Norepi

[deleted697535]

So case comes up from emerg recently.

Septic on peripheral norepi.
No art line or even attempts at one.
Morbidly obese
Lactate 5

Q 1. Norepi. Through a 22g peripheral iv in a crappy forearm vein on the 'palmar' surface. One of those crappy veins under your watch clasp...
8mcg/min
Is this ok?
It was also leaking under the tegederm.



Q2. The norepi bag was spiked with a 3 port infusion set, unmarked, and all 3 ports were not plugged with dead enders or even tape.
Vanco and ppi were also running iv in close proximity so lots of ports for someone to get confused and flush a lot of norepi accidentally.

Is this ok?

Thank you


Once we took out all the patients crappy interstitial 22guages i quickly got a good 16
guage acf with ultrasound, radial aline & got on with her case and tucked her into icu in good shape.

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[MirrorTodd]

No to both and I likely would have done what you did. ED should've put in some sort of better access, they have the ability.

 

[deleted126335]

Is this ok?

Thank you

No. It is not OK.
It is also very common.

 

[Volatile]

The ED gave you a patient with an IV? 🙌

 

[Mman]

i always run norepi through CVP except for very short duration of time. Would never run it through a peripheral of any kind on a morbidly obese patient, even what you think is a great AC vein. Their fat can shift enough when they move to dislodge that IV quickly and it usually takes longer to notice that sort of IV is infiltrated as they can infiltrate a much higher volume before anybody (even the patient) notices.

 

[deleted697535]

Im wondering whether i should escalate this?
Ordinarily i wouldn't care but on this call shift everyone was so sick it cheesed me off.

I worked my ass off over and above what i should have so to get this nonsense wasnt my cup of tea

 

[dabears505]

The more I go along, the more I don't mind running the NE through a piv for a few hours. If it's some very frail patient, and the pressures are like 80 and not 60, I'll send em to the unit with low dose NE. we have an in house picc team that can place a picc 6-8 hrs later if still needed after caught up on volume. Sometimes less is more. 85 year old frail patient weighs 100 lbs and delirius pulling at lines, I'm not jumping the gun to place an art line.

Your example is a bit extreme. But to be honest, of the patient is going to the OR, just do the central line yourself when the patient is asleep and controlled. It's easy to criticize, but doing those lines awake with no sedation especially when they are super dry is not the easiest.

 

[GaseousClay]

Im wondering whether i should escalate this?
Ordinarily i wouldn't care but on this call shift everyone was so sick it cheesed me off.

I worked my ass off over and above what i should have so to get this nonsense wasnt my cup of tea

Escalating won’t do anything. The ED does this all the time knowing intensivists or anesthesiologists will have to put in better access anyway.

 

[PainDrain]

Im wondering whether i should escalate this?
Ordinarily i wouldn't care but on this call shift everyone was so sick it cheesed me off.

I worked my ass off over and above what i should have so to get this nonsense wasnt my cup of tea

Don’t escalate it because it likely will not result in anything positive. What I would do is make sure there was clear documentation in the chart of the peripheral line and what was running through it in the event she developed some tissue necrosis or local infection.

 

[GassYous]

Peripheral norepi has been shown to be safe. But it has only been studied in proximal large veins that were checked regularly.

 

[vector2]

How about instead of escalating it through what is presumably your hospital's version of the malignant, retaliatory, anonymous computer based reporting system we all have, you do what human beings used to do back in the old days and physically go have a chat with the folks who sent the pt up, and calmly and kindly explain to them why what they did was not in the pt's or the care team's best interest.

 

[Airway]

Peripheral norepi has been shown to be safe. But it has only been studied in proximal large veins that were checked regularly.

Placed under ultra sound and in a study (Hawthorne effect?)...
I think it's safe if you are vigilant (or the nurses are in the ICU). I now work somewhere that I doubt it's safety

 

[chessknt]

Im wondering whether i should escalate this?
Ordinarily i wouldn't care but on this call shift everyone was so sick it cheesed me off.

I worked my ass off over and above what i should have so to get this nonsense wasnt my cup of tea

How full is the Ed? What is the staffing ratio? Maybe the rn and md didn’t have time to fix the iv situation. Remember we are in a pandemic and many people everywhere are getting substandard care. If the nurse had 7 patients and the md had 20 then do you still think they should have gone back when they knew patient was coming to you?

 

[GassYous]

Placed under ultra sound and in a study (Hawthorne effect?)...
I think it's safe if you are vigilant (or the nurses are in the ICU). I now work somewhere that I doubt it's safety

So tell me why it is that you're okay with pushing large doses of phenylephrine and vasopressin but not norepinephrine? Do you check your iv sites every time you push a pressor?

 

[Mman]

So tell me why it is that you're okay with pushing large doses of phenylephrine and vasopressin but not norepinephrine? Do you check your iv sites every time you push a pressor?

you are going to notice an infiltration likely far faster with a push than you will with something going slowly on a pump

 

[vector2]

phenylephrine

lol whatever you say Baxter healthcare corporation

 

[coffeebythelake]

View attachment 343325

lol whatever you say Baxter healthcare corporation

 

[dchz]

+1 for not escalating thorough some random computer system.

You're probably not the only one working hard in the hospital right now. Do what you can to rectify the situation and see things from ED's point of view.

If you really wanna be a bro go down to the ED when you're bored and just help with access. Don't judge them unless you've walked a mile in their shoes.

After they know you've seen it through their eyes, your criticism will be much better received.

 

[Urzuz]

If you really wanna be a bro go down to the ED when you're bored and just help with access.

Are you out of your ****ing mind lmao

 

[Airway]

So tell me why it is that you're okay with pushing large doses of phenylephrine and vasopressin but not norepinephrine? Do you check your iv sites every time you push a pressor?

I do try to check my Iv sites routinely intraop Like most people I've seen hands lost. I've seen a breast lost due to proximal CVC port extravasation.

Also I hate when people push vaso. I'm ok w peripheral ne, just that we have to acknowledge the limitations of the safety studies.

 

[deleted697535]

Not many people commented on the giving set with 3 injection ports for the vasoactive...

12 injection ports in very close proximity, none labelled or blanked off

This was the most lethal aspect of the case

 

[chessknt]

Not many people commented on the giving set with 3 injection ports for the vasoactive...

12 injection ports in very close proximity, none labelled or blanked off

This was the most lethal aspect of the case

Of course it was a bad setup but again it is the pandemic. I get phone calls on patients to admit to icu and get me down there to help the Er docs before this is even a single set of recorded vitals. They are swamped

 

[Zekchar]

How about instead of escalating it through what is presumably your hospital's version of the malignant, retaliatory, anonymous computer based reporting system we all have, you do what human beings used to do back in the old days and physically go have a chat with the folks who sent the pt up, and calmly and kindly explain to them why what they did was not in the pt's or the care team's best interest.

Not gonna lie, they wont care. You wont shame them this way and they'll call you a prick and go back to their Instagrams the moment you leave. Was it a appropriate of them and would they have been happy had the same thing been done to their mothers? No. But confronting or discussing it with them wont make them see the light. The only thing that changes practices are bad outcomes. Necrosis of the arm will do far more to change their ways than any long winded speech you plan on giving them.

 

[vector2]

Not gonna lie, they wont care. You wont shame them this way and they'll call you a prick and go back to their Instagrams the moment you leave. Was it a appropriate of them and would they have been happy had the same thing been done to their mothers? No. But confronting or discussing it with them wont make them see the light. The only thing that changes practices are bad outcomes. Necrosis of the arm will do far more to change their ways than any long winded speech you plan on giving them.

You're probably right, but what we do know is that there is a 100% chance they won't change their behavior if they never even realize that someone actually got their feathers ruffled.

 

[Shimmy8]

Every patient that doesn't come to holding with some sort of useable access gets an incident report filed. It's gotten so bad that this is the only way to properly document and prove to our admins that their nurses and PICC/IV therapy/whoever teams are TERRIBLE and there needs to be changes.

 

[dabears505]

My hospital only has infusion tubing with 3 ports built in. We actually don't have a non port tubing.

 

[Fart Daddy Smooth]

Not gonna lie, they wont care. You wont shame them this way and they'll call you a prick and go back to their Instagrams the moment you leave. Was it a appropriate of them and would they have been happy had the same thing been done to their mothers? No. But confronting or discussing it with them wont make them see the light. The only thing that changes practices are bad outcomes. Necrosis of the arm will do far more to change their ways than any long winded speech you plan on giving them.

Respectfully disagree. It's not about shaming, it's about helping people do better. As a nurse, the times that a doctor helped me understand why we do things in a certain way left lasting impressions on me. Increased my respect for the doc and made me wanna do better in the future.

People usually do the best they can with the resources they have, maybe this was a new nurse working with a short staff. Who knows

Submitting an incident report usually just breeds interdepartment strife. HOWEVER .. Repeated incidents afterwards certainly warrant escalation.

 

[zizzer]

First one is not ok to me, especially since everybody outside of the OR tends to use either high 8mg/250mL or even 16mg/250mL concentrations. The nonlabeled lines is not great, but in my view, it's inherent in the anesthesiologist picking up the patient to clarify lines, infusions, and which sites are acceptable to push medications through when picking up a patient. Even though it's less safe to not label lines, it's even more unsafe to push through ports without checking what they are.

 

[Katheudontas parateroumen]

Peripheral NE is generally safe within 5mcg/min but I also think the concentration makes a difference as well. 16mcg/ml is definitely safer than 32.

 

[deleted697127]

You're probably right, but what we do know is that there is a 100% chance they won't change their behavior if they never even realize that someone actually got their feathers ruffled.

I agree. I have never and probably will not ever file an incident report. However, I 100% realize I am laid back to a fault. Some issues need to be raised. If you are a pushover, nothing changes, and they may in fact get worse. Sometimes being a leader involves being the bad guy and sticking up for yourself or your group. You have to pick your battles but some battles do in fact need to happen. This doesn’t necessarily mean raising your voice or throwing someone under the bus, but if you let something slide too many times, it will become the new normal.

 

[deleted697127]

So case comes up from emerg recently.

Septic on peripheral norepi.
No art line or even attempts at one.
Morbidly obese
Lactate 5

Q 1. Norepi. Through a 22g peripheral iv in a crappy forearm vein on the 'palmar' surface. One of those crappy veins under your watch clasp...
8mcg/min
Is this ok?
It was also leaking under the tegederm.



Q2. The norepi bag was spiked with a 3 port infusion set, unmarked, and all 3 ports were not plugged with dead enders or even tape.
Vanco and ppi were also running iv in close proximity so lots of ports for someone to get confused and flush a lot of norepi accidentally.

Is this ok?

Thank you


Once we took out all the patients crappy interstitial 22guages i quickly got a good 16
guage acf with ultrasound, radial aline & got on with her case and tucked her into icu in good shape.

When you see something like this, state the obvious to the nurse that they are really sick and ask if the ER doc is available for sign out. There is a chance they don’t know how sketchy the line set up is but anyone would have trouble denying it in person. “We’re setting up the OR right now. Dr Surgeon is on his way. He should be here in 20 minutes and then we will take him up. Is it possible to try to get a better line in while we’re setting up the OR?” Just like you don’t want to dump on your partners or coworkers, they probably won’t want to look you in the eye and dump nonsense on you either. If they can’t get a line in for whatever reason, at least the point was made.

 

[nimbus]

On the other hand, an Aline is 3 units and a central line is 4 units plus 2 units each for ultrasound guidance. One could view it as the ER sending up a gift.

 

[nimbus]

Peripheral NE is generally safe within 5mcg/min but I also think the concentration makes a difference as well. 16mcg/ml is definitely safer than 32.

Yes lots of EM and ICU literature that says it’s safe as long as the peripheral IV is not shady.

 

[dchz]

On the other hand, an Aline is 3 units and a central line is 4 units plus 2 units each for ultrasound guidance. One could view it as the ER sending up a gift.

Not if your group doesn't value your line skills an arbitrarily takes some away.

 

[dhb]

On the other hand, an Aline is 3 units and a central line is 4 units plus 2 units each for ultrasound guidance. One could view it as the ER sending up a gift.

11 units @ 120$/u is a very nice gift
OP should be sending doughnut boxes to the ER

 

[sevoflurane]

Not if your group doesn't value your line skills an arbitrarily takes some away.

That’s a group problem. I agree w/nimbus. Not only are we doing the right thing, we are also compensating ourselves for the work done. Most of us are exceptionally good at these procedures and I prefer to place my own lines anyways.

 

[sevoflurane]

* have inherited unrecognized ptx post line placement that underwent PPV for a 3 hour emergent case. Recognized, but not pleasant.

 

[deleted697127]

11 units @ 120$/u is a very nice gift
OP should be sending doughnut boxes to the ER

Lol definitely not my unit value.

That’s a group problem. I agree w/nimbus. Not only are we doing the right thing, we are also compensating ourselves for the work done. Most of us are exceptionally good at these procedures and I prefer to place my own lines anyways.

The right thing is lining and resuscitating a hypotensive patient on levophed with a lactate of 5. It’s also not dumping work on your colleagues. ER physicians are also competent at line placement despite your run in with a pneumothorax. This isn’t a compensated SBO going for an ex lap with a 20g. Money shouldn’t have anything to do with it.

I’m not saying refuse to take the patient to the OR if you have an IV that works and the room is ready. I agree the right thing at that point is to do the case and place the line yourself, but that does not change my stance that the patient should’ve already been lined up.

 

[sevoflurane]

Lol definitely not my unit value.



The right thing is lining and resuscitating a hypotensive patient on levophed with a lactate of 5. It’s also not dumping work on your colleagues. ER physicians are also competent at line placement despite your run in with a pneumothorax. This isn’t a compensated SBO going for an ex lap with a 20g. Money shouldn’t have anything to do with it.

I’m not saying refuse to take the patient to the OR if you have an IV that works and the room is ready. I agree the right thing at that point is to do the case and place the line yourself, but that does not change my stance that the patient should’ve already been lined up.

Agree. And depends on the case. Decompensating stab wound to the heart comes straight up to the OR 100% of the time to go on pump lickydy split.

 

[sevoflurane]

Also, ED’s can be extremely busy so I understand that they may be handling multiple crap show cases at once (I am talking level 1/2 trauma centers). Nearly all my emergent crani’s come up w/o lines, but we fast track them super fast.

 

[Arch Guillotti]

I have filed a couple of incident reports over the years. Most of the time they are counterproductive and pointless but every now and then a battle does need to be fought and if it isn’t documented then it didn’t happen.

This case wouldn’t even register on my radra screen to file a report.

 

[sevoflurane]

^same

 

[sevoflurane]

If someone is in florid sepsis and gets 500ccs of NS through a 22g with Norepi at 15mc/min over a 4 hr period, I wouldn’t be happy but again, would just do the right thing and move on.

 

[deleted697535]

11 units @ 120$/u is a very nice gift
OP should be sending doughnut boxes to the ER

Lines are like max 100$ here each

 

[sevoflurane]

Lines are like max 100$ here each

100% depends on payor mix.

 

[sevoflurane]

100% depends on payor mix.

could b less or more

 

[2Fast2Des]

My blended unit value is 34 bux (****ty payor mix), where the hell are you guys working that you get $100 a pop??