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Discussion

D25 infusion through a UAC

Hello! I have a question for all you, NICU nurses. I am pretty new to this. I work in special care nursery. The other night I had a 38 week severe IUGR baby with blood sugars in the 30s-40s beyond 60 hours of life. When I got the patient, she had TPN with D20 running through her UAC and IL running through her periferal IV. UVC placement had been unsuccessful. The baby was also starting on po feeds with breastmilk/formula 15 cc q 3 hours. So, the sugars were still low, the doc decided to discontinue TPN and lipids, start infusing D25, and continuous NG feeds. The veteran nurse who had given me report mentioned that D20 was a max (?), and we should not be going any higher than that. Then the doc did a whole bunch of labs to check insulin, GH, thyroid panel, cortisole levels. Then she ordered hydrocotisone IV. Then she decided to transfer the patient to a higher level hospital with an endocrinologist.

Sometimes I get a feeling that our doctors do not really know what they are doing. We have an educator who is not a NICU nurse. A lot of the policies in our institution are not in place. Nurses that work with me all have different opinions of what to do. I am so frustrated! I have read that nothing should be infused in UAC except for 1/2 NS with heparin and certain additives. I would like to know what other NICUs are doing and if there are any studies on the safety of high concentration dextrose infusion into UAC. Please, help!!!:***:

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    • Featured Replies

    We would not infuse D25 thru a UAC. If they couldn't get a line in the kid, either UVC or a PICC then the baby should have been transferred. Severe IUGR kids have a lot of blood sugar issues. We also would not have been feeding the baby if the glucose was only in the 30's on D20, especially after 60 hours.

    You guys have to sit down and make some policies. If you ever got called to court on this infant you are sunk.

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    • Author

    Do you have a policy for that or is it just something common knowledge?

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    Common knowledge is worthless in court. If it's not a documented policy, you're inevitably going to end up in a bind.

    I feel for you. My unit is also running with barebones p&p. Im trying desperately to get out.

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    We have a whole chart on what can and can't be given thru what line. Our pharmacy made it for our med guidelines.

    Believe me, I have sat on several court cases and they go thru your p/p with a fine tooth comb.

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    • Author

    Thanks! I did call the Pharmacist and asked him if it was OK to infuse D25 through UAC. His answer was, "I am not sure." I ended up talking to my clinical supervisor, who is not a NICU nurse, who called to ask our manager, who is not a NICU nurse, who said it was OK. I am definitely talking to her about setting policies in place. Meanwhile, I am looking for another job.

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    The problem with infusing dextrose in an arterial line is that it's harder to get an accurate sugar off of it, even when you're drawing up waste plus I've been told by our docs that the dextrose in arterial lines tends to make them go bad (stop working) quicker for whatever reason.

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    • Expert

    Our policy is that nothing greater than 10% dextrose run through a UAC. This is NEVER deviated from. The rationale is that infusing high dextrose concentrations can result in streaming of glucose out the end of the catheter into the superior mesenteric artery and celiac artery, stimulating insulin release, and subsequent severe hypoglycemia in the neonate.

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    • Author

    SteveNNP, is there a research article on this? I would really like to show this to my manager and our docs, so we can get a policy done. Maybe, that baby was having low blood sugars, because we were infusing high concentration glucose in the UAC? Thanks so much for your reply.

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    I found this P&P from UCSF - couldn't find an actual article. Parkland hospital also said they go up to a D 15 max in their UACs. "Hypoglycemia can occur if the UAC tip is above the recommended site. The infusionof glucose may stream into the pancreatic a. via the celiac axis, causinghyperinsulinemia and resultant hypoglycemia."

    http://www.ucsfbenioffchildrens.org/pdf/manuals/7_IVCatheters.pdf

    We actually infuse our HA/lipids through UACs all the time instead of starting 2 lines (our docs are old school). We routinely go up to 12.5% and higher if necessary (haven't seen > than D 15 that I can remember - those kids usually get a UVC). Sorry, it doesn't sound like you have much support from your managers and educators.

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    • Expert

    Here's one- I couldn't find the one I saw the other night when I first replied. Do a google scholar search and see what you come up with

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