Chaining Stopcocks instead of Y-Siting Multiple Lines?

[BiscuitStripes, BSN, RN]

I'm new to the ICU, switched from the ED.  On another message board, I read from an ICU nurse that he/she uses several stopcocks chained together, with one end connected to the central line, the back end to TKO fluid, and the side ports for all of their lines so it stays more organized instead of Y-siting everything together. 

I thought this sounded like a really good idea.  I then learned that there are even commercial devices that do this same thing.  I then started in my ICU and we do not have the commercial device. I asked my preceptor and she said no one uses stopcocks, everyone Y-sites everything.  I asked a friend at a different ICU how they do it and he said the same thing, just Y site it. .  

So, I was wondering if anyone else does this with stopcocks or the commercial device?  I hate when a med gets d/c'd and it's the third, fourth, fifth, etc. down the Y-site chain and you have to disassemble everything to get to it.  Plus it tends to get tangled very easily.  Yet since my preceptor said she doesn't do stopcocks and doesn't know anyone else who does, and I'm new to the ICU, I don't want people to think what am I doing if I did it once I'm off orientation?? 

Thoughts? Insight is appreciated! 

I found some pictures to demonstrate what I'm talking about.  One is with stopcocks, the other a commercial device. 

[MunoRN, RN]

The serial Y-siting set-up is a really bad way to set-up multiple infusions.  That leaves large volumes of various medications in the flow paths of other medications, which means that when you start one medication that is Y-sited farther back up the series of connections you're going to be pushing other medications in front of it, and when you stop an infusion at the pump it will continue to infuse for a period time, pushed by other infusing medications.

A manifold with one-way valves is ideal, they provide the smallest dwell volume between the infusions, and prevent medications from finding their way upstream in other infusions that are stopped.  A manifold is essentially a series of 3-way stopcocks put together.

An alternative to a manifold are the short extension splitters, these can combine as many as 9 ports to one attachment, or you can 'daisy chain' multiple smaller splitters.  These have the basic problem as Y-siting multiple infusions off of each other, but with much smaller dwell volumes in the shared fluid flow.  

[Rose_Queen, BSN, MSN, RN]

Part of that second photo looks like what we use in our critical patient drips in the OR- a pre-manufactured manifold with 3 stopcocks, each with a port for a line to connect. It just looks like they put two of them together.

[adventure_rn, MSN, NP]

I think that manifolds (the pre-made multi-stopcocks) make the most sense in practice. All of my ICUs (NICU and PICU) have y-sited, and it can get really confusing really quickly.

That said, I would not go rouge and start making DIY stopcock manifolds yourself. The unit practice is to use y-sites, and if people start using different practices (especially practices they haven't been trained on), there's a higher risk for error. IMO, there's probably also a higher risk for central line infection if you're stringing a bunch of stopcocks together rather than using a pre-made manifold, since each connection point between stopcocks poses a risk for bacterial entry (vs. a manifold, which is a single, plastic closed system).

I could see you getting in trouble if you were to just start doing this, since it isn't in line with the unit policy/practice. The experienced people on the unit might also take offense if they think you're telling them that your way is superior to the way they've always done things (regardless of whether or not it is).

If you really feel strongly about it, your best option is to bring it up to your unit leadership or practice committee. That said, it will probably take months to get it changed, if you can get support for it at all. Product supply chain changes can be difficult to enact, especially if the product is going to be more expensive than what they were previously using. 

For what it's worth, I never remove my drips from my y-sites even after they've been discontinued. I simply turn off the pump and clamp the line at the y-port, then stick a note on the pump saying it's clamped. That way you have a smaller risk of infection with a lower risk that you'll accidentally bolus something in the process of disconnecting the line, and the drip is still readily available if it turns out you need to turn it on again. Granted, that's always been my unit practice/policy.

[BiscuitStripes, BSN, RN]

6 minutes ago, adventure_rn said:

I think that manifolds (the pre-made multi-stopcocks) make the most sense in practice. All of my ICUs (NICU and PICU) have y-sited, and it can get really confusing really quickly.

That said, I would not go rouge and start making DIY stopcock manifolds yourself. The unit practice is to use y-sites, and if people start using different practices (especially practices they haven't been trained on), there's a higher risk for error. IMO, there's probably also a higher risk for central line infection if you're stringing a bunch of stopcocks together rather than using a pre-made manifold, since each connection point between stopcocks poses a risk for bacterial entry (vs. a manifold, which is a single, plastic closed system).

I could see you getting in trouble if you were to just start doing this, since it isn't in line with the unit policy/practice. The experienced people on the unit might also take offense if they think you're telling them that your way is superior to the way they've always done things (regardless of whether or not it is).

If you really feel strongly about it, your best option is to bring it up to your unit leadership or practice committee. That said, it will probably take months to get it changed, if you can get support for it at all. Product supply chain changes can be difficult to enact, especially if the product is going to be more expensive than what they were previously using. 

For what it's worth, I never remove my drips from my y-sites even after they've been discontinued. I simply turn off the pump and clamp the line at the y-port, then stick a note on the pump saying it's clamped. That way you have a smaller risk of infection with a lower risk that you'll accidentally bolus something in the process of disconnecting the line, and the drip is still readily available if it turns out you need to turn it on again. Granted, that's always been my unit practice/policy.

That’s very insightful thank you!

[adventure_rn, MSN, NP]

1 minute ago, BiscuitStripes said:

That’s very insightful thank you!

I appreciate that. You make a lot of great points, and it's clear that you've given this a lot of thought. It would be awesome if you could create a practice change on your unit (like I said, I think that the manifolds make a ton of sense.) Unfortunately, as you probably know, sometimes in healthcare the policy simply doesn't align with what makes the most sense. ?

[JBMmom, MSN, NP]

18 hours ago, BiscuitStripes said:

I found some pictures to demonstrate what I'm talking about.  One is with stopcocks, the other a commercial device. 

Thank you for posting that! I have only worked in my current ICU and everyone Y sites everything and then labels the tubing between Y sites. I do use a stopcock when propofol is being infused with compatible meds. Since propofol tubing needs to be changed every 12 hours I hate it when people make it the last y-site med because then it's infusing through every downstream tubing for more than 12 hours. And if the propofol is the first one, everything needs to be paused and disconnected to change the tubing. 

I will definitely be bringing your picture/device to the attention of my management. Although we recently had a traveler who came in and spent literally hours setting up serial stopcocks for all the drips. Twelve hours later day shift had discarded all of that and gone right back to the Y-site chain. Clearly there's a unit practice component as well. Thank you for sharing. 

[MunoRN, RN]

As an example of what's problematic about the 'daisy-chain' Y-site set up, there's about 3mls between the most distal Y-site and the end of the tubing in common infusion sets.

Let's say you started with Levo and Vaso, one Y-sited into the other, then the patient needed K and Mag replacement so the K was attached to the Y-site of the Levo, and the Mag to the Y-site of the K.  Then later milrinone was added and attached to the Y-site of the mag, the Vaso, Levo, K, and Mag are all currently stopped.

Milrinone typically runs at around 3-6mls/hr, and there are 4 sections of 3mls volume between the tip of the milrinone tubing and the IV port.   That means that at 3mls/hr it will take more than 4 hours for the milrinone to actually get to the patient once the infusion is started.  Even worse, lets say you get a mag level back and they need replacement, so you start the Mag up again and it's at 50ml/hr, this will then push the 12mls of milrinone ahead of it at 50mls/hr, bolusing the patient with 4 hours worth of milrinone in about 15 minutes.   

[BiscuitStripes, BSN, RN]

16 hours ago, MunoRN said:

As an example of what's problematic about the 'daisy-chain' Y-site set up, there's about 3mls between the most distal Y-site and the end of the tubing in common infusion sets.

Let's say you started with Levo and Vaso, one Y-sited into the other, then the patient needed K and Mag replacement so the K was attached to the Y-site of the Levo, and the Mag to the Y-site of the K.  Then later milrinone was added and attached to the Y-site of the mag, the Vaso, Levo, K, and Mag are all currently stopped.

Milrinone typically runs at around 3-6mls/hr, and there are 4 sections of 3mls volume between the tip of the milrinone tubing and the IV port.   That means that at 3mls/hr it will take more than 4 hours for the milrinone to actually get to the patient once the infusion is started.  Even worse, lets say you get a mag level back and they need replacement, so you start the Mag up again and it's at 50ml/hr, this will then push the 12mls of milrinone ahead of it at 50mls/hr, bolusing the patient with 4 hours worth of milrinone in about 15 minutes.   

That break down helps a lot, thank you!

[frozenmedic]

As Muno and others have explained well the serial Y sites are definitely not ideal.  However, if this is the situation you find yourself in (I worked in an ICU that did not allow manifolds for foolish reasons) best practice is to attempt to connect your (compatible) infusions from fastest to slowest. 

For example- infusion A running at 25mls/hr goes directly from pump to patient, then infusion B running at 15mls/hr is Y-sited into A, and infusion C at 6mls/hr is Y-sited into B.  This way, your super slow infusion is gradually mixed with the faster ones and arrives to the patient in a reasonable amount of time.  You also prevent the danger of bolusing many hours of a medication (like milrinone) that have a very slow infusion rate.

Obviously if you're titrating multiple meds this gets more complicated as their rates may vary, but you'll get a sense of general ranges with the concentrations used at your facility.  Milrinone tends to be very slow, vasopressin generally 3-12mls/hr etc. 

You can also group meds by type- for example all (compatible) pressors on one port, all ionotropes on another, all electrolytes on another. Even if you have the fastest-to-slowest order wrong, you're generally titrating pressors etc at modest differences in rates, so these changes hold less risk of a dangerous inadvertent bolus. On the other hand, if you electrolytes are together and you start say, a K-rider to your mag infusion, even if it's faster that 4-20ml bolus of Mag is not a big deal.

Use a combination of these strategies as best suits your patients anticipated infusions and access ports.

[SquatsNScrubs, BSN, RN]

The CVICU I work PRN at uses the first device you posted a pic of (we call it a “river”) and they are wonderful for our post-op open hearts that come out of the OR needing epi, levo, precedex, fluid boluses, etc. We use the Alaris pumps so every med has its own channel, which is also nice. 

The Covid ICU I am on a travel assignment at unfortunately does not use them. We Y-site infusions together like you mentioned. We use Plum pumps which can run 2 meds concurrently, so I try to program my pressors together, sedation together, and have a KVO line going for antibiotics, electrolyte replacement, etc. The pumps stay outside of the pt rooms so we use extension tubing for everything, which makes it even trickier sometimes...ugh! 

Always always have your lines labeled so you know what is going where. What kind of infusion pumps does your facility use? 

[zoidberg, BSN, RN]

I couldn’t live without manifolds. If I walk into my patients room and things are y-ED together then it is now tubing change day and I get new everything and start over. cant stand the IV spaghetti.