Possible DVT Leads to Downgraded IJ – Nurse Clinicians in Action – 48

Possible DVT Leads to Downgraded IJ describes a case where a hospital patient with difficult IV access and a medical history of renal failure requiring hemodialysis, was experiencing a gastrointestinal bleed and needed multiple blood transfusions. The patient’s IV access failed in the middle of a transfusion and the care team was unsuccessful in obtaining new access given the patient’s difficult IV access condition.

Possible DVT Leads to Downgraded IJ

– Clinical Case

An IJ (internal jugular) central line was ordered for a middle-aged hospital renal patient whose IV access failed in the middle of receiving multiple blood transfusions for severely low hemoglobin levels from a gastrointestinal bleed. The nurses and physicians made multiple attempts to place a new PIV but were unsuccessful given the patient’s difficult IV access (DIVA) condition, which the patient’s hemodialysis, past medical history of renal failure, and other factors contributed. The situation was becoming stressful not only because the patient needed to complete the blood transfusion, but they were under a time constraint to regain IV access and complete the transfusion before the blood expired and would have to be discarded.

Knowing that Vascular Wellness response times are very quick and their track record of successfully achieving vascular access when others cannot, the facility contacted the Vascular Wellness 24/7 VST Customer Support Team Call Center and ordered the Physician prescribed Small Bore Internal Jugular (IJ) central line for the patient.

Possible DVT Leads to Downgraded IJ

– Diagnosis and Treatment

A Vascular Wellness vascular access clinician was already onsite at this hospital on another case and was able to arrive at the patient’s room very quickly after receiving the Small Bore IJ service request. Because the response was so fast, the resident and attending physicians did not realize that Vascular Wellness had been contacted, and as such, they were at the patient’s bedside preparing to attempt placement of an IJ when the vascular access clinician arrived. When the physicians learned that the nurse was with Vascular Wellness, they stopped what they were doing and asked the clinician to take over, consistent with the facility’s policies that incorporate and recognize the expertise that Vascular Wellness brings to the bedside.

The Vascular Wellness clinician quickly set up, reviewed the patient’s medical history, and performed a thorough ultrasound assessment on the patient. During the review of the patient’s vasculature, the clinician noted that the patient’s left IJ was fully non-compressible with echogenic material present. Non-compressible vessels cannot be used for line placement, and the presence of echogenic material indicates there could be a blood clot, or specifically a DVT (deep vein thrombosis). The clinician also noted that the right IJ was only partially compressible with a smaller amount of echogenic material present.

From the review of the patient’s medical history that documented a record of dialysis catheters in bilateral IJs, the clinician noted that this could be a contributing factor to the non-compressibility and the presence of echogenic material. Based on this information, the Vascular Wellness clinician expressed concern to the resident physician and explained that placing a CVC (central venous catheter) in a vein that has a blood clot can lead to serious complication, including a pulmonary embolism or stroke. The clinician recommended a venous duplex study of the patient’s internal jugular veins prior to any CVC placement in the IJ.

The physician agreed with the recommendation and asked the clinician to place a PIV instead of the ordered IJ so the patient could complete the blood transfusion while they waited for the duplex to be performed. The clinician proceeded and, while the local staff had previously struggled, placed an ultrasound guided PIV quickly and the transfusion treatment continued on schedule.

The resident physician expressed his thankfulness for the clinician’s assessment skills and recognition of potential thrombosis in the IJ veins. He realized that if their team had proceeded with placing the line, they may not have picked up on a possible blood clot or DVT and the patient could have had a bad outcome.

Vascular Access Experts 

– Key Points

As Vascular Access Experts, our clinicians are not just trained and precepted in placing ultrasound guided PIVs, Midlines, PICCs, and Small and Large Bore lines. They also serve as a critical and trusted extension of the patient’s care team by using their expertise to help identify contraindications and comorbidities during physical examinations and medical history reviews, and then collaborating with providers on their findings and recommendations to help ensure the most safe and effective vascular access device is placed.

Because our clinicians are not paid by procedure with different amounts based on the procedure attempted or performed, they are not incented or faced with a perceived or actual conflict of interest to place the most expensive line with the highest compensation for them, like many other mobile vascular access providers. Instead, they are trained to pivot and recommend the clinically appropriate and safest line for the patient – including if it means downgrading or even eliminating a prescribed line. No matter what type of vascular access device is needed – whether it is a standard line such as a PICC, Midline or PIV, or an advanced line such as a Small Bore or Large Bore central line – our nurse clinicians are trained and have all the supplies needed to ensure your patient can receive prompt care in place, at the patient’s bedside and on the same visit.

This reduces patient complications, avoids internal and external transportation costs, and allows your medical team to focus on their field of practice. Our Vascular Access Specialists are Vascular Access Board Certified (VA-BC) and semiannually skill-verified to ensure we consistently operate at or above industry standards for patient safety, documentation, and evidence-based practices. We have a Director of Research and Development who is responsible for keeping our employees current on the most recent clinical practice guidelines for vascular access and helps continually improve and advance our vascular access services. We actively participate with AVA, INS, CDC, IDSA, Nursing License Boards, Hospital Boards, and The Joint Commission and are known and recognized as subject matter experts. In summary, Vascular Wellness and our clinicians follow best practices and do not recommend central lines when not clinically indicated despite what misinformation other less-skilled mobile companies may be spreading.

Nurse Clinicians in Action is a spotlight series highlighting some of the interesting cases that Vascular Wellness clinicians have encountered and participated in treatment. These cases involve challenging situations or intriguing clinical presentations and may involve more than one Vascular Wellness clinician, as our clinicians have the ability to consult each other while in the field, as well as an on-call Clinical Administrator via a HIPAA (Health Insurance Portability and Accountability) compliant communication app. In addition, our extensive training program and diverse client base, including Level 1 Trauma Centers, Short Term Acute Care Hospitals, Long Term Acute Care Hospitals, and Skilled Nursing Facilities, provide our clinicians with a wide array of clinical experience and why we believe our clinicians, as a group, are the most experienced and best trained and supported vascular access clinicians.

If you require Vascular Access or want to learn more, speak to the team at Vascular Wellness today.
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Vascular Wellness provides:
(1) Comprehensive vascular access services to North Carolina, Oklahoma, South Carolina, and Virginia; and
(2) Customized vascular access services to Arkansas, Delaware, Georgia, Mississippi, Pennsylvania, Tennessee, and West Virginia; and
(3) Support vascular access services to Ohio and Kentucky.