Different Piggyback Antibiotics, Same IV Tubing?? - page 3

Hey all, I just had a quick question about something I was taught in nursing school and was wondering if you learned the same thing, or practice this yourself. You have 2 different IV piggyback antibiotics (compatible or... Read More

  1. 1
    I was taught to back prime and this is acceptable practice where I work.
    nrsang97 likes this.

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  2. 3
    Quote from Serlait
    I can't help wondering if the cost of a secondary set is more or less expensive than the saline used to backprime. Further, the sited article is dated (copyright 2004...which at 8 to 9 years old would this source even be an acceptable source in most evidence based research papers?) and no longer complies with CDC recommendations. It looks as if the Infusion Nurses Standards of Practice were also revised in 2011. See new CDC recommendations here.... CDC - Patient Cleansing - 2011 BSI Guidelines - HICPAC

    I'm actually confused -- which part of the CDC recs are you saying that back-priming doesn't comply with? (I'm tired, so maybe more prone to confusion than usual.)

    The cost of a single secondary set may not outweigh the cost of NS, but when you have a patient on 3-4 coverage, plus electrolyte replacement, I'd imagine that the cost of 5-6 secondary sets can get prohibitive. I've also found, just in my own day to day practice, that running the NS at TKO unless otherwise contraindicated keeps an IV patent for longer so you're also saving on the cost of having to restart an IV every day because the doc insists on running zosyn, vanc, and levaq through a peripheral.
    Aurora77, wooh, and redhead_NURSE98! like this.
  3. 2
    Quote from KelRN215
    When I worked in the hospital, we carried 25 mL bags of normal saline. After an antibiotic was done, we hung this to flush the remainder through the tubing. We did not use separate tubing for every IV med the patient was on.
    This is what we currently do at my hospital...it would not make sense to change secondary tubing for every antibiotic since they are on multiple antibiotics and also receive electrolyte replacements...typically we flush post meds and sometimes pre if its indicated
    wooh and nrsang97 like this.
  4. 0
    Quote from nrsang97
    I back primed IVPB all the time when working in the ICU. It saved a lot of time and cost. I did leave something on a dedicated IVPB tubing like dilantin. Other than that it was backprimed. Otherwise you had a ton of IVPB tubing hanging around. I was taught this in nursing school as well.

    Yes, in adults it's done all the time, unless you need a dedicated line. Been in critical and some acute care for over 20 years, this is nothing new, and is pretty standard in many places.

    Now another way is the use of a soluset.

    In kids, we tend, in most places, to run everything (pretty much) off a medfusion syringe pump. So, after every med, you flush with a syringe full of NSS or sterile water. Now, if it's a line with a medicine that you can't risk boluses into the little one, that is different. If there must be a port dedicated to other meds, that's what's done.

    If it's not about needing a dedicated line or bolusing another med--like a vasoactive one, or something along these lines, if you are using sterile technique and haven't contaminated the fluid or any part of the line, it's no big deal. You have a primary bag into the line and a secondary port. They used to have you hang the primary bag lower (in the days before everything was on a pump), and have the secondary piggy back running it. After a half hour for most antibiotics, you brought the primary line back up, but you let the secondary back fill with the primary line fluid. Now if you have something problematic mixed in the primary bag, this could be an issue--but usually it wasn't unless you had to have med lines that were dedicated. It would be incredibly expensive to hang a new PB line with every dose if you didn't have to.

    I favor medfusion pumps. It's probably a control thing.
  5. 3
    I use the same secondary tubing for all piggybacks, unless they aren't compatible. Backprime.

    I thought it was so strange my 2nd nursing job to see 10 different secondary tubings hanging on the IV pole. A lot of people don't want to change their habits.
    alibee, redhead_NURSE98!, and nrsang97 like this.
  6. 4
    It is the frequent connections and disconnections that is the concern here when you use multiple secondaries or one for each drug.This really increase the opportunity to introduce bacteria into the line. Biofilm gets attached to the catheter and/or connectors,breaks off and then can cause a bloodstream infection. Yes.... this can happen with peripheral IV therapy too. Dr Marcia Ryder explains this very well if you would like to read more. The Biofilm has been found in needleless connectors as well,pointing out why it is really important to changes these per your policy especially on all central lines and scrub the connections for 15 seconds before applying new caps. I see this step skipped often.

    So back to the point...by using the same secondary and not disconnecting (backpriming instead) you are performing best practice. If you feel that you must use multiple secondaries then they should be treated as if they were a primary intermittent in terms of the tubing changes. That is why INS states that secondaries used in that manner need to be changed every 24 hrs. This is the current and best recommendation to date so far. If and when there are more studies that show something else is better INS will stick with this recommendation .

    So if you are doing anything else then make sure you have policies in place for more frequent tubing changes of the secondaries,never use the sloppy practice of" looping",ALWAYS put a sterile new end cap on disconnected IV tubing (a cap from an NS or heparin pre-fill does not count or qualify) and date the tubing so it gets changed in a timely manner.

    Yes the 2004 article still applies as no new studies to prove there is a better way.
  7. 1
    The back-priming a few times takes a fair amount of time, and we all (should) know the wise old saying about "time is money". From a simple cost perspective, calculate the actual amount of time used to use a separate secondary tubing and switching it at the appropriate port on the pump set as needed versus back priming (several times) the tubing. Compare that with the actual cost of a secondary tubing set. By running the numbers (I tend to do that quite often... could have been an accountant ), you will likely see that using a different secondary set is less expensive.

    I just checked the cost of the secondary IV pump tubing; it is $0.70/ea.
    Last edit by Overland1 on Feb 11, '13 : Reason: Accounting Clarification
    Serlait likes this.
  8. 4
    We just use different tubing for every piggyback.
    Maybe it's just a resistance to change I'll own it.
    Maybe it's a safety thing. There's always going to be one person who "forgets" to back prime with the worst possible medication.
  9. 1
    The CDC issued new guidelines as to the time a primary set should remain in use in 2011, this is the conflicting information in the cited article. Also it is noted in the 2010 Lynn Hadaway Associates Inc. link r.e. backpriming "Unfortunately, this is an area of clinical practice that has received no attention and no research." (First line of author's response). And further down in the authors response to a post "Of course there are no studies to refer to about this practice. I would recommend that your practice council consult with a pharmacist knowledgeable about IV drug compatibility information just to be sure. I just checked some recent compatibility information on Vancomycin and found conflicting compatibility information when given with ampicillin, several of the cephalosporins, nafcillin, piperacillin, ticarcillin and tigecycline. I would recommend that you assess the common combinations prescribed by physicians in your facility and then assess the compatibility of those combinations."
    Additionally, per the 2011 CDC guidelines, "No recommendation can be made regarding the frequency for replacing intermittently used administration sets.Unresolved issue " (#2 under Replacement of Administration Sets).

    Hence, the use of backpriming cannot be claimed to be evidence based, therefore, how can it be best practice? I don't see it as not wanting to change habits, but in following the protocols established. It seems to boil down to using the practice that your hospital or agency establishes as best practices. If your agency says a new secondary for each drug and 24 hour use for each secondary and you wanted to argue the issue, what evidence would you present? What research could be presented? At this point, per Lynn Hadaway, "The absence of studies means that we are left to base practices on general principles of infection prevention." (Paragraph 3, author's response).

    It would be extremely interesting to look at the rates of blood stream infections in hospitals with varying practices to see if there is a greater incidence of infection when multiple secondaries are used vs limited access for secondaries. Perhaps a good research topic?
    Last edit by Serlait on Feb 11, '13
    Susie2310 likes this.
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    "Yes the 2004 article still applies as no new studies to prove there is a better way."

    But the 2004 article was not supported by evidence based research. Again, there has been no research to support either practice. How can one claim "best practices" with a dearth of research to support such a claim.

    I find it interesting that if someone is unwilling to switch to another practice, especially when there is absolutely no evidence to support the change, they are accused of being unwilling to "change their habits". Very simply, if you want me to change my "habits" then show me the evidence that supports that change. Please don't site an eight year old article that does not include the most recent recommendations of agencies cited in the article. Both the CDC and INS revised their recommendations in 2011. If I were not willing to change my "habits" in the face of research, THEN I would be deserving of your censure, until then or until I have the evidence to argue for a change, I will follow the protocols of my hospital. I can't imagine trying to defend myself if there were some sort of problem or compatibility issue by saying that I based my practice on an article written in 2004 that was not current.
    corky1272RN likes this.

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