Concurrent meds/interactions?

iluvivt, BSN, RN · Jun 21, 2014

I am not certain what you mean by opinions versus professional judgments so I will just stick with what is considered an acceptable standard.

No it is NOT always better to have as few medications as possible in one port,one peripheral site or one lumen of a VAD to use your words. There are many times though that this is not only ideal but mandatory due to incompatibility issues,titration issue,rate issues or drug issues and even sometimes because it is just better to set it it up that way and I can give an example later. The trend in IV therapy has swung towards venous preservation so much so that even routine site rotation is no longer recommended and a change of a PIV site is now based on assessment. So if it set up so that the IVFs and medications that you have as a secondary piggyback are compatible with the primary IV you should set it up that way. I am referring here to all types of incompatibility (physical, chemical and therapeutic). You must verify drug compatibility prior to co-administration and be aware that you may not always get a sign in the form of a precipitate or other change to alert you after the fact for that would only cover the physical incompatibility! Compatibility is not just based on the function of drugs or IV solutions, for example temperature and concentration can also have an effect as well as other factors. So use the vein and only secure another access if you need it. This also aligns well with infection control practices since another PIV (that is not needed) is another entrance through the your largest protective organ (the skin) and is another source for infection with additional a break into the skin and more ports and access into the body.

There are also times when you just have too many things going and it just makes sense to secure another line even if all the six things or whatever you are giving are compatible.Let me give an examples where you may need to secure another PIV.

1. You have a heparin drip and then have 1 liter of D5 1/2 N with 20 meq KCL at 125ml per hour, Cefazolin q 8 hours, an MS PCA, Zofran IV prn and some IV push Protonix. (how would you set this up assuming you can only use peripherals?)

2. You have a Dopamine drip that must be given peripherally until the PICC line is placed. You also have Vancomycin IV, a Protonix drip, IV push Dilaudid and IV Methyprednisolone dose you need to administer over one hour. Then the provider comes on and orders 2 units of blood. You only have peripherals for now what would you do and how would you set this up and why?

3 You have 1/2 NS infusing at 75 ml per hour and the provider has now ordered some IV Amphotericin. What do you need to do in this situation.

As far as your second question I think this is what you are asking even though he wording is a bit confusing. Many times you will have to push a medication that is incompatible with either the primary IVF or a medication that has been added to it such as penicillin an electrolyte or a vitamin or mineral. In that case YES you can stop the infusion..flush with a compatible flush (usually NS)..administer your medication at the correct rate then administer your flush (depending upon the point of access into the line you may need to administer the last flush at the same rate in which you administered the medication ..do you understand why this is so?)..You also need to think ahead when you are starting the IVs and add a double micro or triple extension set at the cannula site (with devices such as introcan and insytes) the intima is already designed with a Y-site port near the cannula but even then you can still add an extension set to that too. If you are administering at the double or triple micro set that is going directly into the cannula there is a miniscule amount of mixing. I still prefer to put my primary on hold anyway but many times you cannot hold some medications such as vasopressors for even that short time since the pt may be so labile. Be aware that there are some medications that need a D5W flush and not an NS flush!

You can also set up two incompatible drips or primary through one PIV or port but use a double micro set that is attached at the cannula or directly at the port.

I hope this clarified it a bit. I would also urge you to administer any vesicant or irritant or anything with a Ph of less than 5 or greater than 9 or those with greater than

500 mOsm through a central line if you have one. I see this a lot..they have a CVC and they are giving the dopamine peripherally and the heparin in the CVC....do you want to rethink that. This just shows you how confusing it can be and how much you really need to do to set it up the best way. Nurses do this..... the providers just order it and you then figure it out!