INP's.  Is this ever OK???   Shouldn't there be some sort of order from the MD stating why it was placed there?  Would that be acceptable for the nurses to then use the port?  I appreciate any input.

kejeemdnd
Have you actually seen the

Have you actually seen the films yourself? Could this be a communication error?

Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA

lynncrni
 I would definitely want to

 I would definitely want to see the chest film myself, however if you have no training in how to assess tip location on a chest xray it might not mean much to you. In view of the cardiac problems, the catheter tip in the ventricle would be the very first thing I would think of as the cause or contributing factor. I don't know what you mean by INP. An order from the physician will NOT provide protection for you. As the infusion nurse, you have identified this problem with tip location. The patient has a known cardiac issue. I would not use this port until there was some resolution in a collaborative manner. You also did not state what infusion therapy is being given, and for how much longer this is needed. Upper right atrium is acceptable, but no further than 2 cm past SA node. Ventricle is certainly NOT approrpiate but you do have to consider the previous problems this patient had. When did those occur - years ago or recently? 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

campriishe
OK good, my initial gut

OK good, my initial gut instinct was correct. It shouldn't be used.  It was documented by the radiologist who did her L brachiocephalic stenting last month that it was in the R ventricle. Unfortunately, I don't have access to the other facility's procedure information or notes. When I looked at her film, it was clearly very deep as the end of the catheter was slightly curved. Not as sharp as a 'J' but a gentle backward 'J' if you can picture that. When I spoke to the radiologist, he was looking at the film too and that is when he conceded it was deep and needed a revision. Sorry, INP is what we call peripheral lines where I work. She is receiving a cardizem drip, IVF and Vancomycin IV. When I looked thru her chart this morning, there was no mention on how long therapy would be (yet) She was only admitted ~10 hours earlier, not all her consulted physicians had seen her yet. As it stands now at the end of my 10 hour shift, the 2 peripheral IV's I placed are being used for her IV meds, radiology was consulted to revise her port in the morning (they couldn't do it today because her INR was too high)  It just frustrates me to no end that evidence shows where optimal positioning should be but MD's can place stuff wherever they want and don't understand why I (The Vascular Access Nurse) am questioning it and am concerned!!  Guess that is why they get paid the big bucks! I appreciate the feedback!

lynncrni
 Hang in there with great

 Hang in there with great patient care and advocacy and continue to educate our physician colleagues. 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

Danielle McClain
Right Ventricle

That is very unusual! Anytime our team runs into this type of issue we will document our recommendations in the patient's chart. In this case we would make the call to the primary MD ourselves and explain the recommendation. If they continue to insist on the devices use we will inform the primary RN of the facility policy for use and remind her/him that an MD order may not necessarily protect him/her. This is usually when they will contact the nurse manager, the nurse manager contacts someone higher up and eventually the right thing happens for the patient. Just very time consuming if the physician doesn't take the recommendation the first time around.

Danielle McClain RN, BSN

 

campriishe
Today Radiology finally

Today Radiology finally revised her port. Tip is now superior R atrium. When he was questioning the pt, she said she has felt palpitations since the port was placed!  Radiologist actually commented to bedside nurse that he was upset with his 2 collegues that had previously seen this patient and knew of position in R ventricle but did not address it....What do you know, a Vascular Access Nurse actually did something right for a change!--tough feeling to get sometimes when you don't give the answers people want to hear. Sometimes people think we are trying to be difficult...

lynncrni
 Congratulations!! The most

 Congratulations!! The most important job as a nurse is often patient advocacy. 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

jill nolte
good job!

see how important you are? this is why we do all that we do, to protect patients and advance good practice. proud of you! keep going......

JackDCD
 Nice job. Years in that

 Nice job. Years in that location?.....I wonder how many times that was seen and nothing done. Wow, good you brought it to someone's attention

Jack

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