carriers for drips

Surgical Hrt RN · Sep 8, 2005

What is the protocol for hanging a carrier for a cardiac drip that runs at minute amount. ex. dopamine at 1.5ml/hr as example. I work at small hospital not in critical care, but the nurse was asking me when do you start a carrier? Thanks!

Preference would be my answer. I have seen Dopa running by itself at 1.5mcgs. But for me personally, I like carriers, so I usually hang a 0.9 and run it at 10ccs. Also, you may want to check your hospital policy. There may be a policy regarding this. If not, 10cc's is good in my book.

papawjohn · Sep 8, 2005

Hey Avado

I think the issue might be concentration of the drip. I did a quick calculation of a dopa gtt at 1.5ml/hr based on my Hosp's standard concentration (400mg/250ml) for the hypothetical 70kg pt. With that pt and concentration your only giving 0.57 mcg/k/m!!! Why on earth bother?

There's no really good reason that a 'carrier' would be harmful that I can think of but you ARE giving careless people a great opportunity to screw up.

I have seen Nurses ('sposed to be really good nurse--both of 'em) hang an Ancef piggy back onto a Dopa gtt. They were astonished that the pt's blood pressure crashed and quickly increased the rate of the dopa--which made the Ancef go in faster--which then spiked the pt's heart rate when the Ancef finished. One of them even told me--"but I checked and they're compatible".

Never underestimate some people and never increase the complexity of your system if you can help it.

Cynically....

Papaw John

BOY!! Some fast typists here!! I just calculated again and at 1.5mcg/k/m (again--400mg/250ml and pt 70kg) the pump is set at roughly 4cc/hr.

At that point I have two questions. The first is WHY? But assume the Dr ordered it (I dunno--renal perfusion?) so you have no choice. The second question is: does the pump steadily ooze the dopa into the pt or does it 'pulse' the med. If it 'pulses'--the dopa is hitting the bloodstream in discrete little packages a couple of times a minute, which probably the body equilibrates but still seems like bad form. (And my point is?) The addition of a 'carrier' would not HELP if the pump is a steady-state pump cause the blood becomes the 'carrier'. And the 'pulse' pump might be helped a little by having a KVO between pulses.

But you'd still solve all problems by mixing the med yourself. What I'd do is put 100mg/250ml and the pump would have to run 4 times faster without the potential for some fool to hang a piggy back onto the carrier that might not be compatible with dopa. (Of course you'd have a high index of suspicion that someone would replace the bag when empty--with 'full strength' dopa without re-programing the pump.)

Suspiciously...

P-J

avado, BSN · Sep 8, 2005

Hey Avado
I think the issue might be concentration of the drip. I did a quick calculation of a dopa gtt at 1.5ml/hr based on my Hosp's standard concentration (400mg/250ml) for the hypothetical 70kg pt. With that pt and concentration your only giving 0.57 mcg/k/m!!! Why on earth bother?
There's no really good reason that a 'carrier' would be harmful that I can think of but you ARE giving careless people a great opportunity to screw up.
I have seen Nurses ('sposed to be really good nurse--both of 'em) hang an Ancef piggy back onto a Dopa gtt. They were astonished that the pt's blood pressure crashed and quickly increased the rate of the dopa--which made the Ancef go in faster--which then spiked the pt's heart rate when the Ancef finished. One of them even told me--"but I checked and they're compatible".
Never underestimate some people and never increase the complexity of your system if you can help it.
Cynically....
Papaw John

Yes, dr wanted started at .5mcg/kg/min. then titrate every 30 minutes with that dosage for target bp. yes we are at a small hospital, I did not give her an answer because i did not know, since i am not icu nurse. I just wanted to know for my knowledge. I have seen a 3cc/hr drip back flow with blood and was wondering when to add a carrier for small drips like that. I have been curious when i saw that and this reminded to ask someone from a big institution with standard protocols.

hrtprncss · Sep 8, 2005

.5mg/kg/min is not a right dose. 0.5 mcg/kg/min would not suffice as a start up point for bp control, maybe 5mcg/kg/min. but i agree with carriers...unless you know no one is going to be hanging a piggyback on that mainline where u rider ur dopamine then go ahead, but alot of people use a carrier with low start rate then all of a suddens use that main line with the dopamine ridered to piggy back an antibiotic, leading to a bolus of dopamine that's already in the line....i'd keep it alone or only with other pressors.

hrtprncss · Sep 8, 2005

sorry i misread that, i mean 0.5mcg/kg/min not 0.5mg/kg/min, though that's still a very low dose even if it is for the ''supposed'' renal dose

SnowymtnRN · Sep 8, 2005

Greetings, think I'd like to weigh in here. Carriers for inotropic, vasoactive drugs are a bit excessive and prone to accidents. If a person is on say levophed and vasopressin and "carrier" mechanisms were of concern one could mix these drug in larger volumes of fluid. For example, levophed could be mixed 4mg in 250cc. The rate could be very high. Vasopressin, could be mixed 100u in 500cc normal saline, think this works out to 12 cc/hr for the typical septic shock dose rate. Dopamine, however, is the work of the devil and should just go away. Finally, if your pumps are setup/programmed with "gaurdian" or "gaurdrail" software USE IT!!. I can tell you that on more than a few occassions I have found vasoactive drips to be terribly wrong, killing patients as I was getting report and watching monitors. In ALL of these cases the nurse declined to use preprogrammed safety software allready built into the pump. As a side bar, I like to divide my TLC/CVC access in these pt according to purpose rather than compatability. I like all sedation and paralytic on one pump, inotrops and vasopressors on one pump and carriers for abt's, and insulin drips on one pump. Very easy to organize for I&O and harder to screw up.

Surgical Hrt RN · Sep 8, 2005

greetings, think i'd like to weigh in here. carriers for inotropic, vasoactive drugs are a bit excessive and prone to accidents. if a person is on say levophed and vasopressin and "carrier" mechanisms were of concern one could mix these drug in larger volumes of fluid. for example, levophed could be mixed 4mg in 250cc. the rate could be very high. vasopressin, could be mixed 100u in 500cc normal saline, think this works out to 12 cc/hr for the typical septic shock dose rate. dopamine, however, is the work of the devil and should just go away. finally, if your pumps are setup/programmed with "gaurdian" or "gaurdrail" software use it!!. i can tell you that on more than a few occassions i have found vasoactive drips to be terribly wrong, killing patients as i was getting report and watching monitors. in all of these cases the nurse declined to use preprogrammed safety software allready built into the pump. as a side bar, i like to divide my tlc/cvc access in these pt according to purpose rather than compatability. i like all sedation and paralytic on one pump, inotrops and vasopressors on one pump and carriers for abt's, and insulin drips on one pump. very easy to organize for i&o and harder to screw up.

i agree with some of what you say here. however, a carrier is just there to help keep the line patent. when a doc orders a kvo rate isn't it usually at like 20 - 40 cc's? the 10cc's does not affect the rate of the drip of the amount delivered. it is not fast enough. however, when recovering open hearts, we always use a carrier of 0.9 at 20cc's. this rate, at least in my experience, and with a labile patient can make all the difference.

Surgical Hrt RN · Sep 8, 2005

hey avado
i think the issue might be concentration of the drip. i did a quick calculation of a dopa gtt at 1.5ml/hr based on my hosp's standard concentration (400mg/250ml) for the hypothetical 70kg pt. with that pt and concentration your only giving 0.57 mcg/k/m!!! why on earth bother?
there's no really good reason that a 'carrier' would be harmful that i can think of but you are giving careless people a great opportunity to screw up.
i have seen nurses ('sposed to be really good nurse--both of 'em) hang an ancef piggy back onto a dopa gtt. they were astonished that the pt's blood pressure crashed and quickly increased the rate of the dopa--which made the ancef go in faster--which then spiked the pt's heart rate when the ancef finished. one of them even told me--"but i checked and they're compatible".
never underestimate some people and never increase the complexity of your system if you can help it.
cynically....
papaw john
boy!! some fast typists here!! i just calculated again and at 1.5mcg/k/m (again--400mg/250ml and pt 70kg) the pump is set at roughly 4cc/hr.
at that point i have two questions. the first is why? but assume the dr ordered it (i dunno--renal perfusion?) so you have no choice. the second question is: does the pump steadily ooze the dopa into the pt or does it 'pulse' the med. if it 'pulses'--the dopa is hitting the bloodstream in discrete little packages a couple of times a minute, which probably the body equilibrates but still seems like bad form. (and my point is?) the addition of a 'carrier' would not help if the pump is a steady-state pump cause the blood becomes the 'carrier'. and the 'pulse' pump might be helped a little by having a kvo between pulses.
but you'd still solve all problems by mixing the med yourself. what i'd do is put 100mg/250ml and the pump would have to run 4 times faster without the potential for some fool to hang a piggy back onto the carrier that might not be compatible with dopa. (of course you'd have a high index of suspicion that someone would replace the bag when empty--with 'full strength' dopa without re-programing the pump.)
suspiciously...
p-j

papaw,

man are you right! i can't tell ya how many times i have seen piggybacks hanging with drips! yikes!!!!! people just need to be really careful where drips are concerned, and you certainly said a mouthful when you said don't assume they know anything, just cause they have been a nurse for x number of years!