Dumb IVPB question

Nurses General Nursing

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Hi Nurses! I was hoping someone could help with a discussion we were having at work yesterday. We were discussing different ways to run in IV meds, specifically IVIG. Sometimes we piggyback things into the main line after the pump, so that the main fluid runs with the piggyback (example: a K-rider). But one of the RNs had to hang IVIG (a blood product). We looked up our policy on it, and it said to "piggyback it into a D5W bag" and run it through a pump. To me, that meant to hang it like a regular piggyback and to use short piggyback tubing...you can always stop the piggyback and switch back to the main fluid if there is a reaction or something. When we went in to hang it, the pump was still set up from the dose the day before. They had the D5 on the pump and had used long tubing to hook the IVIG in after the pump. That was wrong to me. If you are going to do it like that, it should have been the IVIG in the pump and the d5 hooked into that one, not the other way around. So I guess I'm asking for your opinion...would you have used short or long tubing on this one and why? My thought was short because when I hang blood, we switch the 0.9 off and just let the blood run in, and since IVIG is a blood product, it only made sense to me to do it the same way. I do a lot of blood and platelets, and some FFP, but not much IVIG, so I don't really even remember what I did last time. I hope this even makes enough sense for someone to be able to respond, lol!

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Specializes in CCRN, TNCC SRNA.

I am not sure if I read that post right. I have a cold. Did you say that you saw D5W hung with blood? I thought that NS was the only thing that can be used because it is isotonic and that dextrose products (D5W, etc.) will cause hemolysis of the RBCs;(I guess that depends on what the patient is getting) therefore they should not be used. I usually use the shorter tubing (Longer ones can risk clotting depending on the blood used) and the filter that the blood bank distributes when they send the blood, (via PCT) to the floor

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Specializes in ER, ICU, Infusion, peds, informatics.

if i'm reading your post correctly, then i'm agreeing with you. have the d5w there in case of a reaction, then piggyback the ivig into it, since it (definatly) needs to be controlled by a pump.

if you are putting the d5w on a pump, and then "long-lining" the ivig into it, you are bypassing the pump's ability to control the rate of the ivig.

where i work, we give ivig fairly often (have a few patients that come in for it q4wks or q6wks). we hang it by itself, via a "stepped" infusion rate, with at bag of ns available in case of reaction.

however, we cap off (hep lock cap) all of our ivs, so in case of a reaction, it is very quick and easy to switch to a ns bolus. i know of other places that do not cap off all of their ivs, and they hang a bag of maintenence fluids that they piggyback the ivig into. if there is a reaction, they turn off the ivig and run the fluids.

at any rate, you need to do what your policy states. and if it states to hang it with d5w, then that is what you need to do. but yes, the rate of the ivig needs to be controlled by the pump, not the d5w.

to the above poster: though ivig is a type of blood product, it does not have blood cells in it, so there is no risk of causing a hemolytic reaction by running it with d5w. what fluid it can be run with depends on the particular brand of ivig (according to the literature).

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I run it like a regular piggyback with short tubing through the pump. I do it this way for the very reason that you mentioned, so that if there were a reaction to the IVIG you could quickly switch back to your main fluid.

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[color=#483d8b]we hang it by itself, via a "stepped" infusion rate, with at bag of ns available in case of reaction

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we do it this way also.

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We do the stepped rate also...the starting rate depends on whether it's the first dose or not. And the policy clearly said to "piggyback the IVIG into a 500ml d5w bag" and that it "must be run on a pump", which is what we did, but then another nurse saw it and said "But you should use a long line for it, and put it on the pump, then use another long line to hook the d5w in after the pump (which, as I said before, was the opposite of what I found when we hung the dose for that day). That way, if there is a reaction, you can just run in the d5w fast." I didn't understand that reasoning because you could do the same thing with the pump. I guess I just don't get what the difference is. It doesn't seem to me like there is a reason to have simultaneous d5w running, since (like CritterLover said) it doesn't have any cells in it like other blood products do, and the policy clearly says to piggyback it and use a pump.

I still don't understand what that other nurse was trying to tell me...it's like she was upset about it! She didn't talk to me for the rest of the night, and we normally get on fairly well together. She is quite a bit older than me, and has a lot more experience than I do, but I wasn't questioning her! It wasn't even her patient or anything, she just happened to be in the room and she saw it and asked us why we did it that way. And I said, "well, if it bothers you, we can change it", and she kind of snapped at me and said, "No! You'll waste the medicine!" And it wasn't even my patient either, I was just trying to help. I thought I was being stupid or something!

And we don't use pumps for blood - we use a special filtered Y set with a 250 ml 0.9 NS bag as a backup.

Thank you all for your input! I thought I was going crazy or something!

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You long line K-riders?

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Specializes in ER, ICU, Infusion, peds, informatics.
but then another nurse saw it and said "but you should use a long line for it, and put it on the pump, then use another long line to hook the d5w in after the pump (which, as i said before, was the opposite of what i found when we hung the dose for that day). that way, if there is a reaction, you can just run in the d5w fast."

ok, am i getting this right? she is telling you to run both the d5w and the ivig on separte pumps, but long-line the ivig into the d5w, so that both are running at the same time? if that is what she is telling you to do, i don't see any harm in it. as long as the ivig is being controlled by a pump, it should be fine. (as long as the patient's cardiac/renal function can handle the volume, which most should, since you are proably running the d5w at a low rate unless there is a problem right?) probably "splitting hairs." having the d5w already on a pump would most likely save you a few seconds in giving proper treatment, should a reaction occur. i don't know that it would be a significant savings in time, but if it makes her happy and keeps the peace, so be it.

that being said, be careful of reimbursement issues. at the infusion center where i work, the additional pump would be an extra charge, as would be the "concurrent" infusion of d5w. be certain you have an order to cover the additional charges.

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Maybe she's thinking that if there is a reaction the patient would get less of the ivig if the d5w is below the pump, since if the ivig is piggybacked in above the pump even if you shut it off and turn on the d5w, the patient would still get what is in the tubing (if you are doing it that way) whereas the other way the ivig could be shut off and there would less of it in the tubing since the d5w is below and probably right close to the site, that is if you are not changing tubing when a reaction occurs.

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Maybe she's thinking that if there is a reaction the patient would get less of the ivig if the d5w is below the pump, since if the ivig is piggybacked in above the pump even if you shut it off and turn on the d5w, the patient would still get what is in the tubing (if you are doing it that way) whereas the other way the ivig could be shut off and there would less of it in the tubing since the d5w is below and probably right close to the site, that is if you are not changing tubing when a reaction occurs.

That's my feeling too. I think the most important thing is the IVIG is somehow going through a pump, and that you've got the D5 to cover yourself in case of reaction/policy. If you've got that, which it sounds like you do whether you do it your way or her way, then getting in a tizzy about it is just going to cause bad feelings, not harm to the patient. (

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you long line k-riders?

yep.

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ok, am i getting this right? she is telling you to run both the d5w and the ivig on separte pumps

no, not sepearate pumps. ivig on a pump, d5w roller clamp, but still dripping. we don't charge "by-the-pump", if you will, so cost-wise the only difference is the cost of the tubing (i'm sure long line tubing is more expensive, since we keep that in the pyxis and the piggyback tubing is just in a drawer) and we do have some triple pumps, so it would be possible to do it on one pump. when we do the k-riders, it's 2 seperate pumps (or channels of a triple), but not for this one. i know there's no harm in it, i just couldn't see why she thought i was doing something wrong. i felt really stupid because i didn't understand why she was so adamant about it. i wasn't upset about it, just wondering if i was dumb! :wink2:

the reaction thing makes sense, but it doesn't seem like there would be more than a couple of cc's difference that way...the way she was acting it seemed like something much more serious than that, and i was worried that i was doing something wrong. thanks again, all!

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We run IVIG pretty much every wednesday with or stem cell transplant pts.

We can run it two ways...piggy backed into d5w and also long-lined into d5w. Of course the IVIG has to be run through a run.

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