Infusing TPN - page 3

I remember all through school having it drilled into my head that TPN was to infuse by itself and never to piggyback ANYTHING else into it. Where I work RN's consistently piggyback numerous drugs... Read More

  1. by   New CCU RN
    I have to feel bad for your poor patients passing thru at this "world class hospital" as you poke them q2-q4h bc they are on cvvh .. their arms must be a mess!!!!!!!!!

    That is absurd not to draw through a central line...... and sorry that your world class nurses have infected lines at your world class hospital, but at other places... that isn't the case.....
  2. by   P_RN
    PassingThru I assume you mean MD Anderson?

    Where can we read this protocol?

    My cousin with Hodgkins disease died as a result of sepsis of a central line. She had previously been treated there.
    Last edit by P_RN on Jul 20, '03
  3. by   nowplayingEDRN
    How many have you seen with old dried clotted blood in the caps?
    How many have you replaced that looked like that.?
    How many have been FLUSHED that looked like that? YUK !!!!
    I have seen a few like this and changed them, STERILELY I might add but not enough to merit going into crises mode over using the CVAD as it was intended....to infuse multiple meds and draw blood.

    They KNOW nurses will contaminate .............And they KNOW nurse's forget
    It is so typical of those that live in glass houses to throw stones. Doctors and other medical professionals are so quick to point the finger of blame at the nurse. Yet they forget that without the skilled hands of the nurses caring for these patients the mortality rates would be much higher....they are not taking into consideration that the very spot the CVAD is placed affects whether it clots or not and they are not taking into consideration that not every patient has impeccable hygeine and that there are patients that feel compelled to touch and manipulate lines, dressings and the like. All these things directly affect CVADs....from clots to infections and other complications.
    Again, I can see using extra precautions but it is unethical in my book to perpetually perform venipuncture every 2-4 hours on a patient that has a perfectly functional CVAD that is designed for just that use....and it is down right cruel and unnecessary to put a patient through such discomfort when there is no need to.

    I accept your apology and I thank you for your vote of confidence in me and in my judgement. rest assured, if you were in my care it would be nothing short of World Class care you recieved.

    And yes, Gwenith and P_RN....a World Class facility can not rest on it's laurels alone...for the are still run and staffed by humans and even World Class staff can make mistakes. I will stand my ground.....there is no substitute for good aseptic technique and following the hospital SOPs.
  4. by   SharonH, RN
    As it has already been pointed out, many meds can be piggybacked throught the same line as Hyperal but it is the Lipids which are incompatible with other medications. If you only have one one lumen on your central (or peripheral) line for whatever reason, you simply need to shut off the lipids, flush the line real well, and you can run most anything with the Hyperal. If you are using a pre-mixed bag of Hyperal/Lipids together, obviously that cannot be done. If you have more than one lumen, it is preferable to simply run your other meds through the other lumen.


    Edited to add: The Hyperal should not be interrupted due to the risk of hypoglycemia so you should take care as to how you secondary meds are run with it.



    Originally posted by passing thru
    You're exactly right Untamed. You finally hit the nail on the head. I agree 100 %... Yes, it is THE PRACTITIONER.

    That is the world-class hospitals' reason for NEVER allowing blood to be drawn thru the central line.

    Too much handling, too many entries, too much of everything.

    How many have you seen with old dried clotted blood in the caps?
    How many have you replaced that looked like that.?
    How many have been FLUSHED that looked like that? YUK !!!!

    It is a STERILE procedure. A mask should be worn when changing caps, etc, etc. But, who does?

    And, the world class hospitals' researchers and administrators know a thing or two about human nature.


    They KNOW nurses will contaminate their needles, not set up a sterile field, will withdraw and forget which syringe is their withdrawal syringe and which is for the lab (lab results bears this out.)

    And they KNOW nurse's forget to bring a new rubber cap, so they put the OLD ONE BACK ON after it has laid on the sheets or on the table.

    Or,..... they simply stick the rubber cap thru the gunk and draw.
    YUK !!

    There's gotta be 40 ways to contaminate the central line with EACH BLOOD DRAW.


    That's pretty sad. The overwhelming majority of nurses I work with are simply too professional to be so sloppy and careless.Yes, there will always be an exception because we are human. It sounds like these people dropped the ball. They needed to re-educate their nursing staff instead of simply making allowances for gross incompetence leading to discomfort for the patient.
    Last edit by SharonMH31 on Jul 20, '03
  5. by   Tweety
    Originally posted by UntamedSpirit
    And Gwenith you are right...a blood culture should never be drawn from an existing line....but a fresh veinipuncture site cleansed with chlorohexadine or betadine and then the blood specimen obtained. Otherwise the culture would not give accurate results and treatment would not be appropriate.

    Interesting, because when we have a febrile patient that requires blood cultures we always draw one of the two blood cultures from the line, this is a good indicator if the cause of the fever is an infected line.
  6. by   gwenith
    It is very possible that our TPN solution is formulated somewhat differently to yours as well. We have bags of "premix" which as well as the dextrose/amino acid combo often has a list of added trace elements and vitamins.

    We also can get and have used a premix with the lipids mixed into the bag - sort of looks like you are running custard
  7. by   Tweety
    Original response removed.

    I didn't realize one had to wear a mask when changing caps for drawing blood. I don't except when I change the dressing, then I can honestly say I wear a mask. I always bring fresh caps, and three individual flushes.

    We have pretty good luck with our world class nurses because I rarely see clotted up central lines as Passing Thru described.

    They do get infected, but usually those are the ones that stay in for way to long, like weeks on end.

    While I agree that drawing blood increases the risk of infection, using good technique, it should be no more of a risk that haning a piggyback med q8h.

    If I have a central line, I insist you draw blood from it and spare me the stick. (But I have ropes for veins and wouldn't agree to a central line in the first place.)

    The question is this world class facility with it's world class reasearch hiring world class nurses?
    Last edit by Tweety on Jul 20, '03
  8. by   Tweety
    Originally posted by gwenith
    It is very possible that our TPN solution is formulated somewhat differently to yours as well. We have bags of "premix" which as well as the dextrose/amino acid combo often has a list of added trace elements and vitamins.

    We also can get and have used a premix with the lipids mixed into the bag - sort of looks like you are running custard
    I'm not sure how our TPN is mixed. It comes up from the pharmacy based on what the MD ordered or what the pharmacist ordered. Usually it's a pharmacist managing the TPN forumula's, most of the docs write "pharmacy to manage TPN, etc.". They daily fill out a TPN order.

    We then match the label on the TPN with the additives etc., with the MD's order. We don't do any calcuations whatsoever, does that set us up for liability? Obviously if we notice the pharmacist writes for 2 million units of insulin and the bag says 2 million units and we hang it we are liable.
  9. by   gwenith
    I have a feeling that when we get down to the variances we will find we have been talking about different formulations. Obviously if the bag of TPN has added whatevers in it it will change what it will be compatable with and make compatablity determination more difficult.
  10. by   SharonH, RN
    Originally posted by 3rdShiftGuy
    Original response removed.

    I didn't realize one had to wear a mask when changing caps for drawing blood. I don't except when I change the dressing, then I can honestly say I wear a mask. I always bring fresh caps, and three individual flushes.

    We have pretty good luck with our world class nurses because I rarely see clotted up central lines as Passing Thru described.

    They do get infected, but usually those are the ones that stay in for way to long, like weeks on end.

    While I agree that drawing blood increases the risk of infection, using good technique, it should be no more of a risk that haning a piggyback med q8h.

    If I have a central line, I insist you draw blood from it and spare me the stick. (But I have ropes for veins and wouldn't agree to a central line in the first place.)

    The question is this world class facility with it's world class reasearch hiring world class nurses?

    Exactly. Something's not right here. I know there's a shortage but is is really that bad out there. There are a myriad of other tacks they could have chosen to address a problem of infected lines and poor technique including re-education of nurses, designating nurses to do it(i.e. RNs only, IV team, etc), or making the residents do it. Any of those would have been preferable to making the poor patient bear the consequence of incompetence of both nurses and management.
  11. by   Tweety
    Question. Does one have to wear a mask when hanging piggybacks on someone who doesn't have a running IV, but a central line? Seem like if when drawing blood you have to, then the same should apply with intermittant antibiodics.

    That definately doesn't happen where I work.
  12. by   nowplayingEDRN
    Again, let me reinforce...each facility has a different SOP for doing things. Usually for changing caps, sterile technique is enough but when the dsg change is done, not only should the nurse be masked and gloved but the pt should also wear a mask and be instructed to turn their head away from the insertion site while the dsg change is being performed. I made the offer to Gwenith but I would be delighted to share with my other co-workers and colleuges here on the BB. I have developed an inservice on CVADs....if anyone would like to see it FYI....I have it is in 2 formats...Power Point and MS Word.

    Tweety, usually if the suspect is a central line that has been left too long, we always drew 2 BCx from 2 seperate sites and the MD came in and removed the TLC and the tip sent to the lab for C&S.....and if necessary, insert a new cath in a different location. Believe it or not but some TLC manufacturers have recommended dwell times.
  13. by   Tweety
    Originally posted by UntamedSpirit
    Tweety, usually if the suspect is a central line that has been left too long, we always drew 2 BCx from 2 seperate sites and the MD came in and removed the TLC and the tip sent to the lab for C&S.....and if necessary, insert a new cath in a different location. Believe it or not but some TLC manufacturers have recommended dwell times.
    Are one of those sites for the BC drawn from the central line? Nurses at our facility d/c central lines, and definately send the tip for culture if the patient is febrile.

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