[NICURN9]

Hi. I am just looking for some different perspectives here. What is your hospital policy for using Dopamine and/or Dobutamine as far as piggy-backing, flushing and what sites to use?

I have been a NICU nurse for 8 years. I am PRN now and things have changed some as we have a new set of docs,etc... We always had a policy though that Dop/Dob could only be piggy-back with each other and had to use a peripheral site so that in the even that we had to flush that site we could disconnect the tubing from the hub of the catheter and flush it OUT of the tubing before flusing the site itself.

We find ourselves using more and more of the triple strength dilution meaning that our rate is 0.16cc/HR to deliver the dose. I had a very sick baby the other afternoon and the doc insisted that I switch the Dopamine over and run it through the picc line and give the antibiotics through the peripheral site. I tried to explain to him how dangerous this would be if we had to flush that PICC line, but he would not hear of it. Insisted it would be fine. Granted our PICCs are pretty small but I am guessing that priming volume is about 0.5cc and that would equal 3 HOURS worth of Dopamine if we had to flush it through. He still insisted this was ok and the charge nurse finally informed him that if he wrote the order that way we would do it that way. I was VERY uncomfortable doing this!
Just wondering what your policy is and do you use the triple strength dilution?

[dawngloves]

Triple stregnth? We mostly do 2:1 concentration, sometimes 1:1 with term, 3:1 with micros.
I'm also wondering why that doc wanted the dopa through the PICC? What difference would that make?

[New CCU RN]

I'm a CCU nurse and have never stepped foot into a NICU, but I would think that Dopa through a peripheral would cause tissue necrosis.... we NEVER run it in a peripheral for an adult, why is it ok for a neonate?

[NicuGal]

CCU nurse...sometimes that is the only option we have....it isn't like an adult where we can just throw a subclavian or jugular. Neonates are a whole nother creature

We have gone to quad strength on our littlest ones...we do use a UVC for those and we do use our piccs. We will send the Dopa with the HAL thru the picc and start a peripheral for the others if we don't have a double lumen UVC in. We have several docs that prefer the vasopressors thru a central if we have it. As a matter of fact, I believe our guidelines say so also.

Dopa and Dobut aren't compatible with much...we have a huge chart at work that we use. I know that we don't run them with IL anymore.

When we have to change a line over, we change everything down to the line, including the T-connnector and then we flush the line...it is like 0.2-.4 for a picc if I remember correctly. A T-connecter is almost .5mls. For a Picc/UVC we will withdrawl .2ml's of blood and discard before changing or flushing the line with something different.

[New CCU RN]

I certainly understand that neonates would obviously be harder to get a cental line in... (although we do have our fair share of adults that are extremely difficult to get a central in... ie) in DIC, septic shock so edematous, plt count of 10,000.. you get the picture) You probably have babies with the same scenario...

Anyway, I guess I am wondering if you see alot of tissue necrosis bc of Dopa being through a peripheral... I would think through their fragile veins...

Sorry, just curious..

Also... what is the benefit of quad strength? I guess a decrease amount of fluid is needed to be administered... we will often do that with our CHF'ers... just wondering... thanks

[Tiki_Torch]

In my experience we've only used double strength solutions and infused them through UVC lines or PICCs or Central Lines... except in one case where we had to run it through a PIV but that was for only 3 hours while we were on transport taking an incredibly sick NEC baby to a hospital that could do emergency surgery for his perforation. We prayed over the IV site the entire way, and thank God above, the site held up perfectly.

As far as flushing a line goes, we've always ended up discontinuing the dopamine and dobutamine before the baby's IV fluids were stopped so we never had a reason to flush a line... the line would eventually be "flushed" with the regular IV fluids running through them at a decent rate. I'd be worried about flushing a line with a concentrated strength of these drugs too! The poor kiddo could have a B/P bottom out to China in a heartbeat! I'm curious to see what other nurses have to say about what their NICUs are doing in this regard too.

New CCU RN, you are on the right track in thinking that the more condensed strength medications would be used to limit the volume of fluid a baby receives; this is especially important in micropreemies. Their fluid requirements are very precise...as a matter of fact I recently read that taking 1 cc of blood from a 1500 Gram baby is comparable to taking 70 cc from a normal adult. These babies continually amaze me!!!

[NICURN9]

Well....thanks for the insight. I guess it isn't all that unusual just not OUR policy.

As for tissue necrosis....never really had a problem with it. We watch these IV sites like hawks and babies who are on dop/dob are usually kids who have a nurse standing over their bedside almost constantly so it isn't like we wouldn't notice a bad IV site for 2 hours or something.

I guess my biggest fear with doing this was that it isn't our policy and if someone else were to come into the situation to help (ie nurse on break and baby has an antibx due) she may piggy back another med into the PICC line further up and FLUSH. And I don't know about your unit, but we have a few nurses who are a few fries short of a happy meal.... why the heck they are still working there (for YEARS) is beyond me...but this is a totally plausible scenario.

Another issue with this is that we have a lot of policies and procedure guidelines and protocols but it seems that whenever someone doesn't like it they just change it. Then why the heck do we even HAVE these. Let's just do it freestyle! We have a hard time getting mgmnt to back us up on these things and it is really frustrating.

We never draw blood through our PICC lines but maybe if we are going to be running these drugs through there we need a new protocol that involves aspirating a cc or two before flushing if the need to flush arises.

Thanks again! I feel better!
Kim

[NicuGal]

We keep people from piggybacking things into our lines by putting a strip of white tape over all the unused ports and write in big red letters.... VASOPRESSORS DO NOT FLUSH .

I have to say, we rarely have infiltrates in my unit...something we pride ourselves on. If in doubt, we pull it out. In 17years I have only seen I think 2-3 infiltrates from vasopressors that needed plastics. I have seen more infiltrates from NaHCO3 that have been devastating.

We just went to the quad strength in last 2 years, and yes, it is for fluid management and to optimize any other nutrition we can possibly get into this kid. Weaning is no biggy either as we almost always turn our Dop and Dobut off at 4 mcg .

Just think of this when someone goes against protocal...they are the one that will one day possibly end up in big trouble. Follow the protocals and you don't have to worry about it.

[dawngloves]

I've never had an infiltrate, knock wood! I've seen it once in an adult and caught in in time. When I did big people we would have renal doses in peripheral lines.

[KRVRN]

I've never seen 3:1 or 4:1, we usually do 2:1 on micros and 1:1 on everything else. We usually try to run dopamine through a central line but if it's not available we will run it through a PIV. I guess tissue necrosis is a possibility, though I've never seen it. Sometimes on a small baby you can actually track the vein up the limb because there's a blanched line. We consider that normal.

I've had problem with PIV dopamine if it's in a positional type spot. Baby turns foot one way and the BP falls and falls and then the baby turns it the other way and the BP shoots up because the turning kinks and unkinks the catheter. Sometimes it's hard to tell if it's a labile baby or a positional IV site.

Changing IV sites with pressors is a challenge. The only way to really do it is to put a NS flush on the site and run the flush for a length of time. Likewise the new site will need awhile for the pressor to reach the baby. Hopefully the 2 lengths of time will be close enough to not really screw things up.