Showing posts with label Difficult IV. Show all posts
Showing posts with label Difficult IV. Show all posts

Friday, August 29, 2014

Incompetent IV Placement Botches Execution

The autopsy report on Clayton Lockett has been released. Mr. Lockett was the convicted murderer who was executed by the state of Oklahoma back on April 29. The incident made national headlines when the procedure took over 45 minutes to conclude. Witnesses reported that the prisoner was writhing and appeared to be vocalizing pain after the medications were given. At the time, a doctor stated that the IV had blown and they had to start a new one. Ultimately Mr. Lockett died but due to a cardiac arrest.

The autopsy now shows that Mr. Lockett did indeed pass away from the drugs that were administered, not an MI. However, the reason that death took so long was because the drugs had infiltrated into the soft tissue instead passing directly into his blood stream. And it appeared the prison staff tried REALLY hard to get an IV in. Examination of the body showed IVs were attempted in both arms, the neck, the right foot, and both groins. It seems that the femoral veins too were not successfully cannulated which led to the IV infiltration.

The drugs that were given also came to light. They included midazolam, vecuronium, and potassium. While the dosages that were administered were not listed, it would appear that an IM injection of midazolam may not have been sufficient to cause amnesia if they were giving him the usual IV dose. Vecuronium would also have taken a lot longer and need a bigger dose to work in the soft tissue, possibly causing the prolonged movements that were witnessed. And that potassium injection into muscle would have hurt like heck.

Perhaps before the next time the Oklahoma penitentiary system attempts another execution, they should read my advice on how to start a difficult IV. But then again, convicted murderers like these don't deserve much mercy after the harrowing crimes they committed that landed them on that executioner's table in the first place.

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.

Thursday, September 6, 2012

IV Creativity

Breast IV. Don't try this at home.

I've seen some pretty creative IV's in my career. Some patients are almost impossible to start a peripheral IV. Consequently I've seen patients come to preop with some pretty bizarre locations for their intravenous. I've found them dangling off the knuckle of their fourth finger. I've noticed them inserted over the shoulder and upper chest wall. Then of course there are the foot IV's.

But this one really made me do a double take. The patient was obese, with an AV fistula in one arm and multiple hospitalizations. These are the deadly criteria for trying to find a decent vein. The IV nurse on the ward, in her ingenuity, inserted this catheter into the patient's breast. It was the most unusual place I've yet spotted. Of course being located on the breast made for an awkward tape job trying to secure that IV. But it ran fine and we were grateful for it.