In Arizona, we have to be cautious with conscious sedation and prescribing. There needs to be a reason for the Ativan in the orders. If it's for anxiolysis, then the patient must be exhibiting signs of anxiety like "I feel really anxious" or "I'm nervous" or have ANS signs of elevated HR, BP, etc.
Our team does both adults and children. It is a rare case that we use any sedation medication on any adult. We use just the local Lidocaine with excellent results. Some patients require the Lidocaine creams. We do pain assessments on our patients before and after the procedure, and adults tell us the PICCs cause very little pain, a 0-1. Of course, there are those adult patients that everything just hurts. Those are the patients that require the anxiolysis. Our children are assessed by the PICC team and child life for sedation or distraction. If the child can lie still for a sterile procedure and not vasoconstrict, we use child life, and local, including EMLA or LMX-4. The children who do can't lie still or if vasoconstriction happens and a failed distraction attempt, we consult our pediatric anesthesia team for sedation/general anesthesia. On our pediatric PICC order set, we have routine order for child life, with referral to anesthesia for consult if required. This way, when the physician orders the PICC, he/she can order either. It is then the anesthesiologist who determines the amount of sedation for the procedure from their assessment of the child. We have a pediatric nurse who are in charge of the child, the anesthesiologist in charge of the airway, and the PICC nurse for the PICC. Trust me....this process did not happen over night. It took a lot of planning, trial and error for us to get to this point. When ever possible, we do children without sedation. Our ratio is about 70/30. 70% distraction. Ann Earhart, MSN, CRNI, APRN-BC Clinical Nurse Specialist-Adult Health Vascular Access/PICC Team Banner Desert Medical Center Mesa, Arizona 85213 office-480-512-3980 pager-602-420-3240 e-mail: [EMAIL PROTECTED] ________________________________ From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Nauman, Tanya Sent: Tuesday, June 26, 2007 5:51 PM To: Kilbourne, Susan; [EMAIL PROTECTED]; [EMAIL PROTECTED] Subject: RE: Ativan with PICC placements We have an order for "0.5ml to 2.0ml Ativan, p.o or IV prn for PICC placement, MR x1" as part of our routine orders. We use it about 30% of the time. We try not to overuse it, but for patients who say "I want to be knocked out" or exhibit signs of anxiety that continue after our initial attempts to put them at ease, we do give it. We usually use 0.5mg to 1 mg, but have used up to 4mg.(and we don't "knock them out".) With anxious patients, we often see venospasm making venous access and advancement of the catheter difficult. We realize that Ativan is not a smooth muscle relaxant, but when the patient is relaxed, their veins don't spasm. I like to have the option available as it saves time...rather than waiting around for 20-30 minutes to get a sedation order. We take our peds patients to OR where they receive general anesthesia...this is not what we would like, but we don't have a conscious sedation team or a child life specialist...and after several fiascos in pediatrics, we just take them to OR. Tanya R.N. I.V. Support/PICC team/Educator ________________________________ From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Kilbourne, Susan Sent: Tuesday, June 26, 2007 3:50 PM To: [EMAIL PROTECTED]; [EMAIL PROTECTED] Subject: Ativan with PICC placements I have recently been challenged by a physician on our use of IV Ativan with PICC placement. Our team often will ask for an order prior to PICC placement just in case the patient is anxious about the procedure. I was surprised when I did a recent audit to see that they have been using Ativan in 53% of our PICC placements. I am curious what other teams are doing. Is this standard of practice or have we gone too far on this? Sue Kilbourne Asante Infusion Services NOTE: The information contained in this message may be privileged and confidential and protected from disclosure. If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by replying to the message and deleting it from your computer. E-mail has the potential to have been altered or corrupted due to transmission or conversion. 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