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lessons learned this week

Kathy Kokotis

Bard Access Systems

Lesson one:

x-ray all catheters coming into your facility.  This week one of the hospitals I was at got a PICC line that was placed at another big local hospital by a physcian assistant.  They thought the x-ray was wierd.  It was arterial.  Had they not x-rayed this line they would have used it.

Lesson two:

ICU RN's I have learned have no idea what an occluded line is.  Do you not know that is why you have multi-lumen catheters so if one lumen occludes you tape or tie off the line and write that in the nursing notes.  In fact the brown lumen which is the end lumen of the acute care CVC occludes first.  That is the biggest lumen but they draw labs from that alot as it draws fast.  Than I think it is the white lumen that goes next as the moss crawls uo the catheter.  Did you know that?  Thes best part is the RN's told all this right to the infection control director and medical director who looked totally astonished that the ICU RN's left a catheter lumen clotted like a petrie dish  Hadaway you need to publish this one in the next article you write for Infection Control Resource

Lesson three:

Did you know that Plumer's says to only use 0.5 mg to 1 mg of t-PA in a 3 ml syringe for catheter clearance.  What is that all about.  So you transfer the drug to use it safely?  You contaminate the process.  Or you use the 3 ml syringe and damage the catheter especially a silicone port.  Plumer's was updated 2007 eight edition so there is no excuse for this mis-information out there.  Plus all those authors are those big CRNI's with quite of few of them being past INS presidents.  Do they review this stuff before just putting out a new edition or what????   Hospitals formualte their policies on info from books like this. Maybe they ought to read the ONS Access Guidelines of 2005 as those were updated to reflect a 10 ml syringe and a 2 mg dose of alteplase


Lesson four:

Pharmacists do not all understand catheter clearance.  When treating a catheter according to one of the newest published studies one does not start with 0.5 mg of alteplase in a 5ml syringe and than work our way up to clearance which.  It is also important to restore blood return in a complete not just partial occlusion.  Who writes this stuff.  Believe it or not a large medical teaching institution who never talks to their RN's obviously.

More another day

have a laugh on these.  It is scary out there.





Karen Day
Karen Day's picture
Kathy, got a big kick out


got a big kick out of these especially lesson two, I was beginning to think it was just here but I feel both blessed and priviledged to know that is happening all over(LOL).  thanks for the laughs.



mary ann ferrannini
 Kathy,I had to laugh when
 Kathy,I had to laugh when I read your post as I too have found all of these things happening on a daily basis by the non-IV Therapy RNs. We have trained our entire staff to obtain a Chest radiograph on almost all of the CVCs coming into our facility. Since we are now linked to our sister hospitals we can view all X-ray reports and films on-line,so in some cases we only verify placement before use.  We have had some success instructing the nurses on how and when to treat catheters for thrombotic occlusions,PWOs and they call us for all other non-thrombotic causes. Plumers missed the boat on their instruction,but rest assured that anyone writing policies should use multiple resources and in this case should have checked the available resources from Genetech. At least that is what I have done for the past 20 years when I write P and Ps. Your entire post proves what I have always said "A good Infusion Specialist is worth their weight in gold". 
So many times I have been
So many times I have been called to check a PICC from another facility that X-ray shows is a mid line or malpositioned and no one even noticed.  Radiologists often don't even notice a midline but nurses will use the line anyway calling it a PICC just because it is in the upper arm.  I was called to an ICU th other day because they wanted a PICC repositioned!  It was a mid-clavicular line that someone at an LTAC had inserted and had been used for who knows how long!  They should read Moreau's article about that!
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