Clinical Question: Continuous PCA Infusions w/ XYZ Drip

[CCNP-FL]

Greetings!

One of the senior nurses I work with today spoke to me about my decision to continue a continuous fentanyl infusion with the KVO fluids as Levophed and Vasopressin. I look-up to her and rarely disagree with a senior nurse about a clinical issue. However,

Vasopressin and Levophed are both compatible with fentanyl. The Levophed and Vasopressin were being used continuously throughout the shift and had been on for at least three days. Fentanyl was being used for adjunctive sedation. I have used Versed drips in the past for the KVO for a fentanyl infusion.

Here is how I take it: The patient was receiving compatible fluids through the line. The patient was on severe fluid restrictions despite his hypotension. I did not think that it was necessary to start an NS or LR KVO at 10-50ml/hr when I had a perfectly good source of 20-30ml/hr of a Levophed and Vasopressin drip going. In all honestly, I often use sedation or cardiac drips for KVO fluids to infuse with the continuous PCA so I can use the maintenance fluids for infusions of piggyback antibiotics.

I will speak to the CCU pharmacist about this, but to me I do not see how either of us are in the wrong. I suppose out of an abundance of caution she is right. I contend that what we both do is acceptable. Thoughts? Guidance?

Thanks!

[Nalon1 RN/EMT-P, BSN, RN]

What was the issue raised by the other nurse, just that you should be using NS/D5 for the KVO?

Technically you are using NS or D5 as you KVO since vasopressin and levophed are mixed with NS or D5, as is your fentanyl.

While I am not a "senior" nurse, I do it all the time, and have seen many experienced nurses do it also.

What I do see as a potential problem is if all 3 of these drips are y'ed in together. You can end of with 2-3 feet of tubing with a mix of meds in it. If you stop one it may take a few minutes to completely get it out of the tubing if it is the 3rd one on the line.

If your using a manifold at the hub so all 3 are not mixing till right before they enter the hub, no a problem. A manifold also allows you to add a KVO fluid easily if you stop one of the infusions.

[musingmom]

In my facility, we would not use a continuous PCA, we would just have a fentanyl drip. For titratable drips, our protocol is to use low sorb tubing that does not have y connection and use a manifold.

I only point this out to illustrate that there are several "correct" ways to deliver these drips.

The answer for you would lie in whatever protocol your facility has set up for the PCA fluids. Ours has to be with NS, but we only use it for patient delivered doses, so it doesn't really compare to your situation.

[AliceTrout]

The only real problem I see is that your method is imprecise, particularly if you are trying to titrate one (or more) of those drips/PCA. I used to do the same thing more often, but have since learned that precise control of the things I titrate is worth the hassle of adding in a KVO.

Assuming you are running a maintenance fluid as well, you can (should) always subtract your KVO volumes from that (assuming they are the same fluid) so that your patient is still getting the exact prescribed amount of fluid and uncompromised accuracy in your drips.

[CCNP-FL]

I was looking for the, "how could this affect the patient" part of the answer from my mentoring nurse. The possibility of imprecise titration and delay of changes of drug dosing seems to be the most reasonable answer that I draw from these posts. I should clarify that these are continuous fentanyl infusions utilizing a PCA pump. My hospital requires a KVO of at least 42cc/hr per protocol, but in ICU we inadvertently make up our own rules without meaning to -- myself included (ie. this situation). Thanks for the opinions. I will take this and run with the titration delay issue as the clinical pearl.

Much appreciated! Thanks!

[dexm]

What was the rate of the fentanyl?

[CCNP-FL]

This is what I had setup:

50mcg Fentanyl (1ml/hr) going with Vasopressin 0.04 units/min (6ml/hr) and Levophed titrated from 10-30mcg/min (variable).

[Mavrick, BSN, RN]

Ah, so the Levophed was titrateable. Thus if you changed from 10mcg/min to 20mcg/min, doubling the rate of the Levophed would also double the rate of anything in line with it until the part of the line with the original concentrations has infused. Considering you are only infusing 1ml/hr of Fentanyl, a very small rate change will dramatically affect the amount of Fentanyl delivered, thus sacrificing precise control.

On review, sounds like you already got it. Never mind.

[dah doh, BSN, RN]

42cc/hr as a KVO? Wow! That is super precise! We do 10-30cc/hr at my facility. As to the original topic: yes we use a manifold, stopcocks, or 3 port adapter for compatible gtts. Did you check with your facility's policy or with the pharmacy?

[VANurse2010]

I don't think it matters enough (if at all) to make a clinical difference. I prefer to pair my drip types on each lumen - i.e. sedation together, pressors together, maintenance w/piggbacks etc.

[MendedHeart]

Ah, so the Levophed was titrateable. Thus if you changed from 10mcg/min to 20mcg/min, doubling the rate of the Levophed would also double the rate of anything in line with it until the part of the line with the original concentrations has infused. Considering you are only infusing 1ml/hr of Fentanyl, a very small rate change will dramatically affect the amount of Fentanyl delivered, thus sacrificing precise control.

On review, sounds like you already got it. Never mind.

I think this may depend on pumps. We use "Smart pumps". One pump per infusion and even if something is Y'ed together with something faster, it Will still infuse at the correct rate.