Double Fluid mess ups

[anon456]

I just wanted to post this for all the newer nurses, but also to remind people who don't run into this on a daily basis on your units.

I work peds and we have a lot of patients who are tube-fed either through an NG or a g-tube depending on their conditions/syndromes, etc. Of course when they come in they are often NPO and have IV fluids running. I have had two cases where I took over the care of patients who had both IV fluids and tube-feedings running at the same time. One patient has come back from OR much earlier that day before I got on shift and because there was not an order to d/c IV fluids when restarting tube-feedings, the patient got both. I took over care of the patient at 7 PM but didn't notice the double fluids until about 8:30 PM when I finally had a chance to do a full assessment. The patient was a cardiac baby who also had a trach and some pulmonary disease. I saw that the patient was having increased work of breathing and wet lungs. We had to give several doses of Lasix before the baby finally was able to pee off enough fluid to recover. The MD sat by bedside for about 2 hours and we came close to transferring the patient to ICU.

The lesson is that you have to ask yourself-- why does this patient need both IV and tube-feeds?? It is common when a patient is starting feeds back up to increase feeds slowly and subsequently decrease IV fluids. Last night I had a patient we were doing this on. I had to increase the feeds by 5mL/hr every 6 hours, but the MD did not write the order to decrease IV fluids at the same time. I did it anyway and then called the MD later when I had time and they confirmed that I was supposed to do that, and they apologized for not putting in in the order. I try to look for a TOTAL FLUID ORDER, such as for a baby, 37mL/hr total fluids between IV and tube feeds.

The website www.mdcalc.com has an excellent tool for peds nurses to calculate maintenance fluids, appropriate bolus amounts, and mg/kg/hr urine output. I use it all the time to double check the doctors.

THanks for listening. :-) Nursing humbles me daily.

[uRNmyway, ASN, RN]

I agree, and I get it. But let's face it. We aren't talking about something that will be seriously harmful. Sure, the nurse could have gotten an order from the doctor saying that your child could have more fluids in the buretrol at one time.

But if the negative is some sleep deprivation for having one hour buretrol, and otherwise the very real risk of fluid overloading a vulnerable child (and the last place I worked implemented this protocol because of exactly this, a nurse was lazy, was tired of running to refill every hour and just let it run free. Overloaded little one.), well then, I think its STILL a good policy to have.

[squatmunkie_RN]

I had a patient in his 50s with a torn esophagus. He was being fed through a g-tube on a pump with water flushes. He was still slightly dehydrated, labs showed Na+ of 147. It would've been appropriate for that patient to get some fluids for a bit. Adults are different from kids. But it annoys me too when doctors forget to address IVF

[wooh, BSN, RN]

Yet another example of why a well-educated RN holds the line between "just following doctor's orders" and the safe provision of the medical plan of care. Good spot. And yes, it can absolutely be just as critical for an adult as a baby.

On the other side of the coin, when my 135-pound teenager was admitted to a famous children's hospital post trauma we were awakened every hour by the IV pump alarming that her hourly fluids were completed. Apparently they had a protocol that no more than one hour's worth of fluid was dropped down into the volutrol, to prevent accidental fluid overload in small people, and when that ran dry, the pump beeped. It was as if I were speaking Urdu to explain why this was unnecessary in an adult-sized person with no cardiac or renal pathology. No critical thinking skills in that department, I guess.

As long as you document your reasoning, discussions with physicians and CYA, you're not forced to do anything. We are held to a standard that is much higher than "because the doctor said so".

On that note, I'd much rather be blue in the face or searching for a job than trying to explain to a patient's family or a legal inquiry as to why I carried out an order that I knew was wrong.

I work on one of those peds floors. And doctor orders don't overrule hospital policy. Believe me, I think it's STUPID to have to reset a pump on adult sized patients that can tell me that their IV is blown. But I've got bigger fish to fry as far as fighting stupid policies.

And quite honestly, if you want to be treated like an adult patient, go to the adult hospital.

[megank5183]

I worked in an ICU for years and you would get in BIG trouble if you had double fluids going and I didn't even work in a CCU. There is typically no reason to overload someone on fluids. To new nurses, if you get a patient on double fluids, ALWAYS check with the MD that this is what they want.

[KelRN215, BSN, RN]

Can you give some examples and explain? I guess I just assumed that no one should run excessive amts of fluids beyond what is appropriate for their size/condition. Not talking about boluses-- that's a different situation of course.

We do get adult patients also (18 and up, many of them with "peds" diagnoses like congenital heart problems, rare syndromes, or patients the MD's have decided to keep following when they turn 18) and the same rules apply to them in our hospital.

Here's an example of a CHILD who you would keep IVF going in addition to tube feedings.

Child is admitted for scheduled chemotherapy. Child has a G-tube and gets baseline bolus feeds during the day and continuous overnight feeds. Child is ordered for nephrotoxic chemotherapy that requires several hours of pre- and post-hydration. The child needs the extra fluids because of the chemotherapy and there would be no rationale for holding the tube feedings just because the child is getting more fluid. They are malnourished enough which is why they have the feeding tube so as long as they're tolerating the feeds, they should continue to receive them.

Another one- when I worked neurosurgery, we had patients with rare neurovascular conditions that required at least 1.5x fluid maintenance to ensure cerebrovascular perfusion. Occasionally during surgery, these children would stroke. A child who has had a stroke will almost undoubtedly end up with an NG tube. Even as feeds were being advanced, these children would still be on full volume of IVF for several days.

Now, if you're talking about a cardiac baby or a child with a renal condition, that's obviously a different story but it's not necessarily true across the board that you would decrease or stop IVF just because you are starting tube feeds.

[KelRN215, BSN, RN]

I work on one of those peds floors. And doctor orders don't overrule hospital policy. Believe me, I think it's STUPID to have to reset a pump on adult sized patients that can tell me that their IV is blown. But I've got bigger fish to fry as far as fighting stupid policies.

And quite honestly, if you want to be treated like an adult patient, go to the adult hospital.

I came from one of those floors and I found that policy to be completely insulting. "We don't trust our nurses to assess the IV sites for infiltration hourly per policy so we need to make another policy that they can only set the volume on the pump for 2 hours so they'll be forced to respond to the beeping."

[opdahlamber]

I think we should question every single order that we see that makes us feel all funny inside (nurse's instinct). There is not a dang thing wrong with calling the MD and saying, "I saw this and was wondering..could you explain to me why this is, because I am not sure." Be tactful. Saves our behinds, saves their behinds, and best of all, saves our patient's lives.

[wooh, BSN, RN]

I came from one of those floors and I found that policy to be completely insulting. "We don't trust our nurses to assess the IV sites for infiltration hourly per policy so we need to make another policy that they can only set the volume on the pump for 2 hours so they'll be forced to respond to the beeping."

Well really, most hospital policies are insulting and based on not trusting nurses to use their brains.

[Morainey, BSN, RN]

This is an interesting topic that I would never have thought about because I don't work in peds. It makes perfect sense though.

[NicuGal, MSN, RN]

Most policies come into being because of mistakes someone has made. And believe me, if something goes to court you better be able to state and prove you followed the policy.

We haven't used buretrols on peds in 20 some years.

[wooh, BSN, RN]

Most policies come into being because of mistakes someone has made. And believe me, if something goes to court you better be able to state and prove you followed the policy.

We haven't used buretrols on peds in 20 some years.

We only use them when we do antibiotics that come in a bag instead of syringe. We don't get sent any overage for priming the line so we have to put a flush bag on after each dose and otherwise you end up running air into the line if you miscalculate your volume to infuse after priming. Which would all be solved if they trusted us to run a piggyback, but apparently we're too stupid to run a piggyback.

[nurseprnRN, BSN, RN]

I work on one of those peds floors. And doctor orders don't overrule hospital policy. Believe me, I think it's STUPID to have to reset a pump on adult sized patients that can tell me that their IV is blown. But I've got bigger fish to fry as far as fighting stupid policies.

And quite honestly, if you want to be treated like an adult patient, go to the adult hospital.

Her injuries were such that she needed two different pedi specialists and she was in the ambulance taking her there before we all knew what to expect, anyway. We all know that a 135-lb person who is thirteen doesn't belong on an adult med/surg floor. I just expected better from a pediatric specialty hospital, is all. And protocols and policies can --and should-- be written for different age/sizes.

(It WAS 20 years ago :) but apparently the buretrol has been replaced by the one-hour limit on the pump, so the effect is the same)

We're sort of getting away from the initial question, which was appropriate fluid intake and how to think about it, though. Thanks for writing.