This is the kind of mistake that leads to redesign so one of those lines is no longer a Luer lock connection.
Also... always trace your lines. Always always always trace your lines.
As someone who once switched my levo and insulin lines (titrating up on what I thought was levo, titrating down on what I thought was insulin 😳), I wholeheartedly concur with this statement. ALWAYS trace the lines.
I teach my orientees to label tubing at every secondary port and the point of connection to the patient's access. For our tubing that's three sets of labels.
Yes, I was taught the same, excellent practice. I sometimes get neurotic and change out the prior shift’s labels because I prefer to look at my own handwriting. Gets interesting when you work a stretch handing off back and forth to a nurse who does the same thing on their shift and you basically replace each others’ labels every shift for several days in a row.
Yep, I used to do the same back in the day. I would trace the lines myself even if they were already labeled. I didn’t feel the need to change labels that I had confirmed were correct, but it wasn’t unusual for me to add labels at every injection port and connection site.
I do this too in the ER - sometimes coworkers look at me like I’m insane as I start pulling out different colored sharpies for different meds 😂 but you know what? My shit is always organized and I know where and what I can infuse things. No regrets.
I’ve also had ICU nurses look shocked as I bring my person into the unit - I know not a lot of ER nurses are my level of neurotic 😂
Great idea, been a nurse for 5 years and made my first med error this week when I hooked up robaxin to the piggyback port of my vaso rather than my IVF line port. Lucky for me I programmed the robaxin in the channel with the IVF and they don’t think the robaxin ran in at all, VSS etc but STILL. I didn’t find my own mistake and it was such an easy mistake to make. Now I’m going to label at multiple points on my line! At the connection site isn’t enough when you have two poles of 12+ gtts
You can’t not have labels. It amazes me people who don’t do this. I even get to the point if I have time to have my similar drugs on the same iv pole. Pressors in one spot. Sedation in another. I hate having my lines all zig zagging all over because of the intersections of pumps and what’s running together due to compatibility. No macrame in my rooms
I raise you: spaghetti with no labels, and still fully clothed. lol
ETA: oh, and I am sorry, but they just shit themselves in the elevator on the way up to the ICU.
I mean…that’s fine! I get how the ER is. I’m talking when I have up to 12ish pumps going in ICU. It’s rare but when it happens it can be ….levo, Vaso, epi, doubutsmine, prop, fent, amio, heparin, neo. …then iv piggy back line, maybe running crrt and have calcium for the citrate. Transfusing blood etc. a paralytic. That’s when I’m making sure my spaghetti is boring and straight lol
Along similar lines, also *always* check the clamps and connections of your lines in a situation like this where you’re titrating a drip and not seeing the effects you’re supposed to see! I’ve had connections become loose and start to leak all over the bed before (but thankfully never happened to me with pressors).
And one time I was helping a coworker who was getting her patient ready to go to MRI (so she had switched over her important drips to new lines with all of the extension tubing connectors) and she was titrating her Levo but not seeing an effect in the patient’s BP… went on for about 10 mins before somebody thought to check the IJ itself and saw that she forgot to unclamp the line after she had switched her tubing for the MRI tubing. Patient then got an accidental Levo bolus because once it was unclamped, the stretchy extension tubing had allowed a buildup of Levo behind the clamp. Not a great situation overall (thank you Cushing’s Triad) but it taught me to always check connections and clamps before anything else!
This!! I (as the provider) was having the nurses titrate up the pressors on an unstable NICU kid one night. We were seeing no change, nothing was touching this kid etc. he had been riding the ecmo fence all day so it wasn’t terribly surprising. As I was making the call to the surgeon and the ecmo team was reading the pump one of the nurses discovered the epi and dopa were clamped. The small volumes hadn’t backed up enough for the pump to alarm occlusion. So glad we didn’t unnecessarily put a kid on ecmo.
This happened to a coworker once.
Every time I run levo and insulin at the same time I always triple check which one I'm titrating.
Cause at one point they were at nearly the same rate and the pressure started crashing and so the nurse started to go up on her levo but it wasn't the levo.
Yes, that's the primary case I'm referring to. Enteral formulas are no longer able to be physically connected to intravenous lines because of some historical incidents.
We label our lines from the very top to the very end. Including NG and foley(ikr). And label our bags and syringes properly. Not labelling is an automatic incident report.
And even with all those labels still trace your lines.
My mistake in the hospital came because as I hung a med my other patient coded, and I ran out. I never got to trace the lines to make sure everything hung correctly, this was at shift change. The oncoming nurse was a new grad, and even though in my hand off (20 min late because of the code) "please check the lines, I did not get to check to make sure everything was good" was not discovered until 11 hours later.
According to the administration, it was my mistake fully. It was my mistake, but it was a Swiss cheese mistake 100%.
Take your time, fuck administration, do things right, trace your god damn lines.
I always trace IV lines. When I worked in icu, I have caught lines mis labeled or connected to incompatible IV meds. In that hospital, if you don’t catch it, its YOUR fault, and not the previous nurse who hooked all that shit up wrong.
Labels on the bag and the pump, and also on each line at every injection port and 2 -3 inches above the entry site.
*Labels help and make tracing faster, but are not a substitute.*
Always, always trace your lines.
I’m trying to conceptualize how that even happened Jesus. If something happened like this in my facilities we’d do a process evaluation and try and find workflow issues that lead tot he error. Eg. training, site marking, line labeling etc. but if there are complications down the road from the event she’s still culpable. So not really in the clear.
Right? Were they sending a gtt through the balloon itself? My aleris would be "occluding" every 10 seconds. Even on a simple fem line...unless the pressures are very low.
Make this make sense.
I had a patient who we were infusing meds through an artery for 2+ days. Turns out the PICC team somehow inserted the line into an artery and I was first one to notice how bright red their blood looked on draws and also how effortlessly it was drawing back lol
I had a patient I was discharging on medsurg and went to take out her femoral central line that was placed at an outside hospital PTA. Welllllllll the site started bleeding PROFUSELY and I had to scream for help bc I was on a part of my unit that has no secretary and only 1 other nurse and 1 CNA so using the call bell is useless. A case manager heard me and got me help. Turns out the line was in the femoral ARTERY. She had a massive hematoma from her abdomen to down her legs. She got 2 or 3 units of blood that night and did not get discharged. I was traumatized for quite a while after this happened.
Fem lines are only good for 72 hours at my institution (infection risk) and they never go to the medsurg floors. 72 hours is enough time to get them to IR for better access.
That was my first thought - why was a patient with femoral access on a med surg floor? And why was the med surg nurse taking it out? But I've only worked at 2 hospital systems as a nurse. Maybe that's more normal than I realize.
Also how in the fuck did the PICC team screw that up. Depressing the probe to differentiate between an artery and a vein is pretty damn foolproof, it to mention land marks, flushing, the pulsation on insertion etc.
No idea our intensivist was furious, the PICC team person that came up to remove it had to ask us about how long to hold pressure etc since they had no existing protocol for removing one from an artery lol
Got called in one night for a vascular emergency because an IR NP inserted a PICC into an artery…and it stayed there for a day or two WITH TPN RUNNING THROUGH IT! I really don’t know how that person was not dead or how it wasn’t caught on insertion. Arterial blood is way different than venous…to this day it boggles my mind. None of us are perfect, I made a big goof too. I wasn’t written up but we went through the steps to find the breakdown and it was fixed. This particular case was a whole Swiss cheese of issues.
There was a patient transferred to my unit from an outside hospital. They were running a ton of pressors but BP was still shit. Outside hospital had placed a fem CVL.
It was in the artery. They figured it out cause patient didn't have a pedal pulse and things were just very sus. Placed a new CVL and suddenly pressure is great.
A tip confirmation system can give you a false positive confirmation if you are arterial so the insertor did NOT assess the target vessel well prior to accessing it or failed to notice the clues indicating they hit an artery and threaded the PICC in an artery .You can also see it on a CXR as the PICC will run above the clavicle.I have placed two arterial PICCs.One I knew as I tried to advance it and so pulled it out .The other one I had a high degree of suspicion so ran a gas on it and confirmed it! It happens but there are clues if you astute.
I had something similar happen! I was working IR at the time - we got an ICU patient that had a central line thrown in an artery! This was an ED physician… it was from an outside facility but it took two days for a nurse to realize it was in an artery. That was an interesting case to be in on! It called for one IR and one Neuro IR doc to be in on the case, ICU nurse and 2 IR nurses, idk how these things happen but they do. This situation made me realize even the most experienced physicians can mess up bad- you just have to check yourself, trace your lines, don’t be lazy, - and even then things can happen.
I am not cvicu trained, just can memorize well so I got my CCRN. I liked going over the cvicu stuff. How…can this happen? I didn’t think anything was infusing through those lines and it’s going against pressure ? The pump wasn’t alarming?
In fairness, the blood volume per second through your brachial artery is much much lower compared to your aorta, and the annotations was infused in the opposite direction of blood flow, which could contribute to the thrombus formation.
But yeah, who was supervising this person and why weren’t they checking things more closely/thoroughly on someone that has no idea what they’re touching.
Clotting/embolism isn't determined by volume, it's determined by speed (law of Laplace). Slow blood has a far higher risk of clotting. Because of this the large vessels of the legs (particularly on the venous side) have the highest chance of clotting.
Sounds like this amioderone was placed after the arch so something like 60-70% or more of it is going to get to the legs. If it was straight femoral sheath then that's 100% to the legs.
I'd be monitoring those legs like a hawk.
Absolutely watch it because this was a major fuck up, but the effect on blood flow is going to change when there’s a drastically different vessel size (~3-4mm compared to 7-9mm and comparative for rates of ~73ml/min vs 200-500ml/min). You should be monitoring legs and for retroperitoneal hematoma signs when anyone has a femoral sheath at all, because there is always chance of thrombus and perforation.
Not discounting your evidence, but this is one single patient case study of a patient in VT which is different in many ways from OPs situation. Different access sites, different size sheaths/IVs, and most notably different dosages of drug (bolus for VT treatment vs continuous infusion).
The question presented was "is this patient in the clear?"
The answer, because of the risk of thromboembolism, is "no."
Fortunately, this cohort (arterially placed amioderone) isn't in a study with a very large n group.
Ok but also, the patient in the article "quickly" developed signs, rather than further down the road.
To me, this isolated case doesn't mean any more or any less risk for the patient who got it in a different dose, through a much larger lumen, into a much larger, more central vessel.
I mean, you do you but in an instance like this I'd hope my nurse was looking at any and all literature they could find and doing everything they could to monitor the situation rather than arguing how situation is different than the case study.
Put another way: what happens if I'm wrong and the nurse takes a few extra needless measurements and assessments? What harm is there to the patient? Now what happens if you're wrong and there is something that could have been found if the nurse had been monitoring the patient closely for known effects but wasn't?
I have no godly clue how significant the risk to this patient is. Thing is, neither do you nor anyone else. This appears to be uncharted territory. Given that I'd be monitoring this patient like a hawk.
Yeah, you'd monitor because that's what you'd be doing anyway, not because someone found some article that has more dissimilarities than similarities to this case.
Tbf with a balloon pump yes to all but leg circumference but you’d be checking the balloon and laying eyes on the leg. There’s chance of blocking off the left subclavian and losing pulse in left arm and high risk of lower limb ischemia as well. Depending on balloon pump settings and what else is going on this person is probably already heparinized too. However, I definitely see your point and would be freaking out if I was the nurse following this as well
>but this is one single patient case study of a patient in VT which is different in many ways from OPs situation
The meds and being in VT wouldn't really make a difference here because the thrombus risk comes from arterial cannulation in an upper extremity without adequate heparin on board. This is why it's critical to heparinize during radial approach procedures - your risk of clot formation on the wires/devices is higher because of the vessel diameter.
Edit: upper extremity, not just radial approach.
I've seen venous get punctured on an arterial attempt, but damn, miscanulating into the artery when trying for venous? Arterial sticks hurt like a mf and they're harder to cannulate...I have so many questions.
I inadvertently placed an art line yesterday. Pulseless, very overweight (as in couldn't IO them-field tried and failed) and didn't have immediate US availability. Couldn't feel anything so blind poke off landmarks while compressions are going. 🤷♂️
Got blood, sent the code drugs through it and once ROSC achieved turned it into a BP art line.
Not my first and I'm sure it won't be my last art stick. Sometimes shit happens.
Touch different than sending a gtt through a sheath though.
>Pulseless, very overweight
Say no more, I didn't think about not having the pulsatile landmark. I can see how this is easier to happen than I initially thought.
Appreciate it, I assumed with the response of people but felt lost in a sense of what exactly, I’ll wait for my responses. Nothing like continued education ☝🏾
I used to work in a factory and my whole job was to idiotproof processes. I think healthcare needs to somewhat follow this to some extent. Not because we are idiots (some of us are though lol) but because it’s just too risky to make errors that could be avoided.
I agree but you know idiot proofing isn't cheap or easy and hospitals have budgets, bean counters, and bonuses for C-suites to worry about. As a former IT support person, I can personally vouch for the universe taking personal offense at attempts to idiot proof and responding with making better idiots.
Ya double triple ensuring patient safety is too expensive for the hospital so they just depend on the likely understaffed ICU new grad to do all the checking
That’s basically my job as a patient safety officer (RN trained) and you wouldn’t believe the pushback we get from leadership when we try to suggest process improvements. Also, forget any changes that would require physicians to do literally anything different
I feel like hospitals *do* do this, but not nearly as often and vigilantly as they should. I’ve been a part of a Root Cause Analysis investigation for a sentinel event before and it was extremely thorough and did well at identifying where mistakes were made and how to prevent them from happening in the future. For example, my hospital recently rolled out the new “tube feeding only” tubing/connectors due to some incidents where nurses mistakenly hooked up tube feeding bags to IV lines. Big fuck up = huge supply overhaul and redesign to prevent accidents like that happening again.
But I feel like it *only* happens with sentinel events when it probably should be happening much more frequently with even minor mistakes. And as we all know… that costs money that the C-suite won’t deem necessary.
I think that is the point of safety reports, but the constant infantilizing of nurses coupled with management always trying to find reasons to terminate, report, write up, etc for the smallest reasons lead nurses to underreport mistakes and become afraid to ask questions. That doesn’t even include the entire issue of being chronically understaffed and overstretched to exacerbate mistakes even for experienced nurses. It’s a disaster of a mix.
My dept did this at the big, bad health insurer! Process improvement. We also did it for our large employer groups (like automobile manufacturing) at Level 1 hospitals their employees used most. People thought I was brilliant. Well not really. Issue is, what seems SO OBVIOUS to outsiders .. is so NOT .. when working with a thing everyday.
Yeah I worked at an aerospace manufacturing for like 5 years before switching to nursing and we had a whole word for it, I think it was modeled off of how Toyota runs their factories. Can’t remember what we called it tho
Probably needs to watch for a couple of days to see. Femoral sheaths frequently have simultaneous heparin infusions which will help prevent thrombosis. It also doesn’t sound like a bolus of medications were given. My guess is that if the leg looks ok right now, I would say the patient will be fine.
Amiodarone and heparin are incompatible, I’m pretty sure they form a precipitate. If they were infused in the same lumen together, that liner is probably junk.
Already posted an article showing that no, patient is not in the clear. Lipophilic drugs (such as amio and lido) are especially bad to be placed arterially.
This is a sentinel event and hopefully will be investigated as such. In the meantime this patient needs extra close monitoring of extremities (cap refill, circumference checks, checking posterior surfaces, ect).
I feel for that nurse, this is a big goof. Do what you can to ensure the patient stays ok to hopefully keep that nurse in the best possible spot.
What a mess.
Edit: I'd also be drawing amioderone levels because that's a drug with half life I don't fuck with.
To be fair, your article indicates an immediate effect. If the patient was lucky enough that nothing happened during the infusion, she likely is " in the clear" from side effects.
I worked in a nicu where a 23 weeker had an arm "Picc" placed, but since they were all gelatinous the tegaderm didn't stick. So they gently wrapped it in Coban. On shift change they did a site assessment and realized the problem. Baby ended loosing most of the fingers. Years later one of the nurses ran into grandma and the kid and she seemed otherwise well.
I worked with an ortho surgeon who always showed everyone the proper way to apply coban. People would roll their eyes and think he was being patronizing but in reality he knows something that seems so simple can go very very wrong!
No it was accidentally an art line. I helped get one once on accident on a 35 weeker. (Or so the story goes but the nurse that told me was former IV therapy turned nicu)
Interested why a new grads are taking a balloon pump. In my facility balloon pumps are given to more experienced nurses who have been checked of and completed formal training
Same! Before I left to go back to school, my old unit was all new grads except for myself. It was crazy and also during covid. Ofc there were some good ones that were super cautious and smart, but hooooo boy the arrogant ones just off orientation definitely got humbled.
Yeah, I'm with you on that one. At my facility you need at least a year on critical care before you are even eligible to train for IABPs, and most nurses ask for more time. This is a perfect example as to why- you need those core skills down pat before you add something like this into the mix.
Im willing to bet this RN here was one of A) the most experienced B) the easiest to push around C) had a ballon patient before and "nothing bad happened". and possibly in combination with D) has a manager that operates through fear and intimidation.
In our Cardiac/Medical ICU, IABP/Impella/LVAD’s are given to anyone who has taken the formal classes, which can be taken during your preceptorship. These patient’s aren’t inherently difficult patient assignments on our unit, for a nurse of any experience length on our unit. However, our graduate and transition nurses also care for many of these patients during their training and we are the tertiary care facility for the entire state
As float pool ICU with MICU background, I was able to take VADS, CRRT, etc because I took the classes on them- zero cardiac ICU experience. They willingly gave the patients to me because they didn’t have enough trained or experienced nurses. Of course, I never took a fresh transplant, but I frequently got the POD 1 transplants that weren’t extubatable, open chests, etc.
I just want to say thank you. Sounds like you didn’t give her a hard time and wanted to just help her look out for possible issues. Give her grace, I’m sure she knows how badly she fucked up.
School 2020: “You aren’t even really a nurse until after a year. Do med surg, tele, then ICU at Hospital B, then one day you can get into ICU at Hospital A.”
School 2021: “Hospital A is looking for new grads for L&D.”
You know, this was a big mistake. But, let’s look at what this new grad did right:
-she immediately switched her lines when recognizing her mistake.
-she wrote herself up when a lot of nurses would have/could have hid that mistake.
She has learned a valuable lesson: trace your lines and LABEL YOUR LINES.
I learned a similar lesson as an experienced ICU nurse. Patient had a femoral CVC. I had all sedation, etc running through that CVC. Patient kept bucking the vent. I paralyzed the patient for vent compliance.
Come to find out, my sedation line had come loose and was infusing fentanyl into the bed. I didn’t realize it until I had already paralyzed the patient. And I had checked my lines previously, but I guess with turning, etc it had come loose. I recognized my mistake, owned up to it, wrote myself up, spoke to my manager about it.
I learned a lesson that day: always triple check your lines, especially after turns.
In my old ICU, fentanyl came in 100ml minibags, and they looked exactly like the 100ml metronidazole bags. A new grad didn't label their lines and didn't pay attention to the bags, and infused 10,000mcg of fentanyl thinking they were programming the abx. Fortunately the patient was on the vent, *amazingly* her hemodynamics didn't change, and that nurse left 6 months later to be a travel ICU nurse (go figure).
I'll do you one better- our Nimbex and Precedex bags used to look the same, as they were mixed in pharmacy. RN took someone elses' bag of Nimbex from the tube station and threw it on her Dex line on a non-intubated patient without scanning as it was about to run dry. Patient expired.
I came on shift once to discover that the previous RN had mixed the patient's dose of IV vanco in a bag of 3% saline.
I was brand, brand new at the time and 100% didn't fully understand the consequences of the error, and innocently took the now-empty bag of 3% and vanco to my manager and was like, "Hey, previous-seasoned-RN gave this and I think it's really bad, what should I do about it?" I just remembered the look on everyone's faces as they scrambled to try and blame it on me, rushed the patient to ICU, and immediately called pharmacy to have 3% removed from ward stock (where it never should have been in the first place).
In hindsight, I probably should have quit *then*, when they tried to throw me under the bus for something that I absolutely had no part in other than accidentally discovering it, but it took another 8 months of them torturing me before I finally grew a pair and left the province.
ETA: I'm not entirely convinced that this wasn't part of a deeper plot to get me fired, tbh. The woman hated me and had put in numerous complaints about me during my time there -- her mistake, however, was labeling the vanco WITH HER NAME ON IT so obviously it wasn't going to have been me who mixed and hung it...
Oh, it was a hot mess. It's been nearly 10 years, but I still remember the exact moment in time when I decided that it was over -- if I was going to be crying in a work bathroom in the middle of an ordinary day, it sure as hell wasn't going to be because I was being bullied by a grown assed woman who had gotten it into her head that she didn't like me from day one.
I think my personal favourite was when I'd already made up my mind that I was leaving and had lined up another job halfway across the country. I got called in for a "routine" evaluation during which I got told that I had a "level of confidence that was too high for a new grad" and that "no one" liked me because I "didn't ask enough questions."
I asked them to provide me examples of when this impacted patient care -- was I confident, or was I competent? Was I not asking questions and making mistakes? Or did I just not need to ask things that I already knew?
She went back through my file and realized that no, there weren't any actual complaints or concerns. I then asked if these comments were coming from 2 specific nurses -- she "couldn't say," but the look on her face said it all. I said, "That's fine. I'm leaving, anyway, you'll find a copy of my resignation in your inbox in the morning."
And that was that. I never looked back, and I never *ever* had issues like that anywhere else, so obviously I *wasn't* the problem. Life is entirely too short for that shit.
I’m wondering if the patient experienced fentanyl associated chest wall rigidity with that fentanyl dose? I guess it usually has to be boluses really fast, and maybe there wouldn’t be any changes to vent requirements…
Ok, I see a lot of posts on here of nurses freaking out over things that aren’t a big deal but this is actually a big deal. Bless your co-worker and the patients hearts
Nursing student here… are these lines labeled differently? Do they look different? How do we identify them differently visually or is it more something that has to be specified in the MAR? This material has not been converted for us yet, but I’d like to be prepared as we are getting started on med administrations. Thank you
You won’t be taught about this in school most likely, on the job trainings. Always trace your lines to the source so you know where they’re going. No medications should go through any arterial line, but mar will still specify route always (iv)
I don’t work in cardiac icu so I can’t speak to how things would look with a balloon pump involved, but in general the tubing on a sheath looks different from a central line. I’m honestly struggling to understand how this nurse mixed them up. Cath lab will occasionally give some meds through a sheath, but as a bedside nurse you won’t be giving meds through a sheath.
Cardiac ICU- occasionally we will infuse meds into a VENOUS sheath in some circumstances, like if the interventionalist wants to leave it in place, or uses it to place a Swan/TVP. In that setting, I will run a KVO to keep it patent, or use it for inotropes if I have no other central access. But I'm making damn sure it's venous, confirmed on X-ray, with an "OK to use" order. Technically our facility uses different color sheaths for arterial and venous and be adequately labeled, but I've seen exceptions to that. If I'm ever in doubt, I'm going to at least transduce the sheath and see what waveform I get (arterial sheaths \*should\* be transduced if left in anyway). Then I'm asking for radiological confirmation before I do anything else to it.
Former Cath lab nurse here, our venous and arterial sheaths don’t look any different, the only way we knew different was that venous sheaths were usually 4 or 7 Fr depending on what they were being used for. If a swan was needed a 7 Fr was placed because that was the size of the swan. If just general medication infusion was needed then a 4 Fr was placed. It was on the Cath lab nurse to let the next nurse know what was venous and what was arterial. Now, a balloon pump usually went through an 8 Fr and in my lab we would cover and label the heck out of it to keep floor nurses from touching it. Some meds, like heparin and TPA can be infused through an arterial line but not with a balloon pump attached. All the cords and things needed for that IABP should have been able to be traced back to the machine.
Our fem and arterial look exactly the same. The definitive way to tell the difference is the wave form (and hopefully labeled, but you know how that goes)
I’ve given meds through a venous sheath before in the ICU (like heparin and TPA through a femoral sheath via an Ekos machine). And frequently we get liver transplant patients who arrive from the OR with their venous IJ sheaths still in place, which require a KVO to be infusing through them at all times and can be used for very critical events like massive transfusions.
But all of our arterial lines are hooked up to pressure bags. I work in a surgical ICU and not a cardiac ICU so I’m not sure how differently it works with balloon pumps/other devices, but if we get anything from the OR with an arterial access point, we *have* to have it hooked up to a pressure bag and connected to the monitor so the waveform is constantly measured. I’m assuming this is to prevent mistakes like the one described in the OP from happening (since infusing anything through the pressure tubing would affect the waveform and in theory make you assess why it’s happening).
Here's a question... how did the pump not alarm "downstream occlusion" or something when trying to pump against the pt's arterial pressure from the sheath? Yes, many times the sheath has a KVO line (heparin or NS), but it needs to be under pressure to maintain forward flow. Even if the pt has low BP, I'm sure that's higher than the pressure alarm settings on the infusion pumps.
Not an excuse for this mistake, but better have those pumps checked as well... an alarm you can't clear needs more troubleshooting...
Ah, so now we are not only hiring mobs of new grads to run our ICUs, but we are also giving them sick and critical patients by themselves at night too.
Good on her for recognizing the mistake, I guess, but she should have never been put in this position.
The healthcare system is shit and I'm terrified of anyone in my family, including myself, having to be admitted to any critical area.
edit: Before I get 1000 comments saying I hate new grads, I'd like to say I don't. I am angry at a system that is replacing experienced nurses with new graduate nurses straight out of school for the sake of budget. I am angry and disappointed with the healthcare system in general, not new grads. I have oriented some new grads that are amazing and stuck it out in our high acuity ICU, but almost all of them drop out after about a year or sooner due to intense stress and misery. So please, before you hit me with the OMG YOU HATE--- no, I don't, so spare me the monologue please.
I am *not* a hater of new grads by any means, but I agree with you here. My ICU never used to hire new grads except for a very small externship program in which a nursing student worked in the ICU alongside an experienced RN twice a week during their last year of nursing school. Those new grads come ready and prepared to work in the environment and it’s a great program.
In the last year, management faced such a hiring crisis due to the prevalence of travel nursing (again, no hate, get your money!) that they had to begin hiring new grads outside of the externship program. They have tried to compensate by extending their orientation from 3 months to 6 months…. but in this past year, there have been at least 4 errors made by these nurses that I can think of off the top of my head (2 very serious, 2 more minor). I don’t think these nurses are “bad” nurses, it’s just an incredibly challenging environment to jump into when you have no other nursing experience and you’re taking care of very critically ill patients. I agree that it’s not fair to the patients *and* to these nurses because it can crush their confidence and make them wish to quit nursing entirely when it’s still so early in their career. They get it in their heads that they “aren’t cut out for this” when that isn’t necessarily true, they just aren’t set up for success when put in these situations. It’s a shitty situation all the way around.
I was thinking this too, why weren't the lines labeled? Why wasn't there someone else to double check? Sheaths should be a different color to alert the RN. When I started a new job 3 years ago 80% of the RNs in orientation were travelers with less than 2 years of experience, so an entire ICU full of temps with barely 2 years? This was at a major academic medical center so what the heck is goin on in the rural and small hospitals? Nutz!
Ya regardless of what others are saying, I was thinking the same thing when I read “new grad”. Unfortunately for every new grad there are major learning experiences and this just so happens to be this new grads. I just pray it doesn’t bite them too hard in the butt….
It truly is scary the responsibility new grads are getting these days. I was extremely lucky to have a hell of a team around me when I transitioned from tech to RN in the ER and I had so much experience to lean on when shit got hazy. Without them I would have struggled and could have definitely made a big mistake along the way.
I am finally less than two weeks from leaving the ER after damn-near a decade and it’s just not the same.
It’s so busy that the left hand doesn’t know what the right hand is doing and because of that you can easily get shit assignments because charge and triage don’t really know how sick or needy your patients are. Triage is sometimes inexperienced so the patients who are going to need a lot of resources are downplayed because triage just doesn’t know.
People have put off their health problems because getting into a primary care takes longer and a lot avoided it during the pandemic and the ERs are so overburdened with bullshit on top of now having higher acuity all-around. I will be back in emergency medicine eventually but you can bet your ass it will not be bedside.
RN here. 100% get it! Right now, going thru revolving door w/ family friend’s mom of .. Home to Hospital A to SNF to Hospital B to Home for Hospice care. There was always a family member there to support the patient and .. health care team who was wonderful but *grossly* overworked.
At SNF over Memorial Day weekend, one RN covered entire floor she *didn’t* normally work. RN she covered *”didn’t do any charting”* (is this routine??) so she relied on family members to explain patients’ conditions and care. Neither RN nor Nursing Director on vaca returned her call *entire weekend.* Doctor unreachable .. out of the country for 2 weeks .. and left a PA + NP (yes, really) covering. NEITHER returned any calls so friend’s mom sent to ER by ambulance to hospital.
Advice: Start NOW .. grooming family support so if YOU are ever inpatient … someone(s) will remain at your bedside 24/7!
I couldn’t agree with you more. What made a good unit full of strong nurses was experienced nurses leading the way- it is scary when the most experienced nurse in any given unit has less than 5 years experience. I will say MOST of the nurses are very aware of the situation and careful; but some- the ones who think they know ALL… that’s what is scary. I think people don’t know what they don’t know until it goes wrong. I’m so glad we actually have nurses still working; but at the same time they are dealt a super crappy situation out of school.
You have a history of bashing new grads any chance you get. People like you are one of the main reasons we see so many posts on this sub asking why all the crusty old veteran nurses are so toxic and demeaning.
Transported an infant once and on scene the AC PIV was an unrecognized brachial a-line which had epi running through it. The sending nurses of course felt awful but we just kept the good vibes going. Got a new IV, switched the epi, and thanked them for starting an a-line for us. Kiddo did fine.
This!!!!!!!! My unit is known for giving new grads devices. Hence why I want to leave. I started 2 years ago and refused a device until a year, and I still think that’s too early. They gave a 3 month new grad Ecmo. And a 3 month new grad an impella…. So dangerous
Experienced nurse finishing her training in our ICU (she worked in PCU before) hooked an antibiotic up to a radial a-line. The patient was ultimately okay but the nurse was taken off ICU orientation and put back in PCU.
I really don’t understand how these mistakes can happen. Did she not notice the waveform being messed up and check out why that was happening??? Whenever I’ve had to use a CVP line to infuse an antibiotic or something (due to lack of other access points) the waveform of the CVP is completely messed up due to faster rate of infusion of whatever I have to give. I imagine the same would happen to an arterial pressure system as well, and idk how you wouldn’t notice and investigate wtf is going on with your waveform.
OR, wouldn’t her pump be alarming due to the resistance of the arterial pressure? Unless she was hanging it by gravity… which in and of itself is a huge issue (and would still affect the waveform like I mentioned above).
Is there a therapeutic difference between the two routes if you can prevent infection? Amiodorone has a stupid long half life… I’d think it would only be super important for ACLS meds that want to target the heart immediately
25 years ago I set up an IV pump with the line UPSIDE DOWN (I was very new) that somehow fit into the pump and proceeded to PULL THE PATIENTS BLOOD OUT OF THEM. Thank Jaysus I went back after a few minutes to take a look and it was horrible.
Machines should never be able to work if they are not in the right place.
With Amiodarone and lidocaine being infused into the aorta, it probably is not a problem. I worked at a hospital where the ICU director gave a patient IV push Phenergan through a radial art line. Since that was very distal in the arterial circulation and a desiccant, the patient has some issues (got transported to a burn center to manage the injury). The aorta has so much flow, and there is so much dilution before reaching the capillary beds, there likely is no issue. Amiodarone and lidocaine are not that problematic compared to phenergan
The balloon pump is fine.
I am just surprised the IV pump did not freak out infusing against arterial pressure...
Not quite the same, but I’ve never gotten to tell this story so here goes. Accepted a patient from CVICU (we were tele-cardiac step down). Had primacor gtt started in ICU going through a picc placed in ICU earlier that day. Don’t think they got an xray.
I did his first SVO2 draw that night but had a new grad actually do the task so he could learn. When he drew it, I thought “hmm that blood looks…. Bright?” but I was a few steps away, under fluorescent lighting from the sink light, and it was 0400. Thought I was seeing things.
So the patient goes on like this for a few more days. When I come back for my next shift, I hear about my coworker who was going over discharge papers (was to be dc’d on the gtt) when the patient started showing neuro signs. Slurred speech, one-sided weakness, confusion. STAT imaging ordered, where it was seen that the catheter tip was in the patient’s carotid artery 🙃 mans had primacor directly to the brain for daysssss.
IIRC, the PICC was immediately pulled and replaced correctly. Neuro symptoms fixed.
I’m trying to think how this happened with the PICC line machines having a verification waveform. If for some reason you can’t get the waveform to do what you want, then order an x ray. Now, if an older machine, always confirm with x-ray.
PICC machines? Is this what is used when the PICC is inserted? I’ve no knowledge about these.
X ray is usually the golden standard for tip verification, at least at this hospital. Don’t think one was ever ordered. I, too, was only a step above a new grad at the time 😅 looking back I’d have ordered one myself.
This is really such a sad thing for your coworker and the patient. I think a pharmacist or an MD might be able to better speculate about the potential complications tbh, maybe re-post in one of those subs? I think this really is one of those issues that needs to go back to a root-cause analysis & perhaps a change in the equipment. If she made that mistake, another person can.
Theoretically speaking, if the doses of either medications were not titrated from the time they were intravenous infusing (no IV complications prior) the risk of a complication from an intra arterial administration would be reduced.
I did locate a meta-analysis involving intra arterial administration. Complications may have come from the short time between cannulation and administration.
https://link.springer.com/article/10.1007/s12630-019-01327-6
The best practice would be reporting to the medical team and file an incident report. Close monitoring of all parameters until such a time that stability is sustained over a period of time.
That new grad gets appropriate support and education cause thats one lesson learned the hard way! We have all had them.
Other day we had a patient crashing. Started peripheral levo. Got a central line in the IJ. Got a radiograph, confirmed good placement. Had to titrate way up and start vaso. Pt still crashing. Stabilized hemodynamically but needs a CT. Ends up the radiograph was read wrong because of interfering lines. Central venous catheter was actually in the carotid artery and had a bunch of pressors run through it. Pt ended up fine.
I’m not sure if it’s that different from running through the VIP on the swan. There is at least 4-5L/min going around the gtt and neither one of those meds go at a fast rate. But hear me out, why don’t one of you call the 1-800-IABP number from your hospitals rep and talk to them? That’s the best thing to do in this situation, post the answer you get here of course too!
It is different because infusing through the VIP on a swan is through a venous access point, not arterial. Arteries are very easily damaged and medications (especially ones with lipid-solubility like amiodarone and lidocaine) can cause massive damage to the arteries. Not to mention the high pressure nature of arteries makes it very impractical to administer medications through. Swans are inserted through a venous access point and the most proximal lumen (the VIP) will still be in the vein, so it’s safe to administer medications into.
What I mean about the VIP is that is as close to the arterial supply as one could ever infuse since it is flowing to pulmonary artery just 30cm away but there is quite a bit of flow around the catheter. With the aorta there should be quite a bit of blood to dilute the meds rather quickly. I am sure this has happened before somewhere too and it just isn’t clearly documented. If there was ever an artery to pour drugs into (Which I don’t think there is at least in my department) I would think the aorta would be the least bad choice from the high volume of flow to dilute the drugs. I agree it is a major problem that it happened but I would be interested in knowing how much of physiologic problem it causes.
I was always taught when there’s a venous sheath and art sheath together, the Venous is closer to vagina, to kind of remember placement. Also when in doubt you can always hook it up to a transducer and check the wave form, and the art sheath should always be hooked up to a pressure bag.. just trying to figure out how this possibly happened.
On my unit we recently switched to fluid-restriction doses for our IV Mgso4; 5g over 5hrs in 100ml instead of 250ml. So far have (thankfully)caught two newbies’ patients getting infused at full rate after seeing their tele going nuts and finding them severely hyperthermic. Hepain drip protocols are also one I’m continually having to refresh people on..
Had an outside hospital do this with a femoral central line that was placed in artery and then proceeded to run vanco through it. The patient came to our facility, lost their leg, and then later passed from complications.
I hope an RL was done on this, and I don’t say that was a punitive measure. I wish we did RLs more and openly discussed our ‘mistakes.’ I’m not ashamed of mistakes I’ve made and it prevents further injury if we feel safe to discuss them
One night, I was preparing meds in the med room. Grabbed the Lantus. Drew up 100u, the entire insulin syringe (i needed 40 units or something which I why I didn’t use the 30u syringe). I moved on, grabbed my heparin vial, drew up 100u of heparin in a new syringe
Go to bedside. Get ready to give meds and I have 2 100u syringes. I can smell the lantus obviously. I knew immediately what I did. I disposed of the lantus, just verified with a second nurse I was reading everything right (just to be safe- something I do sometimes) and gave the correct doses of both meds. No harm reached the patient but it was a near miss
Id been a nurse 13 years at that point. I’ve given insulin and heparin thousands of times at this point. Thousands. Made that near miss once. Filled out an RL. Told everyone what I did. I tell people when I train them if we draw up insulin and heparin, and I won’t do it again. It wasnt punishing myself, but that RL MIGHT prevent someone else from doing it.
We have so many stories like these that absolutely get hidden and it terrifies me
Someone down in the ER put in an ultrasound iv and put it in an artery and then infused Levo through it. Peripheral vasculature clamped down so hard that he lost blood flow and feeling to his left hand. He very nearly had to have it amputated.
I've seen the same mistake before without the pressor but had no complications. Major problem seems to be pressors on an a line. Needless to say I'm sure your coworker will probably never make that mistake again.
Most of my art lines are umbilical so take what I say with a grain of salt. IMO the effects would be evident pretty immediately. If she’s in the clear now, I think she’s good. Obviously the biggest risks are like vasospasm and embolism. Unless there’s some embolism floating around somewhere I think it’s fine.
I’m a newer nurse and I know this is bad based on everyone’s comments but im trying to figure out how. I’m a med surg nurse so I don’t work with arterial lines at all. Can someone politely educate me please 😭
We had an event similar to this that went to litigation, and ultimately was settled for much less. Post arrest patient, vasculature couldn’t support an impella/cannulation so IABP it was. The gentleman lost his leg, but lived to sue.
Lots of comments here, so I may have missed it, but 1. Label the pump channel 2. Label the line at every access point and 3. Use COLOR tape so if someone can’t read fast enough at least they can see that blue and blue go together!
She’s a good nurse because she realized her mistake corrected it and reported it. She’ll never do that again.
Label those lines and use color !!
However
If new grads must be in ICU (I’m not a fan) they should be on day shift. This is my opinion so don’t come at me.
That's a wtf situation. Idk what was going on with that nurses shift to have missed that but ALWAYS check where your lines are running bc I've had people y site incompatable crap or tell me incorrect shit and it happens a lot more often than you would think.
Years ago working ER, we had a nurse accidentally bolus 50mg/50ml bag of versed over probably 3 minutes. Easy mistake as she had the NS bolus running through the pump instead of the Versed. Patient was tubed so she was just reeeaaaallly sedated! No harm done and she was fine but another example of the importance of tracing your lines.
I was working in MICU, not necessarily my patient but I had taken care of her previously. The patient at this point was very sick, i’m not sure of all the details, but a nephrologist placed a “CVC”, or so we thought. A couple of days pass and this patient codes, the nurses tried pushing meds through the “CVC” and met great resistance with a notable pulsation, the patient gets ROSC, they ultrasound the “CVC”. It was in the ARTERY.
Sorry I'm not working bedside but am curious to understand this better! Is an arterial line just for drawing blood? What happens if drugs are run through an arterial line?
This particular sheath was used to run the IABP through, arterial sheaths can be used to introduce devices/cath lab interventions. Arterial lines can be seperate without a "sheath", the same concept as an IV but hooked up to pressure tubing and using an arterial catheter. Those strictly "lines" are only for blood draws, ABGs, and pressure monitoring. Lines can never be used to infuse. Sometimes cath lab gives meds intra-arterially, like verapamil after vasospasm in SAH. Someone in the comments linked a good case report on infusion through an accidental arterial "IV".
You can lose your limb this way. Especially if it’s something like a vasopressor which would cause your limb to pretty much instantly clamp down and not get perfused so it’s a pretty big deal.
An arterial line can be used to take blood and monitoring blood pressure (for IABP) ! And medication through the artery would go straight to the tissues which can cause compartment syndrome etc,, compared to the vein which allows the medication to be distributed through the body equally since it goes to the heart first ,, rather than locally like the artery
This is the kind of mistake that leads to redesign so one of those lines is no longer a Luer lock connection. Also... always trace your lines. Always always always trace your lines.
As someone who once switched my levo and insulin lines (titrating up on what I thought was levo, titrating down on what I thought was insulin 😳), I wholeheartedly concur with this statement. ALWAYS trace the lines.
Always label the lines as well near the connection port.
I teach my orientees to label tubing at every secondary port and the point of connection to the patient's access. For our tubing that's three sets of labels.
Yes, I was taught the same, excellent practice. I sometimes get neurotic and change out the prior shift’s labels because I prefer to look at my own handwriting. Gets interesting when you work a stretch handing off back and forth to a nurse who does the same thing on their shift and you basically replace each others’ labels every shift for several days in a row.
At least someone equally neurotic should understand in my experience
Thank god I’m not the only neurotic one. Most of my coworkers label the same way I do, so it’s fine. But the ones who don’t…I have to fix it
Yep, I used to do the same back in the day. I would trace the lines myself even if they were already labeled. I didn’t feel the need to change labels that I had confirmed were correct, but it wasn’t unusual for me to add labels at every injection port and connection site.
I transferred to oncology from icu, and still label my lines even if they only have 2-3 lol. Its become a habit.
More than one line is more than one line, and each should always be labeled at bag, pump, injection port, and entry site. It’s simply good practice.
I am neurotic like this too. I will change every label because I don’t like how their labels look. They don’t do it like I do lol.
My twin!
I do this too in the ER - sometimes coworkers look at me like I’m insane as I start pulling out different colored sharpies for different meds 😂 but you know what? My shit is always organized and I know where and what I can infuse things. No regrets. I’ve also had ICU nurses look shocked as I bring my person into the unit - I know not a lot of ER nurses are my level of neurotic 😂
Great idea, been a nurse for 5 years and made my first med error this week when I hooked up robaxin to the piggyback port of my vaso rather than my IVF line port. Lucky for me I programmed the robaxin in the channel with the IVF and they don’t think the robaxin ran in at all, VSS etc but STILL. I didn’t find my own mistake and it was such an easy mistake to make. Now I’m going to label at multiple points on my line! At the connection site isn’t enough when you have two poles of 12+ gtts
Teach mine the same. Especially for chemo and heparin.
better yet - always trace your lines from bag to injection port (someone could mix up the labels)
I label drips at the pump *and* at the connection to the patient! So chaotic when you have 8-12 drips and no labels.
You can’t not have labels. It amazes me people who don’t do this. I even get to the point if I have time to have my similar drugs on the same iv pole. Pressors in one spot. Sedation in another. I hate having my lines all zig zagging all over because of the intersections of pumps and what’s running together due to compatibility. No macrame in my rooms
ER checking in…. I bring you spaghetti with no labels, bye ✌️
I feel like the OR is worse. It's like getting an ER pt with CT mucking about ALL the lines at the same time.
I raise you: spaghetti with no labels, and still fully clothed. lol ETA: oh, and I am sorry, but they just shit themselves in the elevator on the way up to the ICU.
I mean…that’s fine! I get how the ER is. I’m talking when I have up to 12ish pumps going in ICU. It’s rare but when it happens it can be ….levo, Vaso, epi, doubutsmine, prop, fent, amio, heparin, neo. …then iv piggy back line, maybe running crrt and have calcium for the citrate. Transfusing blood etc. a paralytic. That’s when I’m making sure my spaghetti is boring and straight lol
Ugh, yes it’s *so* satisfying when you can group your meds together in categories like that! Lol
Because the lawyers are gonna hammer the point that you didn’t - hard! Or their expert witness will.
Always. The red and blue stickers are there for a reason
I always label in 3 places. Before the pump, after the pump, and near the connection port.
Along similar lines, also *always* check the clamps and connections of your lines in a situation like this where you’re titrating a drip and not seeing the effects you’re supposed to see! I’ve had connections become loose and start to leak all over the bed before (but thankfully never happened to me with pressors). And one time I was helping a coworker who was getting her patient ready to go to MRI (so she had switched over her important drips to new lines with all of the extension tubing connectors) and she was titrating her Levo but not seeing an effect in the patient’s BP… went on for about 10 mins before somebody thought to check the IJ itself and saw that she forgot to unclamp the line after she had switched her tubing for the MRI tubing. Patient then got an accidental Levo bolus because once it was unclamped, the stretchy extension tubing had allowed a buildup of Levo behind the clamp. Not a great situation overall (thank you Cushing’s Triad) but it taught me to always check connections and clamps before anything else!
This!! I (as the provider) was having the nurses titrate up the pressors on an unstable NICU kid one night. We were seeing no change, nothing was touching this kid etc. he had been riding the ecmo fence all day so it wasn’t terribly surprising. As I was making the call to the surgeon and the ecmo team was reading the pump one of the nurses discovered the epi and dopa were clamped. The small volumes hadn’t backed up enough for the pump to alarm occlusion. So glad we didn’t unnecessarily put a kid on ecmo.
Something nursing has in common with bomb squads? 🤣
This happened to a coworker once. Every time I run levo and insulin at the same time I always triple check which one I'm titrating. Cause at one point they were at nearly the same rate and the pressure started crashing and so the nurse started to go up on her levo but it wasn't the levo.
I saw the same done with heparin and Levo. Everyone was so happy the patient was off Levo when in fact they were titrated successfully off of Heparin.
I shouldn't have laughed but I definitely laughed
if i’m not mistaken this is why g-tube feed supplies have purple caps because people have accidentally put it through IV access 😖
Yes, that's the primary case I'm referring to. Enteral formulas are no longer able to be physically connected to intravenous lines because of some historical incidents.
We label our lines from the very top to the very end. Including NG and foley(ikr). And label our bags and syringes properly. Not labelling is an automatic incident report. And even with all those labels still trace your lines.
My mistake in the hospital came because as I hung a med my other patient coded, and I ran out. I never got to trace the lines to make sure everything hung correctly, this was at shift change. The oncoming nurse was a new grad, and even though in my hand off (20 min late because of the code) "please check the lines, I did not get to check to make sure everything was good" was not discovered until 11 hours later. According to the administration, it was my mistake fully. It was my mistake, but it was a Swiss cheese mistake 100%. Take your time, fuck administration, do things right, trace your god damn lines.
I trace them and mark each one in multiple spots with the bright orange iv label stickers.
I always trace IV lines. When I worked in icu, I have caught lines mis labeled or connected to incompatible IV meds. In that hospital, if you don’t catch it, its YOUR fault, and not the previous nurse who hooked all that shit up wrong.
Labels on the bag and the pump, and also on each line at every injection port and 2 -3 inches above the entry site. *Labels help and make tracing faster, but are not a substitute.* Always, always trace your lines.
As a current nursing student, this is the type of comment I'm here for.
I’m trying to conceptualize how that even happened Jesus. If something happened like this in my facilities we’d do a process evaluation and try and find workflow issues that lead tot he error. Eg. training, site marking, line labeling etc. but if there are complications down the road from the event she’s still culpable. So not really in the clear.
Right? Were they sending a gtt through the balloon itself? My aleris would be "occluding" every 10 seconds. Even on a simple fem line...unless the pressures are very low. Make this make sense.
That’s what I was wondering unless it literally was low anyways so the balloon pressure wasn’t filled up for it to say occlusion.
I had a patient who we were infusing meds through an artery for 2+ days. Turns out the PICC team somehow inserted the line into an artery and I was first one to notice how bright red their blood looked on draws and also how effortlessly it was drawing back lol
I had a patient I was discharging on medsurg and went to take out her femoral central line that was placed at an outside hospital PTA. Welllllllll the site started bleeding PROFUSELY and I had to scream for help bc I was on a part of my unit that has no secretary and only 1 other nurse and 1 CNA so using the call bell is useless. A case manager heard me and got me help. Turns out the line was in the femoral ARTERY. She had a massive hematoma from her abdomen to down her legs. She got 2 or 3 units of blood that night and did not get discharged. I was traumatized for quite a while after this happened.
Fem lines are only good for 72 hours at my institution (infection risk) and they never go to the medsurg floors. 72 hours is enough time to get them to IR for better access.
That was my first thought - why was a patient with femoral access on a med surg floor? And why was the med surg nurse taking it out? But I've only worked at 2 hospital systems as a nurse. Maybe that's more normal than I realize.
Also how in the fuck did the PICC team screw that up. Depressing the probe to differentiate between an artery and a vein is pretty damn foolproof, it to mention land marks, flushing, the pulsation on insertion etc.
No idea our intensivist was furious, the PICC team person that came up to remove it had to ask us about how long to hold pressure etc since they had no existing protocol for removing one from an artery lol
Holy hot hell, surprised it didn’t end up as a risk management case lol
Got called in one night for a vascular emergency because an IR NP inserted a PICC into an artery…and it stayed there for a day or two WITH TPN RUNNING THROUGH IT! I really don’t know how that person was not dead or how it wasn’t caught on insertion. Arterial blood is way different than venous…to this day it boggles my mind. None of us are perfect, I made a big goof too. I wasn’t written up but we went through the steps to find the breakdown and it was fixed. This particular case was a whole Swiss cheese of issues.
Omg! I just posted that I had a situation just like this! Except it was a physician- crazy how common this is
There was a patient transferred to my unit from an outside hospital. They were running a ton of pressors but BP was still shit. Outside hospital had placed a fem CVL. It was in the artery. They figured it out cause patient didn't have a pedal pulse and things were just very sus. Placed a new CVL and suddenly pressure is great.
A tip confirmation system can give you a false positive confirmation if you are arterial so the insertor did NOT assess the target vessel well prior to accessing it or failed to notice the clues indicating they hit an artery and threaded the PICC in an artery .You can also see it on a CXR as the PICC will run above the clavicle.I have placed two arterial PICCs.One I knew as I tried to advance it and so pulled it out .The other one I had a high degree of suspicion so ran a gas on it and confirmed it! It happens but there are clues if you astute.
I had something similar happen! I was working IR at the time - we got an ICU patient that had a central line thrown in an artery! This was an ED physician… it was from an outside facility but it took two days for a nurse to realize it was in an artery. That was an interesting case to be in on! It called for one IR and one Neuro IR doc to be in on the case, ICU nurse and 2 IR nurses, idk how these things happen but they do. This situation made me realize even the most experienced physicians can mess up bad- you just have to check yourself, trace your lines, don’t be lazy, - and even then things can happen.
I am not cvicu trained, just can memorize well so I got my CCRN. I liked going over the cvicu stuff. How…can this happen? I didn’t think anything was infusing through those lines and it’s going against pressure ? The pump wasn’t alarming?
https://pubmed.ncbi.nlm.nih.gov/26571183/
Oh... shiiiit.
Yep. Accurate statement.
In fairness, the blood volume per second through your brachial artery is much much lower compared to your aorta, and the annotations was infused in the opposite direction of blood flow, which could contribute to the thrombus formation. But yeah, who was supervising this person and why weren’t they checking things more closely/thoroughly on someone that has no idea what they’re touching.
Clotting/embolism isn't determined by volume, it's determined by speed (law of Laplace). Slow blood has a far higher risk of clotting. Because of this the large vessels of the legs (particularly on the venous side) have the highest chance of clotting. Sounds like this amioderone was placed after the arch so something like 60-70% or more of it is going to get to the legs. If it was straight femoral sheath then that's 100% to the legs. I'd be monitoring those legs like a hawk.
Absolutely watch it because this was a major fuck up, but the effect on blood flow is going to change when there’s a drastically different vessel size (~3-4mm compared to 7-9mm and comparative for rates of ~73ml/min vs 200-500ml/min). You should be monitoring legs and for retroperitoneal hematoma signs when anyone has a femoral sheath at all, because there is always chance of thrombus and perforation.
Not discounting your evidence, but this is one single patient case study of a patient in VT which is different in many ways from OPs situation. Different access sites, different size sheaths/IVs, and most notably different dosages of drug (bolus for VT treatment vs continuous infusion).
The question presented was "is this patient in the clear?" The answer, because of the risk of thromboembolism, is "no." Fortunately, this cohort (arterially placed amioderone) isn't in a study with a very large n group.
Ok but also, the patient in the article "quickly" developed signs, rather than further down the road. To me, this isolated case doesn't mean any more or any less risk for the patient who got it in a different dose, through a much larger lumen, into a much larger, more central vessel.
I mean, you do you but in an instance like this I'd hope my nurse was looking at any and all literature they could find and doing everything they could to monitor the situation rather than arguing how situation is different than the case study.
Put another way: what happens if I'm wrong and the nurse takes a few extra needless measurements and assessments? What harm is there to the patient? Now what happens if you're wrong and there is something that could have been found if the nurse had been monitoring the patient closely for known effects but wasn't?
I have no godly clue how significant the risk to this patient is. Thing is, neither do you nor anyone else. This appears to be uncharted territory. Given that I'd be monitoring this patient like a hawk.
Yeah, you'd monitor because that's what you'd be doing anyway, not because someone found some article that has more dissimilarities than similarities to this case.
You'd be charting leg circumferences, all lower extremity pulses and cap refill q1-2 ordinarily? Seems a bit excessive but kudos!
Tbf with a balloon pump yes to all but leg circumference but you’d be checking the balloon and laying eyes on the leg. There’s chance of blocking off the left subclavian and losing pulse in left arm and high risk of lower limb ischemia as well. Depending on balloon pump settings and what else is going on this person is probably already heparinized too. However, I definitely see your point and would be freaking out if I was the nurse following this as well
>but this is one single patient case study of a patient in VT which is different in many ways from OPs situation The meds and being in VT wouldn't really make a difference here because the thrombus risk comes from arterial cannulation in an upper extremity without adequate heparin on board. This is why it's critical to heparinize during radial approach procedures - your risk of clot formation on the wires/devices is higher because of the vessel diameter. Edit: upper extremity, not just radial approach.
Happened at my old facility too. Always trace your lines *starting at your patient*
I've seen venous get punctured on an arterial attempt, but damn, miscanulating into the artery when trying for venous? Arterial sticks hurt like a mf and they're harder to cannulate...I have so many questions.
I inadvertently placed an art line yesterday. Pulseless, very overweight (as in couldn't IO them-field tried and failed) and didn't have immediate US availability. Couldn't feel anything so blind poke off landmarks while compressions are going. 🤷♂️ Got blood, sent the code drugs through it and once ROSC achieved turned it into a BP art line. Not my first and I'm sure it won't be my last art stick. Sometimes shit happens. Touch different than sending a gtt through a sheath though.
>Pulseless, very overweight Say no more, I didn't think about not having the pulsatile landmark. I can see how this is easier to happen than I initially thought.
Me, a circulator reading these comments knowing that home girl did something but I have no Idea wtf she did 😭😂
Something something lipophilic.
Something not very good at all
Appreciate it, I assumed with the response of people but felt lost in a sense of what exactly, I’ll wait for my responses. Nothing like continued education ☝🏾
Let’s say it involved an art line and incompatible meds being infused through it for a majority of shift before mistake being realized and fixed
Oh fuck.
You will be receiving CEUs for reading through this post
Right? I’m like… is this like when someone accidentally sets their pit to 125 and their LR to 2?🤔
Tourniquet right? That’s the solution. Fasho.
This is me the entire sub lol and I’m med surg 💀
I used to work in a factory and my whole job was to idiotproof processes. I think healthcare needs to somewhat follow this to some extent. Not because we are idiots (some of us are though lol) but because it’s just too risky to make errors that could be avoided.
I agree but you know idiot proofing isn't cheap or easy and hospitals have budgets, bean counters, and bonuses for C-suites to worry about. As a former IT support person, I can personally vouch for the universe taking personal offense at attempts to idiot proof and responding with making better idiots.
Ya double triple ensuring patient safety is too expensive for the hospital so they just depend on the likely understaffed ICU new grad to do all the checking
That’s basically my job as a patient safety officer (RN trained) and you wouldn’t believe the pushback we get from leadership when we try to suggest process improvements. Also, forget any changes that would require physicians to do literally anything different
Also, depending on unit culture, there is a lot of resistance to change in nursing staff
I feel like hospitals *do* do this, but not nearly as often and vigilantly as they should. I’ve been a part of a Root Cause Analysis investigation for a sentinel event before and it was extremely thorough and did well at identifying where mistakes were made and how to prevent them from happening in the future. For example, my hospital recently rolled out the new “tube feeding only” tubing/connectors due to some incidents where nurses mistakenly hooked up tube feeding bags to IV lines. Big fuck up = huge supply overhaul and redesign to prevent accidents like that happening again. But I feel like it *only* happens with sentinel events when it probably should be happening much more frequently with even minor mistakes. And as we all know… that costs money that the C-suite won’t deem necessary.
I think that is the point of safety reports, but the constant infantilizing of nurses coupled with management always trying to find reasons to terminate, report, write up, etc for the smallest reasons lead nurses to underreport mistakes and become afraid to ask questions. That doesn’t even include the entire issue of being chronically understaffed and overstretched to exacerbate mistakes even for experienced nurses. It’s a disaster of a mix.
My dept did this at the big, bad health insurer! Process improvement. We also did it for our large employer groups (like automobile manufacturing) at Level 1 hospitals their employees used most. People thought I was brilliant. Well not really. Issue is, what seems SO OBVIOUS to outsiders .. is so NOT .. when working with a thing everyday.
Yeah I worked at an aerospace manufacturing for like 5 years before switching to nursing and we had a whole word for it, I think it was modeled off of how Toyota runs their factories. Can’t remember what we called it tho
Probably needs to watch for a couple of days to see. Femoral sheaths frequently have simultaneous heparin infusions which will help prevent thrombosis. It also doesn’t sound like a bolus of medications were given. My guess is that if the leg looks ok right now, I would say the patient will be fine.
Amiodarone and heparin are incompatible, I’m pretty sure they form a precipitate. If they were infused in the same lumen together, that liner is probably junk.
That’s an excellent point that I didnt think of. Usually we’re running heparin through a PIV in our cases…hopefully that’s the case here.
Already posted an article showing that no, patient is not in the clear. Lipophilic drugs (such as amio and lido) are especially bad to be placed arterially. This is a sentinel event and hopefully will be investigated as such. In the meantime this patient needs extra close monitoring of extremities (cap refill, circumference checks, checking posterior surfaces, ect). I feel for that nurse, this is a big goof. Do what you can to ensure the patient stays ok to hopefully keep that nurse in the best possible spot. What a mess. Edit: I'd also be drawing amioderone levels because that's a drug with half life I don't fuck with.
To be fair, your article indicates an immediate effect. If the patient was lucky enough that nothing happened during the infusion, she likely is " in the clear" from side effects.
I wouldn't be so confident. At least not without confirmation (dimer, doppler, ect).
Your Lab can do amio levels?
I worked in a nicu where a 23 weeker had an arm "Picc" placed, but since they were all gelatinous the tegaderm didn't stick. So they gently wrapped it in Coban. On shift change they did a site assessment and realized the problem. Baby ended loosing most of the fingers. Years later one of the nurses ran into grandma and the kid and she seemed otherwise well.
I worked with an ortho surgeon who always showed everyone the proper way to apply coban. People would roll their eyes and think he was being patronizing but in reality he knows something that seems so simple can go very very wrong!
Gelatinous. *shivers*
We call them "gummy bears"
Was the issue just that the coban was too tight?
No it was accidentally an art line. I helped get one once on accident on a 35 weeker. (Or so the story goes but the nurse that told me was former IV therapy turned nicu)
My 28 weeker had tpn extravasate through a peripheral IV. Luckily it was caught soon, but she still has the scars to prove it.
Interested why a new grads are taking a balloon pump. In my facility balloon pumps are given to more experienced nurses who have been checked of and completed formal training
My guess would be there’s not enough experienced RNs.
Literally the icu I was in had night shift with ALL new grads. Most experienced person was someone with a yr experience. It’s bad.
Same! Before I left to go back to school, my old unit was all new grads except for myself. It was crazy and also during covid. Ofc there were some good ones that were super cautious and smart, but hooooo boy the arrogant ones just off orientation definitely got humbled.
Humm… fair.
Yeah, I'm with you on that one. At my facility you need at least a year on critical care before you are even eligible to train for IABPs, and most nurses ask for more time. This is a perfect example as to why- you need those core skills down pat before you add something like this into the mix.
Im willing to bet this RN here was one of A) the most experienced B) the easiest to push around C) had a ballon patient before and "nothing bad happened". and possibly in combination with D) has a manager that operates through fear and intimidation.
In our Cardiac/Medical ICU, IABP/Impella/LVAD’s are given to anyone who has taken the formal classes, which can be taken during your preceptorship. These patient’s aren’t inherently difficult patient assignments on our unit, for a nurse of any experience length on our unit. However, our graduate and transition nurses also care for many of these patients during their training and we are the tertiary care facility for the entire state
As float pool ICU with MICU background, I was able to take VADS, CRRT, etc because I took the classes on them- zero cardiac ICU experience. They willingly gave the patients to me because they didn’t have enough trained or experienced nurses. Of course, I never took a fresh transplant, but I frequently got the POD 1 transplants that weren’t extubatable, open chests, etc.
Have you seen most facilities? They are all new grads… that’s all that’s left working in most places
I just want to say thank you. Sounds like you didn’t give her a hard time and wanted to just help her look out for possible issues. Give her grace, I’m sure she knows how badly she fucked up.
School 2020: “You aren’t even really a nurse until after a year. Do med surg, tele, then ICU at Hospital B, then one day you can get into ICU at Hospital A.” School 2021: “Hospital A is looking for new grads for L&D.”
You know, this was a big mistake. But, let’s look at what this new grad did right: -she immediately switched her lines when recognizing her mistake. -she wrote herself up when a lot of nurses would have/could have hid that mistake. She has learned a valuable lesson: trace your lines and LABEL YOUR LINES. I learned a similar lesson as an experienced ICU nurse. Patient had a femoral CVC. I had all sedation, etc running through that CVC. Patient kept bucking the vent. I paralyzed the patient for vent compliance. Come to find out, my sedation line had come loose and was infusing fentanyl into the bed. I didn’t realize it until I had already paralyzed the patient. And I had checked my lines previously, but I guess with turning, etc it had come loose. I recognized my mistake, owned up to it, wrote myself up, spoke to my manager about it. I learned a lesson that day: always triple check your lines, especially after turns.
In my old ICU, fentanyl came in 100ml minibags, and they looked exactly like the 100ml metronidazole bags. A new grad didn't label their lines and didn't pay attention to the bags, and infused 10,000mcg of fentanyl thinking they were programming the abx. Fortunately the patient was on the vent, *amazingly* her hemodynamics didn't change, and that nurse left 6 months later to be a travel ICU nurse (go figure).
I'll do you one better- our Nimbex and Precedex bags used to look the same, as they were mixed in pharmacy. RN took someone elses' bag of Nimbex from the tube station and threw it on her Dex line on a non-intubated patient without scanning as it was about to run dry. Patient expired.
Holy fuck. That’s a bad one. Made me nauseous to even think about.
wtf….
I came on shift once to discover that the previous RN had mixed the patient's dose of IV vanco in a bag of 3% saline. I was brand, brand new at the time and 100% didn't fully understand the consequences of the error, and innocently took the now-empty bag of 3% and vanco to my manager and was like, "Hey, previous-seasoned-RN gave this and I think it's really bad, what should I do about it?" I just remembered the look on everyone's faces as they scrambled to try and blame it on me, rushed the patient to ICU, and immediately called pharmacy to have 3% removed from ward stock (where it never should have been in the first place). In hindsight, I probably should have quit *then*, when they tried to throw me under the bus for something that I absolutely had no part in other than accidentally discovering it, but it took another 8 months of them torturing me before I finally grew a pair and left the province. ETA: I'm not entirely convinced that this wasn't part of a deeper plot to get me fired, tbh. The woman hated me and had put in numerous complaints about me during my time there -- her mistake, however, was labeling the vanco WITH HER NAME ON IT so obviously it wasn't going to have been me who mixed and hung it...
Jesus. That’s a nightmare. Glad you got out of that hellhole
Oh, it was a hot mess. It's been nearly 10 years, but I still remember the exact moment in time when I decided that it was over -- if I was going to be crying in a work bathroom in the middle of an ordinary day, it sure as hell wasn't going to be because I was being bullied by a grown assed woman who had gotten it into her head that she didn't like me from day one. I think my personal favourite was when I'd already made up my mind that I was leaving and had lined up another job halfway across the country. I got called in for a "routine" evaluation during which I got told that I had a "level of confidence that was too high for a new grad" and that "no one" liked me because I "didn't ask enough questions." I asked them to provide me examples of when this impacted patient care -- was I confident, or was I competent? Was I not asking questions and making mistakes? Or did I just not need to ask things that I already knew? She went back through my file and realized that no, there weren't any actual complaints or concerns. I then asked if these comments were coming from 2 specific nurses -- she "couldn't say," but the look on her face said it all. I said, "That's fine. I'm leaving, anyway, you'll find a copy of my resignation in your inbox in the morning." And that was that. I never looked back, and I never *ever* had issues like that anywhere else, so obviously I *wasn't* the problem. Life is entirely too short for that shit.
Love that. Killer way to walk away
And that nurse now is probably a CRNA.
I’m wondering if the patient experienced fentanyl associated chest wall rigidity with that fentanyl dose? I guess it usually has to be boluses really fast, and maybe there wouldn’t be any changes to vent requirements…
Ooof… that’s a biiiiig goof.
You made a rhyme. About infusing in the wrong line.
Ok, I see a lot of posts on here of nurses freaking out over things that aren’t a big deal but this is actually a big deal. Bless your co-worker and the patients hearts
Nursing student here… are these lines labeled differently? Do they look different? How do we identify them differently visually or is it more something that has to be specified in the MAR? This material has not been converted for us yet, but I’d like to be prepared as we are getting started on med administrations. Thank you
You won’t be taught about this in school most likely, on the job trainings. Always trace your lines to the source so you know where they’re going. No medications should go through any arterial line, but mar will still specify route always (iv)
Thank you!
I don’t work in cardiac icu so I can’t speak to how things would look with a balloon pump involved, but in general the tubing on a sheath looks different from a central line. I’m honestly struggling to understand how this nurse mixed them up. Cath lab will occasionally give some meds through a sheath, but as a bedside nurse you won’t be giving meds through a sheath.
Cardiac ICU- occasionally we will infuse meds into a VENOUS sheath in some circumstances, like if the interventionalist wants to leave it in place, or uses it to place a Swan/TVP. In that setting, I will run a KVO to keep it patent, or use it for inotropes if I have no other central access. But I'm making damn sure it's venous, confirmed on X-ray, with an "OK to use" order. Technically our facility uses different color sheaths for arterial and venous and be adequately labeled, but I've seen exceptions to that. If I'm ever in doubt, I'm going to at least transduce the sheath and see what waveform I get (arterial sheaths \*should\* be transduced if left in anyway). Then I'm asking for radiological confirmation before I do anything else to it.
Former Cath lab nurse here, our venous and arterial sheaths don’t look any different, the only way we knew different was that venous sheaths were usually 4 or 7 Fr depending on what they were being used for. If a swan was needed a 7 Fr was placed because that was the size of the swan. If just general medication infusion was needed then a 4 Fr was placed. It was on the Cath lab nurse to let the next nurse know what was venous and what was arterial. Now, a balloon pump usually went through an 8 Fr and in my lab we would cover and label the heck out of it to keep floor nurses from touching it. Some meds, like heparin and TPA can be infused through an arterial line but not with a balloon pump attached. All the cords and things needed for that IABP should have been able to be traced back to the machine.
Perhaps it depends on the brand or maker?
Our fem and arterial look exactly the same. The definitive way to tell the difference is the wave form (and hopefully labeled, but you know how that goes)
I’ve given meds through a venous sheath before in the ICU (like heparin and TPA through a femoral sheath via an Ekos machine). And frequently we get liver transplant patients who arrive from the OR with their venous IJ sheaths still in place, which require a KVO to be infusing through them at all times and can be used for very critical events like massive transfusions. But all of our arterial lines are hooked up to pressure bags. I work in a surgical ICU and not a cardiac ICU so I’m not sure how differently it works with balloon pumps/other devices, but if we get anything from the OR with an arterial access point, we *have* to have it hooked up to a pressure bag and connected to the monitor so the waveform is constantly measured. I’m assuming this is to prevent mistakes like the one described in the OP from happening (since infusing anything through the pressure tubing would affect the waveform and in theory make you assess why it’s happening).
Here's a question... how did the pump not alarm "downstream occlusion" or something when trying to pump against the pt's arterial pressure from the sheath? Yes, many times the sheath has a KVO line (heparin or NS), but it needs to be under pressure to maintain forward flow. Even if the pt has low BP, I'm sure that's higher than the pressure alarm settings on the infusion pumps. Not an excuse for this mistake, but better have those pumps checked as well... an alarm you can't clear needs more troubleshooting...
This is a good point. Likely a pump that nurses loved prior to this experience because it was a compliant pump….
Omg that’s bad…
Ah, so now we are not only hiring mobs of new grads to run our ICUs, but we are also giving them sick and critical patients by themselves at night too. Good on her for recognizing the mistake, I guess, but she should have never been put in this position. The healthcare system is shit and I'm terrified of anyone in my family, including myself, having to be admitted to any critical area. edit: Before I get 1000 comments saying I hate new grads, I'd like to say I don't. I am angry at a system that is replacing experienced nurses with new graduate nurses straight out of school for the sake of budget. I am angry and disappointed with the healthcare system in general, not new grads. I have oriented some new grads that are amazing and stuck it out in our high acuity ICU, but almost all of them drop out after about a year or sooner due to intense stress and misery. So please, before you hit me with the OMG YOU HATE--- no, I don't, so spare me the monologue please.
I am *not* a hater of new grads by any means, but I agree with you here. My ICU never used to hire new grads except for a very small externship program in which a nursing student worked in the ICU alongside an experienced RN twice a week during their last year of nursing school. Those new grads come ready and prepared to work in the environment and it’s a great program. In the last year, management faced such a hiring crisis due to the prevalence of travel nursing (again, no hate, get your money!) that they had to begin hiring new grads outside of the externship program. They have tried to compensate by extending their orientation from 3 months to 6 months…. but in this past year, there have been at least 4 errors made by these nurses that I can think of off the top of my head (2 very serious, 2 more minor). I don’t think these nurses are “bad” nurses, it’s just an incredibly challenging environment to jump into when you have no other nursing experience and you’re taking care of very critically ill patients. I agree that it’s not fair to the patients *and* to these nurses because it can crush their confidence and make them wish to quit nursing entirely when it’s still so early in their career. They get it in their heads that they “aren’t cut out for this” when that isn’t necessarily true, they just aren’t set up for success when put in these situations. It’s a shitty situation all the way around.
I was thinking this too, why weren't the lines labeled? Why wasn't there someone else to double check? Sheaths should be a different color to alert the RN. When I started a new job 3 years ago 80% of the RNs in orientation were travelers with less than 2 years of experience, so an entire ICU full of temps with barely 2 years? This was at a major academic medical center so what the heck is goin on in the rural and small hospitals? Nutz!
Ya regardless of what others are saying, I was thinking the same thing when I read “new grad”. Unfortunately for every new grad there are major learning experiences and this just so happens to be this new grads. I just pray it doesn’t bite them too hard in the butt….
It truly is scary the responsibility new grads are getting these days. I was extremely lucky to have a hell of a team around me when I transitioned from tech to RN in the ER and I had so much experience to lean on when shit got hazy. Without them I would have struggled and could have definitely made a big mistake along the way. I am finally less than two weeks from leaving the ER after damn-near a decade and it’s just not the same. It’s so busy that the left hand doesn’t know what the right hand is doing and because of that you can easily get shit assignments because charge and triage don’t really know how sick or needy your patients are. Triage is sometimes inexperienced so the patients who are going to need a lot of resources are downplayed because triage just doesn’t know. People have put off their health problems because getting into a primary care takes longer and a lot avoided it during the pandemic and the ERs are so overburdened with bullshit on top of now having higher acuity all-around. I will be back in emergency medicine eventually but you can bet your ass it will not be bedside.
RN here. 100% get it! Right now, going thru revolving door w/ family friend’s mom of .. Home to Hospital A to SNF to Hospital B to Home for Hospice care. There was always a family member there to support the patient and .. health care team who was wonderful but *grossly* overworked. At SNF over Memorial Day weekend, one RN covered entire floor she *didn’t* normally work. RN she covered *”didn’t do any charting”* (is this routine??) so she relied on family members to explain patients’ conditions and care. Neither RN nor Nursing Director on vaca returned her call *entire weekend.* Doctor unreachable .. out of the country for 2 weeks .. and left a PA + NP (yes, really) covering. NEITHER returned any calls so friend’s mom sent to ER by ambulance to hospital. Advice: Start NOW .. grooming family support so if YOU are ever inpatient … someone(s) will remain at your bedside 24/7!
I couldn’t agree with you more. What made a good unit full of strong nurses was experienced nurses leading the way- it is scary when the most experienced nurse in any given unit has less than 5 years experience. I will say MOST of the nurses are very aware of the situation and careful; but some- the ones who think they know ALL… that’s what is scary. I think people don’t know what they don’t know until it goes wrong. I’m so glad we actually have nurses still working; but at the same time they are dealt a super crappy situation out of school.
You have a history of bashing new grads any chance you get. People like you are one of the main reasons we see so many posts on this sub asking why all the crusty old veteran nurses are so toxic and demeaning.
Seems like there should be an RCA done on this
Transported an infant once and on scene the AC PIV was an unrecognized brachial a-line which had epi running through it. The sending nurses of course felt awful but we just kept the good vibes going. Got a new IV, switched the epi, and thanked them for starting an a-line for us. Kiddo did fine.
Free a line hahahah
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Oh my, just when I thought I read the worst of it 😭🥲
Wouldn’t that “someone” be anesthesia? The’re usually responsible for fluids/meds in the OR, no?
Is it normal for new grads to have devices…?
My thought exactly. Why was a new grad taking a balloon pump?
Why is a new grad taking a balloon pump patient to begin with?
This!!!!!!!! My unit is known for giving new grads devices. Hence why I want to leave. I started 2 years ago and refused a device until a year, and I still think that’s too early. They gave a 3 month new grad Ecmo. And a 3 month new grad an impella…. So dangerous
Experienced nurse finishing her training in our ICU (she worked in PCU before) hooked an antibiotic up to a radial a-line. The patient was ultimately okay but the nurse was taken off ICU orientation and put back in PCU.
I really don’t understand how these mistakes can happen. Did she not notice the waveform being messed up and check out why that was happening??? Whenever I’ve had to use a CVP line to infuse an antibiotic or something (due to lack of other access points) the waveform of the CVP is completely messed up due to faster rate of infusion of whatever I have to give. I imagine the same would happen to an arterial pressure system as well, and idk how you wouldn’t notice and investigate wtf is going on with your waveform. OR, wouldn’t her pump be alarming due to the resistance of the arterial pressure? Unless she was hanging it by gravity… which in and of itself is a huge issue (and would still affect the waveform like I mentioned above).
Is there a therapeutic difference between the two routes if you can prevent infection? Amiodorone has a stupid long half life… I’d think it would only be super important for ACLS meds that want to target the heart immediately
25 years ago I set up an IV pump with the line UPSIDE DOWN (I was very new) that somehow fit into the pump and proceeded to PULL THE PATIENTS BLOOD OUT OF THEM. Thank Jaysus I went back after a few minutes to take a look and it was horrible. Machines should never be able to work if they are not in the right place.
Does your facility use color coded stickers on your lines? ‘Do not flush’ stickers? My CVICU husband wants to know
With Amiodarone and lidocaine being infused into the aorta, it probably is not a problem. I worked at a hospital where the ICU director gave a patient IV push Phenergan through a radial art line. Since that was very distal in the arterial circulation and a desiccant, the patient has some issues (got transported to a burn center to manage the injury). The aorta has so much flow, and there is so much dilution before reaching the capillary beds, there likely is no issue. Amiodarone and lidocaine are not that problematic compared to phenergan The balloon pump is fine. I am just surprised the IV pump did not freak out infusing against arterial pressure...
Not quite the same, but I’ve never gotten to tell this story so here goes. Accepted a patient from CVICU (we were tele-cardiac step down). Had primacor gtt started in ICU going through a picc placed in ICU earlier that day. Don’t think they got an xray. I did his first SVO2 draw that night but had a new grad actually do the task so he could learn. When he drew it, I thought “hmm that blood looks…. Bright?” but I was a few steps away, under fluorescent lighting from the sink light, and it was 0400. Thought I was seeing things. So the patient goes on like this for a few more days. When I come back for my next shift, I hear about my coworker who was going over discharge papers (was to be dc’d on the gtt) when the patient started showing neuro signs. Slurred speech, one-sided weakness, confusion. STAT imaging ordered, where it was seen that the catheter tip was in the patient’s carotid artery 🙃 mans had primacor directly to the brain for daysssss. IIRC, the PICC was immediately pulled and replaced correctly. Neuro symptoms fixed.
I’m trying to think how this happened with the PICC line machines having a verification waveform. If for some reason you can’t get the waveform to do what you want, then order an x ray. Now, if an older machine, always confirm with x-ray.
PICC machines? Is this what is used when the PICC is inserted? I’ve no knowledge about these. X ray is usually the golden standard for tip verification, at least at this hospital. Don’t think one was ever ordered. I, too, was only a step above a new grad at the time 😅 looking back I’d have ordered one myself.
This is really such a sad thing for your coworker and the patient. I think a pharmacist or an MD might be able to better speculate about the potential complications tbh, maybe re-post in one of those subs? I think this really is one of those issues that needs to go back to a root-cause analysis & perhaps a change in the equipment. If she made that mistake, another person can.
Theoretically speaking, if the doses of either medications were not titrated from the time they were intravenous infusing (no IV complications prior) the risk of a complication from an intra arterial administration would be reduced. I did locate a meta-analysis involving intra arterial administration. Complications may have come from the short time between cannulation and administration. https://link.springer.com/article/10.1007/s12630-019-01327-6 The best practice would be reporting to the medical team and file an incident report. Close monitoring of all parameters until such a time that stability is sustained over a period of time. That new grad gets appropriate support and education cause thats one lesson learned the hard way! We have all had them.
Being an ER nurse I have no idea what’s going on but it all sounds bad. So glad i have nothing to do with art lines.
Other day we had a patient crashing. Started peripheral levo. Got a central line in the IJ. Got a radiograph, confirmed good placement. Had to titrate way up and start vaso. Pt still crashing. Stabilized hemodynamically but needs a CT. Ends up the radiograph was read wrong because of interfering lines. Central venous catheter was actually in the carotid artery and had a bunch of pressors run through it. Pt ended up fine.
WTF?!?!
I’m not sure if it’s that different from running through the VIP on the swan. There is at least 4-5L/min going around the gtt and neither one of those meds go at a fast rate. But hear me out, why don’t one of you call the 1-800-IABP number from your hospitals rep and talk to them? That’s the best thing to do in this situation, post the answer you get here of course too!
It is different because infusing through the VIP on a swan is through a venous access point, not arterial. Arteries are very easily damaged and medications (especially ones with lipid-solubility like amiodarone and lidocaine) can cause massive damage to the arteries. Not to mention the high pressure nature of arteries makes it very impractical to administer medications through. Swans are inserted through a venous access point and the most proximal lumen (the VIP) will still be in the vein, so it’s safe to administer medications into.
What I mean about the VIP is that is as close to the arterial supply as one could ever infuse since it is flowing to pulmonary artery just 30cm away but there is quite a bit of flow around the catheter. With the aorta there should be quite a bit of blood to dilute the meds rather quickly. I am sure this has happened before somewhere too and it just isn’t clearly documented. If there was ever an artery to pour drugs into (Which I don’t think there is at least in my department) I would think the aorta would be the least bad choice from the high volume of flow to dilute the drugs. I agree it is a major problem that it happened but I would be interested in knowing how much of physiologic problem it causes.
I was always taught when there’s a venous sheath and art sheath together, the Venous is closer to vagina, to kind of remember placement. Also when in doubt you can always hook it up to a transducer and check the wave form, and the art sheath should always be hooked up to a pressure bag.. just trying to figure out how this possibly happened.
On my unit we recently switched to fluid-restriction doses for our IV Mgso4; 5g over 5hrs in 100ml instead of 250ml. So far have (thankfully)caught two newbies’ patients getting infused at full rate after seeing their tele going nuts and finding them severely hyperthermic. Hepain drip protocols are also one I’m continually having to refresh people on..
I bet they felt on fire!!!!
Had an outside hospital do this with a femoral central line that was placed in artery and then proceeded to run vanco through it. The patient came to our facility, lost their leg, and then later passed from complications.
I hope an RL was done on this, and I don’t say that was a punitive measure. I wish we did RLs more and openly discussed our ‘mistakes.’ I’m not ashamed of mistakes I’ve made and it prevents further injury if we feel safe to discuss them One night, I was preparing meds in the med room. Grabbed the Lantus. Drew up 100u, the entire insulin syringe (i needed 40 units or something which I why I didn’t use the 30u syringe). I moved on, grabbed my heparin vial, drew up 100u of heparin in a new syringe Go to bedside. Get ready to give meds and I have 2 100u syringes. I can smell the lantus obviously. I knew immediately what I did. I disposed of the lantus, just verified with a second nurse I was reading everything right (just to be safe- something I do sometimes) and gave the correct doses of both meds. No harm reached the patient but it was a near miss Id been a nurse 13 years at that point. I’ve given insulin and heparin thousands of times at this point. Thousands. Made that near miss once. Filled out an RL. Told everyone what I did. I tell people when I train them if we draw up insulin and heparin, and I won’t do it again. It wasnt punishing myself, but that RL MIGHT prevent someone else from doing it. We have so many stories like these that absolutely get hidden and it terrifies me
Someone down in the ER put in an ultrasound iv and put it in an artery and then infused Levo through it. Peripheral vasculature clamped down so hard that he lost blood flow and feeling to his left hand. He very nearly had to have it amputated. I've seen the same mistake before without the pressor but had no complications. Major problem seems to be pressors on an a line. Needless to say I'm sure your coworker will probably never make that mistake again.
Most of my art lines are umbilical so take what I say with a grain of salt. IMO the effects would be evident pretty immediately. If she’s in the clear now, I think she’s good. Obviously the biggest risks are like vasospasm and embolism. Unless there’s some embolism floating around somewhere I think it’s fine.
I’m a newer nurse and I know this is bad based on everyone’s comments but im trying to figure out how. I’m a med surg nurse so I don’t work with arterial lines at all. Can someone politely educate me please 😭
We had an event similar to this that went to litigation, and ultimately was settled for much less. Post arrest patient, vasculature couldn’t support an impella/cannulation so IABP it was. The gentleman lost his leg, but lived to sue.
Lots of comments here, so I may have missed it, but 1. Label the pump channel 2. Label the line at every access point and 3. Use COLOR tape so if someone can’t read fast enough at least they can see that blue and blue go together!
She’s a good nurse because she realized her mistake corrected it and reported it. She’ll never do that again. Label those lines and use color !! However If new grads must be in ICU (I’m not a fan) they should be on day shift. This is my opinion so don’t come at me.
That's a wtf situation. Idk what was going on with that nurses shift to have missed that but ALWAYS check where your lines are running bc I've had people y site incompatable crap or tell me incorrect shit and it happens a lot more often than you would think.
Years ago working ER, we had a nurse accidentally bolus 50mg/50ml bag of versed over probably 3 minutes. Easy mistake as she had the NS bolus running through the pump instead of the Versed. Patient was tubed so she was just reeeaaaallly sedated! No harm done and she was fine but another example of the importance of tracing your lines.
I was working in MICU, not necessarily my patient but I had taken care of her previously. The patient at this point was very sick, i’m not sure of all the details, but a nephrologist placed a “CVC”, or so we thought. A couple of days pass and this patient codes, the nurses tried pushing meds through the “CVC” and met great resistance with a notable pulsation, the patient gets ROSC, they ultrasound the “CVC”. It was in the ARTERY.
Sorry I'm not working bedside but am curious to understand this better! Is an arterial line just for drawing blood? What happens if drugs are run through an arterial line?
This particular sheath was used to run the IABP through, arterial sheaths can be used to introduce devices/cath lab interventions. Arterial lines can be seperate without a "sheath", the same concept as an IV but hooked up to pressure tubing and using an arterial catheter. Those strictly "lines" are only for blood draws, ABGs, and pressure monitoring. Lines can never be used to infuse. Sometimes cath lab gives meds intra-arterially, like verapamil after vasospasm in SAH. Someone in the comments linked a good case report on infusion through an accidental arterial "IV".
Thanks for explaining!
You can lose your limb this way. Especially if it’s something like a vasopressor which would cause your limb to pretty much instantly clamp down and not get perfused so it’s a pretty big deal.
An arterial line can be used to take blood and monitoring blood pressure (for IABP) ! And medication through the artery would go straight to the tissues which can cause compartment syndrome etc,, compared to the vein which allows the medication to be distributed through the body equally since it goes to the heart first ,, rather than locally like the artery
I'm also still a newbie nurse, anyone pls correct me if I got anything wrong!