Thursday, November 1, 2012

The Infuriatingly Incompetent Inpatient Intravenous

Our surgery schedules can get pretty hectic at times. With impatient surgeons pacing in the hallways and tightly packed starting times, a fast turnover of the operating room is essential. That's why it's a relief when I see that my next patient will be an inpatient. Half of the time I spend on my preop interview with a patient can be eaten up by starting an intravenous. Between spiking an IV bag, collecting the IV supplies, and starting the IV on the patient, this process can easily take ten minutes, longer if the patient has difficult veins.

With an inpatient though, the IV is supposed to be already in place. Thus it should be a breeze to just walk into the room, chat with the patient for a few minutes, then roll him into the operating room. Simple as that. Except it is usually not that easy. Unfortunately, for some reason, many of our inpatients don't come to the OR with a functioning IV. Often the patient comes down without any IV fluids running, just a heplock. When I hang an IV bag in preop and hook it up to the heplock, the bag won't drip freely. If I try to flush the line, nothing will go in. The IV has clotted, which it is prone to do if there are no fluids running to keep it open. It is especially true with the tiny IV's many of our patients seem to receive on the floor, like 22 or 24 GA sizes.

What's worse are the patients who come from the floor with an IV pump dripping some medication into the catheter at a glacial pace, like 10 cc/hr. You are deceived into thinking the IV is working. However, when I try to check the integrity of the IV by flushing a small syringe of fluid, the patient complains of pain. I check the IV site and realize the little bolus of fluid revealed the ugly truth about that IV, it is not actually in the vein. The slow rate of the IV pump masked the fact that the medication has extravasated into the tissue but was not felt by the patient.

Sometimes inpatients come down with no IV's at all. I always found it curious that a person who is sick enough to be admitted into the hospital would have no venous access for medications, or heaven forbid, an emergency resuscitation. Our hemodialysis patients usually fall into this category. They have difficult veins to begin with and they are prone to fluid overload. Thus many of them don't get IV's while they are in the hospital. Until they finally come down to the operating room for a procedure and guess who has to start one.

These inpatient IV mishaps occur surprisingly often. I would guess it is at least a third of the time our inpatients arrive in preop without a working catheter. It happens so often that I'm always pleasantly surprised when an inpatient comes down with one that actually works.

1 comment:

  1. I cannot agree more, starting an IV with all of the components locked up in several different places with a hard flinching stick is enough to set the schedule back 30 min easy, god forbid an IV be started on the floor!