Hi,
Our vascular access team, some ED nurses and some ED pysicans at our hospital all place ultrasound guided peripheral catheters. Recently, the vascular access nurses were called to assist with a difficult access on 2 year old in the ED. On arrival the patient was having seizures and the nurses recommended an IO immediately. There were 3 MD's present one who agreed with the vascular nurses. One MD was trying to scan the patient with ultrasound for a suitable vein and the other MD present was encouraging her to do so. Long story short, the MD found the femoral vein and placed a BD 1.88in long peripheral catheter. I brought this to the attention of the quality department. The ED PI specialist spoke with the ED medical director who told her that this is a new and accepted procedure. I am a member of INS and AVA and hold my CRNI. I was dumbfounded that I hadn't heard of it. I also looked in our hospital's clinical decision support program, UpToDate, and do not find it anywhere in the pediatric access algorithm. I think the PI was told this to shut the subject down. I plan to speak with the physician now myself. I want to make sure I am not missing something that mght be new. Is anyone placing peripheral lines in the femoral vein, pediatric or otherwise, and do you have some evidence for it? It doesn't seem right to me, the femoral vein is generally thought of as a central vein and I don't think a 1.88 inch peripheral catheter would be centrally place on a 2 year old. No x-ray was done.
I have not seen this. i would have concern for the static length and the composition of the catheter,
Insertion of any VAD into the femoral vein is a long standing practice. What is new is US guided mid thigh insertion of a long catheter. PICCs are the longest so they are being used for midthigh sites to be able to reach the IVC above the diaphragm. In this situation, there is a strong need for rapid access and the evidence is signficant to use IO, when it takes more than a 1-2 minutes to insert a PIV. IO is left in only for 24 h giving time to adequately plan for vascular access. The issue with the 1.88 inch PIV in the femoral is how long was it allowed to dwell. Also what med was given - a vesicant or nonvesicant? With leg movement and walking for a 2 year old, infitration/extravasation would be huge concern if this were allowed to dwell more than a few hours. But I don't know of any data on PIV complications in this site because it is usually not done.
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
The catheter didn't dwell for more than 12 hours. I think it was placed at around 9pm. My night IV therapist did not make an attempt at a PIV in another location, but as soon as we came on in the mornig it was our first stop after hearing about it in report. This was definately not a mid thigh picc placement. But I did wonder why they didn't use the pedi CVC, and I did not get an answer to that... No vesicants infused through it and they did try to immobilize her hip and leg so she couldn't move too much.
I still don't feel it was the correct thing to do. I know necessity is the mother of invention but I think the IO would have been the best choice, 2nd would have been a pedi cvc. Additionally we have a very small pediatric population and we care for very stable children who get shipped the minute they become unstable. Our pediatric floor is only 4 beds and is often closed or used for adults. Femoral lines, even placed using the correct devices are something our pediatric nurses just don't see. From a quality and safety standpoint I think using a device in a manner it wasn't intended to be used for and sending a patient to a floor where the nurses have little to no experience with femoral lines in general is just not a good idea. It is a classic issue at my hospital which has been repeated in many forms-just because a doctor can do something doesn't mean the nursing staff can adequately care for the patient- this might depend on patient ratio, skill, or acuity.