Infusing TPN - page 4

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   nowplayingEDRN
    No, Tweety.....that would be 2 different venipuncture sites. The site that will be used for the veinipuncture is cleansed with either betadine or chlorhexadine and then the blood sample is taken. If it is the RN d/cing the TLC then...she would send the tip for culturing.
  2. by   Tweety
    Here, we do one peripheral site and one bc from the central line.
  3. by   P_RN
    I guess this goes with beating a dead horse, but I still want to read the policy from the #1 cancer treatment center. Passing- thru where can it be found?
  4. by   helix
    Okay,
    Having read everyone's posts, I would like to add my two cents, whether I am right or wrong. We hang TPN thru the central line that has lipids already in it. We are NEVER allowed to piggyback anything into it. I was surprised to read that other hospitals allow it.
    Secondly, we draw blood from our central lines, and have a very low incidence of infection. For a while, we had a high rate of infection, but the infection control team found that it was the type of dressings we were using, and this was changed. We keep close records on infections and the events surrounding them. We have dead-ender valves that have a blue membrane that wipes clean and is needleless. We are by policy to change them with every blood draw, but I know for a fact that I am one of the only nurses to do this. We wear gloves and clean the membrane and hub with alcohol, draw out the blood, hand it to the lab person with the alcohol wipe between our gloved hand and the hub, then draw another, and flush the line. I prefer to clamp the tubing, use the alcohol to take off the old dead-ender and attach the new one that has a syringe with my flush solution on it, then unclamp and flush.
    I would like to know from those that do ivpb into the tpn...do you use a separate pump or interrupt the tpn? I wonder about the drop in blood sugar as well.
    Also, we have a policy that allows hyperal thru a peripheral iv dependent on the osmolality of the solution. We always protest, but there are a couple of doctors that do it anyway.
  5. by   jnette
    re the CVADs...

    in hemodialysis a good one third to one half of our patients have central venous catheters.. permanent.. and most of our patients come to us with one in place until their fistula
    "strengthens" or their graft surgery site is ready to use. Often it takes up to 6weeks for a fistuals to be ready to use.

    On all these patients with either temp. or permanent catheters, we must draw labs weekly and some more often. Not only that, but these catheters are opened, heparin blocks removed,flushed, and attached to the bloodlines for dialysis 3x/wk., plus at the end of tx. once again detached, flushed and blocked.

    With all the above opportunities for potential infection to set in by "careless nurses", I find it amazing that in the 6 years I have been doing this, we have had only 2 cases of sepsis.. and both due to the patients' personal hygiene habits... (ie., chewing tobacco at home, and dribbling saliva and tabacco onto their chest, which somehow even manages to get underneath the transparant dressings.)

    All our labs (and there are MANY) are drawn through the CVAD before the start of tx. We use clean, not sterile gloves, nor do we prepare a sterile field. We DO wear a mask as does the pt., ANYtime we remove the caps and draw labs or attach/remove the lines. The catheter ends are wrapped in betadine soaked 4x4s for 10 minutes before removing the caps, and at the end of tx., before we detach the lines, flush, and block.

    So I just don't think the "careless nurses" theory holds water, nor does the thought that accessing these lumens to draw blood or labs perpetuates infection/sepsis.

    JMHO here...

  6. by   renerian
    Follow hospital policy. renerian
  7. by   jnette
    I agree, Ren. And this is our written policy.
  8. by   ceecel.dee
    Originally posted by Dplear
    TPN on the average costs 28 (twenty eight) dollars a bag to make. The most expensive item in the TPN is the bag itself which goes for around 20-25 bucks. The average charge is around 2000-3000 dollars a bag. Nice profit there.

    Dave
    WOW! I thought it was a lot more....I mean...way more!
    I'm going to ask a friend in the office to show me what we charge!
  9. by   ceecel.dee
    Originally posted by New CCU RN

    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.....
    I must agree.
  10. by   jnette
    Originally posted by ceecel.dee
    WOW! I thought it was a lot more....I mean...way more!
    I'm going to ask a friend in the office to show me what we charge!
    MORE ??? M-O-R-E ....??????? Can it possibly be MORE?
  11. by   ceecel.dee
    Originally posted by 3rdShiftGuy
    Original response removed.

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

    Patients needing IV access for "weeks on end" are the indication for the central line, in many cases. Our infection rate remains nill.
  12. by   caroladybelle
    Originally posted by P_RN
    I guess this goes with beating a dead horse, but I still want to read the policy from the #1 cancer treatment center. Passing- thru where can it be found?
    I would also like to know that info P_RN. As well as how it and by what organization it was so rated.

    At Hospital of U of Penn - Bone Marrow Transplant unit:
    As a general rule, most patients have at least a double or triple lumen access, or more than one CVAD access with multiple lumens each. The patients are extremely immunocompromised. I saw little to no line infection there, compared to many facilities. Nurses draw most labs from the CVAD. Lines that must be used for certain meds (TPN/Insulin/Heparin/Tacrolimus) are marked so that the measuring labs are not drawn from them. And if all possible, no other meds go through the TPN line. Blood cultures sometimes are one from the line and one peripherally, or both peripherally or both from line depending on MD orders.

    PS. I believe HUP is where they discovered the "Philadelphia Chromesome" used in cancer diagnosis. I do not know it's numerical ranking on polls.

    In a small "podunk" hospital in the Mtns of Georgia with a very dedicated nursing staff and a patient population that included multiple leukemic inductions and consolidations (very immunocompromised ca patients), I also noted few to no line infections. Line caps were changed with all blood draws and transfusions. Nurses drew most blood labs from the CVADs, excluding coags on heparin infusion patients, and peripherally ordered BCs. No masks were used when drawing blood. And if at all possible, no meds were permitted to go through the TPN line. If they had to, the PharmD was to authorize it on a daily basis.

    The reason for the PharmD. needing to authorize meds going through the TPN line. The PharmD (doctor of pharmacy), in that facility ordered the TPN by reviewing the MD orders (regarding fluid restrictions/CHF issues) and the labs that indicate electrolyte needs. That means that on some patients, the contents of the TPN may vary widely from day to day. And what may be compatible one day, may not be compatible the next. And what may not cause precipitation one day, may do so on the next.

    I have seen many drugs such as Primaxin, Ativan, and Phenergan precipitate in IV lines.

    As far as MDs knowing that drugs are compatible, that would depend on where you are. I know some wonderful ones that had to be taught by Nurses that Ampho B and Dilantin are highly incompatible with anything. When we explained that Dilantin is very irritating to peripheral veins, and Cerebyx was preferred, they changed immediately. And judging from the number of HIV patients with pneumocysitis that have orders for fluid restrictions of 1L/24 hours to include IVs and Q6 hour Bactrim (500cc a bag) orders, many of them do not know how things are mixed. Also, each patient generally has several MDs, all in their own little speciality world, frequently unaware of the big picture.

    As a Nurse, we are the ones administering the drugs, it is our responsibility to administer them correctly. We are also the ones that deal with the big picture.

    "PER USUAL"
  13. by   gwenith
    Caroladybelle once again you have written an eloquent and succinct post!

    I agree whole heartedly with the point about teh doctors not knowing how to administer drugs. I have seen them insist on us giving all teh vitamins at once - teh burrette jellied!! Yup it didn't just interact it turnedto jelly!! Can't tell how many times I have stood next to the doctor with the "Drug administration" book showing how a drug is recommended to be given!!!

    I guess because we are responsible for the administration we are more careful and try ot ensure that we do not mix drugs period.

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