Can you piggyback critical meds like IV Potassium or Mag at your hospital?

[UM Review RN]

I was taught that we cannot piggyback potentially dangerous IV meds like KCl and Magnesium.

Instead, we hook up the KCL to a primary line that goes directly to the pump and then to the patient. That line is labelled.

Then, if the patient needs IV fluids like NS and we've okayed it with Pharmacy, we can add that to the port closest to the patient on a drip or with a flow meter, but it will not be on the pump. It is not required to label that line.

Question: Are you allowed to piggyback medications like that at your hospital? Why or why not?

[MaryAnn_RN]

Our potassium is pre-diluted 1mmol/ml and we run that into a CVC.

[nancythenurse]

Hello,

Ive been an RN for 3 yrs but just started in Acute Care, this is my first full week after orientation. Im working med surg. Our "K Riders" come from pharmacy as 10 mEq mixed in 50 of NS bag. I ran 3 KRiders on a patient yesterday as a secondary (hooked to the primary line above the pump). Each K Rider runs over one hour. The rate on the secondary (KRider) was 50 per hour, the primary rate on the NS was 200 per hour. My patient complained of burning about 2.3 of the way through the first KRider, so I bumped the rate down to 30, she was fine. But at the end of the second KRider, when the pump returned to the primary flow she complained of burning. So, I realized that what had happened is that the primary fluid had quickly flushed the last little bit of K in. The vein was fine when I adjusted the rate down until I finished flushing the line. I was talking to another nurse who explained about hooking the K rider into primary tubing and using a second pump to run into the Y port, below the pump, so the K would be diluted. (Light bulbs when on, I get it). However, the charge nurse overheard, and when to see how I originally set up the infusion. She then proceeded to tell me that it was hooked up all wrong and I could have harmed the patient, and that she was going to have to write me up. I was flabbergasted, there is not a facility policy that states it has to be set up with 2 pumps that I can find. I even ran it by our DON, and he was not concerned about how I had it set up (but also stated that I could use the y port with a second pump). DId I REALLY blow it? THanks in advance I have been really worried about this all nite.

[GM2RN]

Hello,

Ive been an RN for 3 yrs but just started in Acute Care, this is my first full week after orientation. Im working med surg. Our "K Riders" come from pharmacy as 10 mEq mixed in 50 of NS bag. I ran 3 KRiders on a patient yesterday as a secondary (hooked to the primary line above the pump). Each K Rider runs over one hour. The rate on the secondary (KRider) was 50 per hour, the primary rate on the NS was 200 per hour. My patient complained of burning about 2.3 of the way through the first KRider, so I bumped the rate down to 30, she was fine. But at the end of the second KRider, when the pump returned to the primary flow she complained of burning. So, I realized that what had happened is that the primary fluid had quickly flushed the last little bit of K in. The vein was fine when I adjusted the rate down until I finished flushing the line. I was talking to another nurse who explained about hooking the K rider into primary tubing and using a second pump to run into the Y port, below the pump, so the K would be diluted. (Light bulbs when on, I get it). However, the charge nurse overheard, and when to see how I originally set up the infusion. She then proceeded to tell me that it was hooked up all wrong and I could have harmed the patient, and that she was going to have to write me up. I was flabbergasted, there is not a facility policy that states it has to be set up with 2 pumps that I can find. I even ran it by our DON, and he was not concerned about how I had it set up (but also stated that I could use the y port with a second pump). DId I REALLY blow it? THanks in advance I have been really worried about this all nite.

If it's not written policy and your DON approved it, I don't see how you can be written up.

But for future reference, even if it's not written policy where you work, any "high risk" IV medication should be run on its own pump, like potassium, heparin, etc. If in doubt, it is always better to run a med on its own pump than to piggyback it, at least until you are more experienced with those types of medications. If you do that, you shouldn't have any problems.

BTW...It's policy at my facility to always have a second nurse double check and sign off on the setup and rate of meds like potassium and heparin before actually starting the pump. If you have a policy like that, this should have been caught then. If not, maybe this policy should be instituted at your facililty.

[nancythenurse]

Thank you so much for your reply and advice. I actually talked to the DON after the fact, I was so upset by the whole thing. This was literally my 5th solo shift, and I personally would not have approached it the way that the charge nurse did (I make a mistake once, okay correct me but dont write me up unless there was patient harm; I make it again, then write me up either way). There is a cosign policy for insulin and pediatric meds, but other wise there is not a policy for double checking other meds. I definitely learned a lesson the hard way, at least my patient outcome was okay. I immediately took action when she said it was uncomfortable, and there was no infiltration, phelebitis, etc. Her IV site was stilll intact, although in hindsight I should have started a new one.

[GM2RN]

Thank you so much for your reply and advice. I actually talked to the DON after the fact, I was so upset by the whole thing. This was literally my 5th solo shift, and I personally would not have approached it the way that the charge nurse did (I make a mistake once, okay correct me but dont write me up unless there was patient harm; I make it again, then write me up either way). There is a cosign policy for insulin and pediatric meds, but other wise there is not a policy for double checking other meds. I definitely learned a lesson the hard way, at least my patient outcome was okay. I immediately took action when she said it was uncomfortable, and there was no infiltration, phelebitis, etc. Her IV site was stilll intact, although in hindsight I should have started a new one.

No problem. You should do fine.

One more piece of advice if you don't mind. Unless there is some compelling reason to run it faster, I always start potassium at the slowest rate and maybe increase it a little if there are no complaints. Patients getting IV potassium will usually be in the hospital at least overnight, so there's usually no reason to rush it and risk ruining the patient's veins and getting complaints...

[#1ME]

We run K and Mag as a primary and don't piggyback it, if we were to piggyback it, would do it with NS. Either way, we mix the 20meq KCL bag with 25 MG of Lidocaine which would be 2.5cc, to help prevent irritation/pain fom the KCL.

[deemalt, BSN, RN]

I think that one thing should be made clear (this took me a while to figure out too). When you piggyback or run something as the secondary, your primary fluid is suspended. That primary infusion stops and whatever is in the rider/secondary/piggyback is the only thing going through the line. I think that some folks feel that the primary is further diluting the piggy back/secondary but it is not. It is there so that the line does not run dry when the piggyback is finished.

I have found that the technique described where K spiked as a primary with its own pump and NS is run through an additional pump, then attached below the pumps causes the least discomfort to the pt.

[tiggerjoy]

Ours hang with separate pumps, with both having primary lines. mg hooked after the primary line pump (NS pump), when putting in volume of MG rider compensate for line amount. running med over 4 hours.

understand concept of missed med.

Other hospitals i have been running it as a piggy back connecting bag to primary bag (NS) connecting prior to pump. (lowering primary bag).

If set right, the right amount is going in,( I think i remember a rate of 25 or 27ml hour)

100ml bag.

anyway the I have seen two problems with this, one must remember a piggy back runs alone, which means the primary stops dripping with the piggy, unless bags are set equal. so one must remember to not bolus when air in the line, because its the piggy thats going, second, if you haven't set the volume right your piggy stops and the NS continues, your pt does get the mg, till you notice, because an alarm will not go off.

But in the end of both argument, I think as long as the rate is low either way is safe, if mixed with the NS should be sufficient.

[shortstuff_RN]

Our IV pumps have the ability to run concurrently. So primary fluid + potassium (at Y-site) run concurrently over 2 hours or more. No need for an extra pump if your pumps have a "concurrent infusion" option.

[psu_213, BSN, RN]

Yes, I piggyback K and Mg. And by piggyback, I mean as a secondary. In which case, the "big bag" of NSS is not running and not diluting the K (our K comes in premixed bags of 10 meq/100 mL NSS). As for Mag, I piggyback that as well--recommended at 1 gram/hr, although one doctor had me run 2 grams over 30 minutes for an asthma attack.