Multiple drip administration

  1. 1
    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 searched both allnurses and google for an answer to my question but have not really found anything.

    In my situation the pt was on levo, vaso, fentanyl, diprivan, epi, 0.9 maintenance as well as receiving boluses of 0.9 and albumin, and multiple ABX piggybacks. We were also treating according to CVP so I needed to keep that port open. The pt. also had TPN so that took up another port. I had one lumen to run all the other meds through so I made a bridge, grouped my vaso actives together and then plugged them into the bridge according to rate. I was taught by my main preceptor to place the most turbulent or highest flow rate, closest to the pt. which I did. Several coworkers argued with me and stated you should place the slowest drip rate closest since the higher rate meds would "push" the slower rate meds in. I have only found one article online regarding this issue and it basically said that placement of medication on a multi infusion set can affect the rate of delivery to pt. It listed a formula where you need to know the dead space and resovoir of your IV tubing etc, but it didn't give any real answers just concluded this was an area where further study was warranted.

    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.

    How do you guys place your meds? And do you have any resources with rationale? I have looked in my AACN book, my critical care references, and unit policies with no success. My rationale for following my preceptors methods was that she had the most years of experience.
    Last edit by Sugarcoma on Jan 5, '12 : Reason: spelling
    fiveofpeep likes this.
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  4. 30 Comments so far...

  5. 2
    I have never used a bridge but when I have 2 gtts that are compatible I always piggyback the faster one into the slow one. so the slow one is the one connected to the patient.
    turnforthenurseRN and Sugarcoma like this.
  6. 3
    I try to use a three line principle as much as possible (vasoactive/sedation/bolus). I'd prob handle it like this:
    Distal lumen CVC: CVP measurements (intermittent) with your maintenance fluid + boli of fluids, antibiotics etc.
    Lumen 2: TPN
    Lumen 3: vasopressors and inotropes

    And then I'd insert a peripheral IV for the continuous sedation/analgetics. I know running propofol over a P-IV isn't ideal but that's how we generally bridge until we find an intensivist that places a 4- or 5- lumen CVC somewhere else or an extra 1- or 2- lumen CVC.

    My rational is that we have doctors that like to give boli with the sedatives and they generally don't check if there is something else they are bolussing as well hence in our institution we run them via seperate lines/lumen.

    I try to place my vasoactive medication at around heart height of the patient to minimize gravitational influences when switching syringes.
    And I personally place the fastest running drug at the back of the tray, but I have no rational for that other than that it seems the most logical (as said above it drives in the other meds) and when D/Cing meds that one is usually the last to go so it has an esthetic reason as well.
    GrnTea, Sugarcoma, and fiveofpeep like this.
  7. 1
    Quote from belgianrn
    i try to place my vasoactive medication at around heart height of the patient to minimize gravitational influences when switching syringes.
    can you elaborate on this? i don't understand.
    Sugarcoma likes this.
  8. 2
    I agree with the way you have it set up.

    I would put the main IV bag for each port at the end of the string to push the rest through.
    MegNeoNurse and Sugarcoma like this.
  9. 2
    Quote from Sugarcoma

    In my situation the pt was on levo, vaso, fentanyl, diprivan, epi, 0.9 maintenance as well as receiving boluses of 0.9 and albumin, and multiple ABX piggybacks. We were also treating according to CVP so I needed to keep that port open. The pt. also had TPN so that took up another port. I had one lumen to run all the other meds through so I made a bridge, grouped my vaso actives together and then plugged them into the bridge according to rate. I was taught by my main preceptor to place the most turbulent or highest flow rate, closest to the pt. which I did. Several coworkers argued with me and stated you should place the slowest drip rate closest since the higher rate meds would "push" the slower rate meds in. I have only found one article online regarding this issue and it basically said that placement of medication on a multi infusion set can affect the rate of delivery to pt. It listed a formula where you need to know the dead space and resovoir of your IV tubing etc, but it didn't give any real answers just concluded this was an area where further study was warranted.

    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.

    How do you guys place your meds? And do you have any resources with rationale? I have looked in my AACN book, my critical care references, and unit policies with no success. My rationale for following my preceptors methods was that she had the most years of experience.
    I would place the O.9ns @150/hr the furthest away from the patient with the Diprivan and fentanyl so that a consistant infusion rate propels in the titrated meds at a consistant rate. No matter how you titrate or bolus your sedation it is delivered at a consistant
    rate. The albumin could be given with the TPN as albumin is frequently given in TPN but only as a last resort as the TPN needs to be in a designated line. As long as the are compatable I would put the meds that made the B/p go up together and the meds that bring it down together. Using the CVP is perfect because you can use it for a reading when needed and meds the other times when it is not being read.

    There are no articles because I don't think anyone has ever studied it but in my experence this is what I would do and the saline will be the last to be removed as you always need you flush. But everyone has their prefecence.....check with your educator. I hope I helped.

    being new to ICU this site may help....http://www.icufaqs.org/
    fiveofpeep and Sugarcoma like this.
  10. 2
    Thank you Esme, for the website recommendation.
    usalsfyre and Esme12 like this.
  11. 0
    BelgianRN, do you mean you level the bag near the heart? Like we do with ARTS at the phlebostatic axis so it is close to the right Atrium?
  12. 2
    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.
    Sugarcoma and Esme12 like this.
  13. 2
    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

    Hoping this makes more sense, I can always post a picture of how the line up at our bedside is.
    Sugarcoma and fiveofpeep like this.


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