Standard concentrations and frequency of infusate changes

Specialties PICU

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Specializes in NICU, PICU, PCVICU and peds oncology.

This may seem like a rather odd set of questions, but bear with me.

1) Do you prepare your drug infusions or does pharmacy prepare them for you? If pharmacy prepares them for you, you may or may not have responses for the remaining questions.

2) If you prepare your own, how often do you change the bag or syringe containing your infusions?

3) If you prepare your own, do you have a variety of "standard" concentrations to choose from, based on the size of your patient?

4) If you prepare your own, do you prepare a fixed amount of fluid and then decant what you'll need for the hang time of that infusion into a smaller syringe, discarding the rest?

5) Do you use heparin in your pressure lines?

6) Do you use dextrose-containing solutions for your CVP and/or LAP monitoring lines?

7) Do you run your pressure lines on pumps, and if so, which type - volumetric or syringe?

8) How often do you change the flush solution you're using for these pressure lines?

9) What would you say your CRBSI rate is?

We've just moved to the use of standard concentrations for our infusions. But we have as many as six different "standard" concentrations for some drugs, based on the patient's size. For our smaller patients we can expect even the most dilute concentration to run at a very low rate, and therefore for accuracy we're using the smallest syringe that will hold the volume we'll need for the hang time of the drug - for RN-prepared meds it's only 24 hours where it used to be 72 hours before we made this change. But we're expected to mix up 50 or 100 mL of a solution then decant the amount needed for 24 hours into that smaller syringe. The reason for this we're told is that because we mixed it and not pharmacy or a factory, we might have contaminated the solution in the preparation.

Nothing has been said about stability and in fact, if pharmacy prepares it, we can let it hang for 48 hours, while commercially-prepared solutions can hang for 96 hours. We get virtually nothing prepared by pharmacy other than TPN, immunosuppressants and unit doses of some antibiotics. The only commercially-prepared infusions we have are some antibiotics (Cipro, Flagyl), dopamine and heparin in dextrose 100 units/mL. Where we used to waste hundreds of thousands of dollars' worth of drugs and supplies annually, we'll now be wasting millions.

We still use heparin in our pressure lines, 1-2 units per mL NS (500 mL prepared) for art lines and either 1 unit per mL D5W or D10W (500 mL prepared) depending on the patient's size. This we prepare at the bedside and are now being required to change the bag q24h on the off chance it may have been contaminated when we mixed it. We run our patients

We were just congratulated on going more than 66 days without a CRBSI - we've been following this new practice for only 48 days. These changes have greatly added to our workload, having first to look up what the variations of "standard" exist for our infusions, choosing the most appropriate one for the patient, looking up the recipe, mixing up the "standard" volume then decanting into the desired size syringe, documenting everything and then hanging the new infusions. When you've got a bunch of drugs infusing in the same lumen as your epinephrine and you've got to change every one of them every day... If we were running everything on a volumetric pump where it was just swapping out the bag, like they do with adults, no harm no foul. But we are required to run anything with vasoactive properties plus anything driving it on syringe pumps. No quick swaps there. I think we're just asking for trouble. Thoughts?

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1. This depends. Most vasoactive medications we prepare the initial bag/syringe. Replacement bags/syringes are prepared by the pharmacy.

2. Bags/syringes that are prepared on the unit expire 12 hours after preparation.

3. Yes. For most of our infusions two concentration based on weight. Syringe size is determined by patient weight.

4. Yes.

5. Yes, except ECMO.

6. No.

7. Yes, for patients less than 15 kg. Volumetric.

8. 96 hours.

9. I'm not sure what our rate is based upon CRBSI/1000 days, however it seems that we go ~4 months between occurrences.

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Hello Jan

1. We prepare the first syringes when the patient is admitted. Next day pharmacy prepares all syringes and bags.

2. We change the bag or syringe every 24 hours unless it has a special time limit.

3. We have standard concentrations for our patients. Pharmacy is refining each year.

We use the same size syringe for all infusions to match the concentrations.

We use prepared bags e.g. dopamine but it all depends on their weights.

4. Never decant

5. Heparin in all lines.

6. Yes to dextrose. Sometimes saline/heparin with cvp

7. all pressure lines on syringe pumps

8. all flush solutions changed every 24 hours.

I totally understand changing vasoactives daily when it is a syringe verses a bag. I double pump or I set up another pump and line and switch out close to the patient.

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Specializes in NICU, PICU, PCVICU and peds oncology.

Thanks for the comments. Hopefully I'll hear from a few more people before I go to our CNS with a list of common practices.

I forgot to mention that once we've decided which of the as many as SIX possible concentrations we're going to use, we then fill out a label with the drug name and chosen concentration, stick it to the order sheet and scan the orders to the pharmacy. They're supposedly making a list of the most often used concentrations for each of our thousand and one infusions so that "someday" they'll be mixing them for us. I'll believe it when I see it because there are a lot of times when the antibiotics they're supposed to send up to us as unit doses don't arrive.

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Specializes in NICU, PICU, PCVICU and peds oncology.

Our CNS actually attached that reference to the email telling us to change our pressure line BAGS daily and the transducer/tubing q96h. I don't think it had been read the GH because I read and dissected it then emailed her about the contradictions.

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Specializes in ICU, APHERESIS, IV THERAPY, ONCOLOGY, BC.

Great discussion. I have worked in IV therapy and was a member with INS ( Intravenoous Nursing Society, MA) at that time. We followed INS and CDC guidelines re. all iv lines, bage, central and perifieral lines. I understand that nurses are expected to add drugs to perfusions, especially in critical care settings.

Is every one using a laminar flow hood for admixtures or another method for adding meds? Pharmacy prepared meds tend to reduce risk of contamination / infection, however there are other aspects, such as line changes, the distance of line vs insertion site and the integrity of the site. Are routine resites still practiced on short term ivt pateints or is the tendency to use PICC lines more popular, especailly as this is a nursing approved intervention following an appropriate training and demonstrated skill in practice.

Critical care units are especially challenged with rapidly changing rx when supporting cardiac outputs, pressures, and septic shock.

I found INS to be very helpful with on going ed.and policies. re. infuson policies and advice

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How right you are about pharmacy prepared infusions verses made in critical care.

Reduce risk of contamination especially if the pharmacy complies with chapter 797.

Not to mention all the interruptions the critical care nurse experiences.

Our manager has a membership in INS. We follow the line changes noted in the CDC guidelines. We do not practise re-sites. We now use much more picc's plus cvl's.

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1) Do you prepare your drug infusions or does pharmacy prepare them for you? If pharmacy prepares them for you, you may or may not have responses for the remaining questions.

Pharmacy prepares all our infusions.

2) If you prepare your own, how often do you change the bag or syringe containing your infusions?

(We drew up our own epinephrine from a bag to syringes once and the pharmacist told us that med would only be good for 1 hour...though if we had hung the bag it would be good for 24h.)

3) If you prepare your own, do you have a variety of "standard" concentrations to choose from, based on the size of your patient?

THough we don't prepare our own, the MDs utilize standard concentrations (A through E) when ordering based on the patient's size.

4) If you prepare your own, do you prepare a fixed amount of fluid and then decant what you'll need for the hang time of that infusion into a smaller syringe, discarding the rest?

n/a, this seems like poor practice to me though as you will be entering the vessel storing the extra med more than once...

5) Do you use heparin in your pressure lines?

yes, almost all the time

6) Do you use dextrose-containing solutions for your CVP and/or LAP monitoring lines?

not usually

7) Do you run your pressure lines on pumps, and if so, which type - volumetric or syringe?

pumps for patients under 10kg; and i'm not sure of which kind of pump as I have not actually had the less than 10kg patient with pressurized lines.

8) How often do you change the flush solution you're using for these pressure lines?

q24h; tubings q96h

9) What would you say your CRBSI rate is?

quite low, i think it's been at least 6 months. We also utilize CHG-impregnated dressings over our central venous and art lines (for patients over 2 months of age) and use curos green caps on all central lines.

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Specializes in NICU, PICU, PCVICU and peds oncology.

3) If you prepare your own, do you have a variety of "standard" concentrations to choose from, based on the size of your patient?

THough we don't prepare our own, the MDs utilize standard concentrations (A through E) when ordering based on the patient's size.

We're still fumbling around with this. Some drugs we have only 2 possible choices and others we have 6. The only way to know what the choices are is to pull up the spreadsheet with all of our infusions listed, put in the patient's weight and the desired dose and write down the choices. Then we go to another application to find the recipe and a weight-based rate chart. It's very labour-intensive and our physicians aren't going to know any of this because they view it as the nurse's job. They just write a dose and we do the rest.

4) If you prepare your own, do you prepare a fixed amount of fluid and then decant what you'll need for the hang time of that infusion into a smaller syringe, discarding the rest?

n/a, this seems like poor practice to me though as you will be entering the vessel storing the extra med more than once...

Actually we only enter the vessel once. We throw the rest of the admixture away along with the syringe it was mixed in.

8) How often do you change the flush solution you're using for these pressure lines?

q24h; tubings q96h

Are you mixing up 500 mL bags for this?

9) What would you say your CRBSI rate is?

quite low, i think it's been at least 6 months. We also utilize CHG-impregnated dressings over our central venous and art lines (for patients over 2 months of age) and use curos green caps on all central lines.

We've been told NOT to use Biopatches on any of our lines except femoral arterial lines. But in practice we just don't use them at all. I can't remember the last time I saw one on a line. Oh wait... we admitted an oncology patient from the ward who had one at the exit site of his Broviac. Our dressings are Tegaderm IV (unmedicated) and we use white or red plastic dead enders on our ports. I would love it if we were using Curos or Swab caps. We're already wasting millions of dollars' worth of drugs and supplies, why not spend just a little more and protect the ports?

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Replying from my phone-thanks for clarifying about the bigger solutions being drawn into syringes, that makes more sense. Our pharmacy would still say no way to us doing it ourselves though as I understand that's how it used to be done, many moons ago.

As far as the standard concentrations go, the docs do it. We can ask them to change it but typically if the rates seem wacky pharmacy will call them and have it fixed on their own.

Our heparinized pressure bags are 250units/500ml.

We only use biopatches around port needles-the dressings I'm referring to are these: http://www.3m.com/product/information/Tegaderm-CHG-IV-Dressing.html

We also do daily bathing with chg wipes for all patients (central line or not) over 2 months of age.

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Also--I will check our CLABSI rate when I get to work tonight.

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