IV compatibility question?

Nurses Medications

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Hi everyone,

Yesterday I had a patient who was on 3 IV antibiotics: zosyn, zyvox, and levaquin. We use micromedex to check compatibility so I found through there that zosyn and zyvox were compatible, so there was no need to change the tubing. I was using normal saline for the primary line to piggyback the antibiotics into. I programmed the normal saline to run for a volume of 10 ml at 10 ml/hr once the piggybacks finished. The levaquin was the third one that I hung, after the normal saline had run through, and I disconnected the previous secondary tubing and hung the levaquin piggyback with the new tubing after the flush had run (with the old piggyback tubing from the zosyn still attached, if that makes sense?). If I remember correctly, the zosyn was the one that was hung before the levaquin, and zosyn and levaquin are not compatible. (So the order was zyvox, NS primary, zosyn, NS primary, levaquin, NS primary). I was wondering if the 10 ml primary was enough to clear the tubing of the medication? Thank you and please let me know your thoughts, I truly appreciate it.

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Specializes in ICU.

I think primary tubing is approximately 30cc worth of fluid, maybe 20-25 but definitely more than 10. When I run flushes I run them at 200-300cc/hr for 30cc, otherwise you spend an hour flushing the line. I am also one of those who uses a back-flush of the primary IVF to clear the secondary tubing whether the drugs are compatible or not, and just use the same tubing. So far I've never had a problem in doing that. Hope that helps! :)

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Thank you for your response. Do you think I should be worried? I don't know, I am just stressed out about this and keep looking up things...It's hard for me to leave work at work but now I feel like--what if I did something wrong :(? Thank you again for responding.

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Specializes in ICU.

I wouldn't worry, usually when meds are incompatible and they mix they will crystallize, and you would have known if that happened. Just flush in between with 30cc from now on. Oh and also (this just occurred to me, and I am no genius when it comes to physics BUT)- wouldn't the flush still have been in between the zosyn and the levaquin? I don't know..maybe I'm overthinking this, lol.

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Yes, you're right, I hadn't thought about that! I did not notice any crystallization, but would it usually happen immediately, and would the patient have a reaction immediately? Levaquin is yellow so would the precipitate be white? I guess I was just worried that there could still be some towards the bottom of the tubing or traces of it in the tubing. Other nurses have told me that if two IV meds are incompatible, as long as you flush the whole line with NS then that is sufficient. I definitely hadn't considered that even when the levaquin starts running, it would still need to push all the saline before it got to the patient. Again, I appreciate your response. I hope it won't always be like this where all I can do is sit in front of my computer and stress out about everything...I just can't help but worry about everything I did or didn't do or how the patient is doing even though a new nurse is taking care of the patient now. I will take your advice and run the flushes at a faster rate and a greater volume from now on!

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Specializes in ICU.

As far as I know, it does happen immediately, however I've never actually seen it happen.

It won't always be like this. Give yourself some breathing room from the job. You had the patient for 12 hours (or 8, or whatever), and now your turn is done...another nurse is taking care of them, like you said. Everyone feels this way especially in the beginning. As your confidence grows, your worries will decrease. Let your time off be your time off! :redbeathe

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Thank you, I truly hope so. I know that someone else is now caring for the patient, I just worry that something will have happened to the patient because of me. It has been hard for me to think of anything else but work, even on my days off because I always think of what I should have done differently. Thank you again for your reply :heartbeat

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Just so you know, medications that are incompatible should never be infused through the same line, even with flushing. In this case I am sure you are fine but for future reference, the technical answer would be to utilize a Y-site IV extension and infuse the incompatible meds separately, start a secondary PIV site for the incompatible med/back-up IV site, or the best answer (should the patient remain on IV meds longer than 7 days) is to recommend a PICC line.

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Our policy at our hospital now is to back prime the primary into the secondary then spike the new bag rather than get new tubing. I guess it is to prevent infection. I'm sure this policy is backed by evidence based research. I usually flush the line with 30ml of the primary before running the next secondary.

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Our policy at our hospital now is to back prime the primary into the secondary then spike the new bag rather than get new tubing. I guess it is to prevent infection. I'm sure this policy is backed by evidence based research. I usually flush the line with 30ml of the primary before running the next secondary.

That comes from the Infusion Nurse Society (INS) 2011 Standards of Practice 43.I.D

"43.I.D., p. S55

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 administration sets."

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someday if you're bored and have some leftovers, throw a little iv dilantin or diazepam in some leftover iv tubing with multivits. niiiiiice crystals. yep, it happens fast. you'd see it. you can sleep easy now.

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