we all know that INS standards for things like Dopamine, Nipride,etc recommend a central line. Although we teach and teach, these standards are not always met. Our ICU patients often times have only PIV's when they should have CVLs. Administration is looking into making it a hard and fast rule that these types of meds HAVE to go into a central line. Which is a good thing. Here is the dilema: Dopamine gets ordered at 2am. MD says "we're not putting in a CVL in the middle of the night, get a STAT PICC."  Our 140 bed hospital cannot support a 24/7 PICC team. Is there some kind of standard or recommendation that states it is acceptable to run Dopa (or whatever) for xxx amount of time until a CVL gets placed? How is this handled in other facilities?
My strong opinion is that they should place the CVL if that is what the pateint needs no matter what time of day. But I know that it isn't always that easy.
If that dopamine infiltrated and there was a law suit, surely the lawyers wouldn't care about what time of day it was. If the patient required regitine, would medicare pay for it?
On another point; The CDC recomends a PICC line for patients requiring greater than 5 days of therapy regardless of what the infusate is. Isn't it the rare ICU patient who is going home within 5 days anyway? A good early assessment program would identify these patients automatically.
But, again, I know that it is much easier said than done.
I wonder what your risk management team would suggest.
Thanks,
Mike Brazunas RN
Clinical Specialist
AngioDynamics
MIKE--The CDC statement you site is very powerful (recommend a PICC for patients
requiring > 5 days of Tx)--Can you please tell us what document to quote for this Best
Practice--Thank you in advance of your response
Robbin George RN VA-BC
I am also very curious about the "5 day recommendation". I don't think I have ever heard that recommendation before. I would also like to know how hospitals that do not have 24 hour coverage for PICC placement handle administration of medications that should be given centrally. Do you drop a central line before you will administer the medication(s)? Is there an acceptable but probably unwritten "window" where you will allow the medications to be given peripherally prior to getting a central or PICC line placed? And what about the scenario where a patient has had a PICC and it has gotten "accidentally" removed, only has 48 hours worth of IVAB therapy remaining? I have gotten calls to replace these PICCs with a new one, gone to assess the patient and found clinically silent thrombus in the vessel where the PICC was, and the opposite arm was either not an option due to a type of dialysis access, or had an obstruction that prevented threading a new PICC to the SVC. In these scenarios what do the rest of you consider to be the most reasonable and cost effective solution?
Halle Utter, RN, BSN
Intravenous Care, INC
Hallene E Utter, RN, BSN Intravenous Care, INC
First of all, my apologies, I missquoted the CDC.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm
C. Use a midline catheter or PICC when the duration of IV therapy will likely exceed 6 days (244). Category IB
As you see it says 6 days not 5.
INS standards say to use a central line (eg PICC) when pH is less than 5 or greater than 9 or Osmilarity greater than 500.
If the infusate is within these parameters, then the leanth of anticipated therapy needs to be considered. I would say definitely greater than 6 days but maybe fewer based on the patients vascular status.
Thanks,
Mike Brazunas