Multiple drip administration Multiple drip administration - pg.2 | allnurses

Multiple drip administration - page 2

I recently had a pt. with multiple drips through one triple lumen central line. I am new and recently off orientation where I had multiple preceptors who each told me something different. I have... Read More

  1. Visit  Esme12 profile page
    1
    And we need to remember not everyone responding is from the US as there are other countires here with different laws, policies and equiptment.
    fiveofpeep likes this.
  2. Visit  MunoRN profile page
    1
    By "Bridge" I'm guessing you mean what is called a manifold where I work. It makes no difference what order you connect them. Same with piggybacking one fluid into another line, once the connection is made it becomes a y-splitter, it makes no difference if you connect the tip of line A into the distal port of line B or vice-versa in terms of fluid flow.
    Sugarcoma likes this.
  3. Visit  Reno1978 profile page
    1
    Quote from Sugarcoma
    I ended up doing the following: TPN in one lumen, Bridge on the other with 0.9@ 150 first, diprivan @ 50mcg second, Fentanyl at 50mcg third, Levo @ 50, fourth, EPI fifth and Vaso @ 0.04 last with a 0.9 chaser at KVO rate. I used my CVP port since we were measuring hourly for boluses, ABX, and pushes.
    I don't see a need for the 0.9 chaser connected to your vaso. Although it infuses at a small rate, you have your 0.9 @ 150ml/hr running behind it which will help deliver it to the patient faster.
    Sugarcoma likes this.
  4. Visit  Sugarcoma profile page
    1
    We also plug a chaser line into the last connection when we build bridges. They are multiple stopcocks connected to each other. I found a picture of something very similar here:http://img.hisupplier.com/var/userIm...Stopcock_s.jpg

    So I was able to pick my former preceptor's brain a little bit for rationale. She told me the reason she sets it up with the fastest med first is because that is usually your maintenance fluid, which is usually 0.9 and because it is positioned on the stopcock first you can use it as a push line without worrying about what is compatible with what, if you have to push something fast.
    fiveofpeep likes this.
  5. Visit  mvanz9999 profile page
    1
    Quote from MunoRN
    By "Bridge" I'm guessing you mean what is called a manifold where I work. It makes no difference what order you connect them. Same with piggybacking one fluid into another line, once the connection is made it becomes a y-splitter, it makes no difference if you connect the tip of line A into the distal port of line B or vice-versa in terms of fluid flow.
    Wow. The first person that states what I think! It makes no difference, in general, what order you connect your drips. People are fond of stating that the fastest fluid in the back of your other connections will make them flow faster and at a more consistent rate. However, it really makes no difference. The higher flow rate fluid in the back isn't pushing anything. Think of your maintenance fluid like a river. It's flowing at a fast rate, regardless of where you add something (front or back). It gets watered down and carried along with the river regardless of where you add it.
    Sugarcoma likes this.
  6. Visit  Reno1978 profile page
    1
    Quote from Sugarcoma
    She told me the reason she sets it up with the fastest med first is because that is usually your maintenance fluid, which is usually 0.9 and because it is positioned on the stopcock first you can use it as a push line without worrying about what is compatible with what, if you have to push something fast.
    That sounds dangerous. If you used that first 0.9 line to push an IV medication, you're bolusing the patient with all of the vasoactive medication in the line ahead of that connection, and you will have to worry about compatibility unless you shut off all the stopcocks to your medicated drips, and flush it with saline before and after your push...but again, that's an awful idea to bolus anything through your lumen with vasoactive drips infusing.
    Sugarcoma likes this.
  7. Visit  Sugarcoma profile page
    0
    Quote from reno1978
    that sounds dangerous. if you used that first 0.9 line to push an iv medication, you're bolusing the patient with all of the vasoactive medication in the line ahead of that connection, and you will have to worry about compatibility unless you shut off all the stopcocks to your medicated drips, and flush it with saline before and after your push...but again, that's an awful idea to bolus anything through your lumen with vasoactive drips infusing.
    i'm sorry, i mis-typed. it would actually be positioned last on the stopcock, or closest to the patient, with the drips behind it. because i am new and do not have much compatibility memorized i always try to keep an open lumen in case i have to push something fast. if i cannot do that, i will use the cvp port. i am going to continue this practice.

    wow. the first person that states what i think! it makes no difference, in general, what order you connect your drips. people are fond of stating that the fastest fluid in the back of your other connections will make them flow faster and at a more consistent rate. however, it really makes no difference. the higher flow rate fluid in the back isn't pushing anything. think of your maintenance fluid like a river. it's flowing at a fast rate, regardless of where you add something (front or back). it gets watered down and carried along with the river regardless of where you add it.

    this is what i initially was thinking myself. that because the medication is being delivered at a controlled rate via an infusion pump, position on the bridge wasn't an issue but my preceptor and coworker's felt otherwise. it really doesn't seem to matter how i set things up. it seems like the nurses who follow me always find fault with my set up. lol. i guess that is nursing.
    Last edit by Sugarcoma on Jan 9, '12 : Reason: spelling and grammar
  8. Visit  Sugarcoma profile page
    1
    If anyone is interested I found another article online regarding this issue on the website anesthesia-analgesia.org. Interesting reading.

    http://www.anesthesia-analgesia.org/.../1147.full.pdf
    fiveofpeep likes this.
  9. Visit  Reno1978 profile page
    2
    Quote from Sugarcoma
    I'm sorry, I mis-typed. It would actually be positioned last on the stopcock, or closest to the patient, with the drips behind it. Because I am new and do not have much compatibility memorized I always try to keep an open lumen in case I have to push something fast. If I cannot do that, I will use the CVP port. I am going to continue this practice.
    I understand that - there is still vasoactive medication between that point and where the lumen empties into the patient. If you do not have a free line available for emergency drugs, which is sometimes the case, the best choice to have to "give something fast" would not be the line in which vasoactive drugs are infusing. Just my 2 cents.
    Sugarcoma and NRSKarenRN like this.
  10. Visit  ShaunES profile page
    1
    cvp is useless to assess volume status and you should ignore it; better yet, put your vasoactive medications on the distal lumen and you have another free lumen.

    last or first it doesn't matter, there's going to be a good whack of medication in the actual catheter itself that you will bolus if you put anything on it.

    our standards are: vasoactive medication on its own lumen unless paired with other vasoactive medications.

    (does central venous pressure predict fluid responsiven... [chest. 2008] - pubmed - ncbi for my cvp claim; "
    the pooled area under the roc curve was 0.56 (95% ci, 0.51 to 0.61)"; may as well flip a coin.)
    Sugarcoma likes this.
  11. Visit  Sugarcoma profile page
    0
    Quote from shaunes
    cvp is useless to assess volume status and you should ignore it; better yet, put your vasoactive medications on the distal lumen and you have another free lumen.last or first it doesn't matter, there's going to be a good whack of medication in the actual catheter itself that you will bolus if you put anything on it.our standards are: vasoactive medication on its own lumen unless paired with other vasoactive medications.(does central venous pressure predict fluid responsiven... [chest. 2008] - pubmed - ncbi for my cvp claim; "
    the pooled area under the roc curve was 0.56 (95% ci, 0.51 to 0.61)"; may as well flip a coin.)
    thank you for the link, very interesting!
  12. Visit  NotReady4PrimeTime profile page
    1
    Quote from umcRN
    I know this is a controversial subject and different places have different policies but I work in peds and we can run compatible meds with TPN, we rarely have triple lumens and PIVS never last in our kiddos though they always have them. If this was my patient I would keep the CVP open with a med port so I could give antibiotics and boluses through there. I would do a train with the maintenance at the end (furtherst from the patient) & KVO and then put the other drips from slowest to fastest, closest to furthest away. I would then run the TPN with the sedation and also have a med line there for meds if needed, but like I said at my facility we often run things with TPN and do not keep it as a dedicated TPN line, however we keep a med line attached and keep it a closed system.
    This is similar to how we practice on our unit. With some minor differences... Many of our cardiac kiddies will have triple-lumens (our cardiac anaesthetists are pretty slick with the line insertions) and we have a common practice for what we run where. The distal port is always our CVP/push/med port. Medial port gets the amino acids-dextrose solution (once we start it), lipid emulsion and occasionally compatible other infusions although we try very hard to keep our TPN in a dedicated line. If push comes to shove and we have a PIV, we might put the lipids there so that we can run lipid-incompatible meds with the AADS. Vasoactives and compatible sedation will then run in the proximal port. Morphine, midazolam and milrinone are all compatible with epinephrine and norepinephrine so they'll all go together. As for the order of operations, vasoactives go proximal to the patient and if a drive is required due to low flow rates, it goes most distal. It's only sensible to minimize the dead space that a vasoactive drug has to move through to get to its target.

    Quote from BelgianRN
    All our vasoactive meds are delivered in 50 cc syringes (except levosimendan) and we don't routinely close the lines before changing the syringes. This means that when we switch the line is open and under gravitational influences for about 1 - 2 seconds. So when switching the syringes I'll always hold the opened line level to the heart so that we don't get fluids running in or out freely but instead the fluid in the open line remains static.

    As a result patients remain much more stable on switching syringes compared to others that change the lines well above patient level as they tend to give the patient a bolus of vasoactives. Or the ones that change it at ground level since they will have backward flow and end up with hypotensive patients.

    I might have to add that all our syringe pumps are on a vertical stander next to the patient. So I'll usually make sure the vasoactives are in the syringes that are around patient level and not the top or the bottom pumps as I know the routines of some of my colleagues
    I've never quite thought of it that way, but it does make some sense! We mix our own infusions right at the bedside and vasoactives go in 60 mL syringes. With our "old" syringe pumps, this method could actually save the roller coaster rides for the amusement park. With our "new" pumps, which all of us would like to heave through the wall, we have to double-pump everything that's running with our vasoactives because they take so long to get back up and running. I'll have to try this with our "old" pumps and see what happens.


    Quote from ShaunES
    Seems much simpler to just use a bag and then you never have to stop it.
    The only problems with that solution with peds patients is that they're usually fluid restricted so the volume of an infusion on a volumetric pump would be too high and because these kiddies are much smaller reservoirs, the pulse delivery system of volumetric pumps causes pretty significant peaks and valleys in their BP. We even see huge swings in BP from having other infusions running on them into other lumens when the patient is on vasoactives. When that happens then EVERYTHING goes into a syringe.

    Quote from Reno1978
    That sounds dangerous. If you used that first 0.9 line to push an IV medication, you're bolusing the patient with all of the vasoactive medication in the line ahead of that connection, and you will have to worry about compatibility unless you shut off all the stopcocks to your medicated drips, and flush it with saline before and after your push...but again, that's an awful idea to bolus anything through your lumen with vasoactive drips infusing.
    Absolutely!! Vasoactive meds should never be bolused except in a code situation. The risks are so high as to be unacceptable. (In peds, one could kill a patient that way.) And of course, with their short half-lives they can't really be interrupted either (which is what happens in situations like I've described immediately above... bolus then lag, bolus then lag - VERY bad for neonates!). In adults, a drop in SBP from 110 to 80 isn't nearly the same thing as a drop from 80 to 50 in a toddler.
    Sugarcoma likes this.
  13. Visit  needshaldol profile page
    5
    This is what I think. I think you ICU nurses need to start out at (U.S.) $150,000/year starting salary!

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