Incompatible medications and IV tubing, IV's.

[MunoRN]

So I'll admit I stole this topic from another site, but here's the question:

Do your policies allow for medications to be administered separately (not simultaneously) through an IV line so long as the line is sufficiently flushed between medications?

If so, does this also apply to secondary tubing (using a backflush)?

[iluvivt, BSN, RN]

I have been backpriming for 33 years. It is not a new concept and it a very acceptable practice. It does lower the risk the infection risk since you are not constantly connecting and disconnecting secondaries. Also with using multiple secondaries then you should change those every 24 hours since they would be considered primary intermittent since they function that way. Primary intermittent tubing should also be changed every 24 hrs. Remember: the secondaries do not have to be compatible with each other but each secondary MUST be compatible with the primary IVFs.

See if this helps: http://lmcalaris.squarespace.com/storage/Backpriming-Hadaway%20nursing%20art.pdf

[MunoRN, RN]

I have been backpriming for 33 years. It is not a new concept and it a very acceptable practice. It does lower the risk the infection risk since you are not constantly connecting and disconnecting secondaries. Also with using multiple secondaries then you should change those every 24 hours since they would be considered primary intermittent since they function that way. Primary intermittent tubing should also be changed every 24 hrs. Remember: the secondaries do not have to be compatible with each other but each secondary MUST be compatible with the primary IVFs.

See if this helps: http://lmcalaris.squarespace.com/storage/Backpriming-Hadaway nursing art.pdf

I completely agree, although as best as I can tell, the INS disagrees, which makes it very difficult to make backpriming a policy.

[Anna Flaxis, BSN, RN]

There's absolutely no reason to believe the physics of flushing is any different depending on the 'direction' of the flush' other than the backflow valve in primary tubing, tubing is not directional.

It doesn't matter if some if it gets absorbed into the tubing, the issue is with widely opposing pH levels, even a 'lazy' flush dilutes the varying pH fluids enough to prevent the formation of any precipitate.

Again, I was just theorizing.

Exactly, this was the basis of this discussion until it got deleted, so what is the recommendation of the INS?

According to the Infusion Nursing Standards of Practice, 2011, under Standard 43, Practice Criteria II, Section D:

When compatibility of infusates is verified, use of secondary administration sets that use back-priming infusion methods are preferred due to reduced need for disconnecting secondary intermittent infusion sets.

[MunoRN, RN]

According to the Infusion Nursing Standards of Practice, 2011, under Standard 43, Practice Criteria II, Section D:

When compatibility of infusates is verified, use of secondary administration sets that use back-priming infusion methods are preferred due to reduced need for disconnecting secondary intermittent infusion sets.

And that's where the inconsistency comes in; does that refer to compatibility of the primary and secondary fluid, or different secondary fluids? The common rule is that incompatible fluids cannot run concurrently in the same lumen, but the line can be flushed between different incompatible fluids allowing different incompatible fluids to be run through the same line/IV (so long as it is flushed in between and not run together at the same time).

[Anna Flaxis, BSN, RN]

Try not to overthink it. ;P

[MunoRN, RN]

Try not to overthink it. ;P

I'm not sure that actually thinking about it counts as overthinking. It's a pretty simple question, does the INS recommendation say that the same secondary line cannot be used even if it is flushed just as well as the primary line? According to Lynn Hadaway, the default spokesperson for the INS, it does and it doesn't. The problem seems to be underthinking, not overthinking.

[iluvivt, BSN, RN]

Let me look some things over again but this is how I have practiced for years: Any secondary you are administering must be compatible with the primary and the secondaries do not have to be compatible with each other. This does however require good technique with several backprimes and I even let the primary run for a bit to just assure that there is nothing left in the tubing.

I am leery of administering certain things that I know can be troublesome so it pays off to know what these drugs are and why they can be tricky. Some medications are formulated in non-aqueous solvents because they are very poorly water soluble so when you mix them with with water or saline they may precipitate. The classic example is Valium but others that also are made with non-aqueous solvents are digoxin, clonazepam, phenytoin, amiodarone and phytomenadione. You also have to be careful with calcium and magnesium preparations. If you look at the periodic table you will see these are divalent cations. They want to to lose two electrons to be stable as indicated by the fact they are group 2 in the periodic table. They easily can form a calcium or magnesium salt So do not mix Calcium an Magnesium..also keep in mind that some IVF solutions do contain some Calcium.

Remember too that not all incompatibilities are visible. You should however look for any signs that a chemical reaction has occurred by the formation of a precipitate or look for a color change (even if slight) a gas formation.....not a good sign..stop the infusion and flush at the site and then change all the tubing.

Just a few thoughts but I will look it over again.