Fluid bolus by gravity or pump?

[delphine22]

No one seems to be able to give me a straight answer on this. I was thinking (uh oh, here she goes again) my way made more sense, but there might be something obvious I'm missing, so please correct me!

When I have to give a liter NS bolus quick ("wide open," as they say) and I have peripheral access that's reasonably stable, and the pt is not a CHFer or has other fluid balance problems (besides needing fluid), I hang gravity tubing. My preceptor told me I should put it on the pump and set it to 999 mls/hr.

My thinking is, what if that's faster than the PIV can take? I'm afraid of blowing my IV bc the pump "pushed" the fluid in too fast.

However, it seems the gravity tubing (and I don't use it a lot, and have no ER experience) varies its flow with what the vein can handle, and will flow slower if the pt's moving around or the catheter is smaller. Obviously this is not ideal for a fidgety pt, but if mine's relatively still, and I want to protect their IV, is gravity tubing the better choice?

My preceptor was doubtful it would go in fast enough. But I had a 500cc bolus flow into a 20g IV in less than 20 minutes. So obviously the vein could handle more than the pump would have set it at (half an hour).

Please give me your thoughts/experience. Thanks! :)

[beckster_01, BSN, RN]

If it is non-urgent (low urine output, mild hypotension, etc.) then I use the pump. If I am really trying to get it in then I am using a pressure bag. I don't generally just let it hang because there have been too many times when I check on it and hardly any fluid has infused for various reasons (generally with blood products). I like to know exactly how fast and how much fluid has infused without having to guess, and like the nice steady rate I get with the pump. And usually if I use the pump I am hanging the bolus as a secondary which is just faster/easier.

[ICUPrincessNurse]

Depends. Through a PICC? Sometimes I'll use the pump if it doesn't flow. Mild hypotension/low UOP through a well flowing PIV or CVC? Gravity. Legit hypotension/code? Pressure bag. Code/trauma/bad GI bleed? Level I transfuser.

[delphine22]

S/n from my studying, AACN says the best place to infuse a bolus is not through a CVC but through a large gauge short-length peripheral catheter. Something else for me to chew on!

[Loo17]

Where I work we use Protectiv IV catheters and the flow rate for an 18g is 110ml/min, 65ml/min for 20g, 38 ml/min for a 22g. So running a liter through a pump at 999ml/hr would actually infuse the fluid at a significantly slower rate than running the liter wide open. It typically takes about 15min for me to infuse a liter wide open into a patient with a good flowing 20g.

[delphine22]

Keep in mind, though, Loo17, that what the manufacturer says the catheter will do is not necessarily what happens in real life. Is the IV in the antecubital while the pt has his arm flexed? Is it in a smaller vein, or near a valve? Or has the vein been traumatized by nursing actions? By my count the 22g catheter would need 15-20 seconds for a 10 ml flush to go in. I do mine slow, but I can't remember a time, esp in an emergent situation, when I've pushed in a saline flush THAT slow.

[Loo17]

delphine22 said:

Keep in mind, though, Loo17, that what the manufacturer says the catheter will do is not necessarily what happens in real life. Is the IV in the antecubital while the pt has his arm flexed? Is it in a smaller vein, or near a valve? Or has the vein been traumatized by nursing actions? By my count the 22g catheter would need 15-20 seconds for a 10 ml flush to go in. I do mine slow, but I can't remember a time, esp in an emergent situation, when I've pushed in a saline flush THAT slow.

I agree with what you are saying. I interpreted the OP's post to state that they were concerned that running a pump at 999ml/hr might be faster than the IV could handle not that they were worried it was faster than the patients vein could handle. If vein integrity is a concern I wouldn't run fluids wide open or at a fast rate on a pump.

All I was trying to say was that if you run an infusion by gravity/wide open it could potentially infuse much faster than a pump set at 999ml/hr. Obviously the nurse would need to use their judgement based on the physical conditions and patients veins. If the IV was in a good position and was capable of flowing at the rate listed by the manufacturer than it would also be capable of handling the pump rate of 999ml/hr because that would be slower.

Our 22g caths are capable of infusing a max 38ml/min. Meaning if perfect conditions exist it would be ok to push a 10ml flush in about 5 sec but if you slam the 10ml in less time than that the manufacturer cant guarantee it wont fail. There is never a guarantee that the patients vein wont fail.

[commonsense]

Go with your gut.

[sarahicu]

Personally if I am not in the room to monitor the bolus (i.e. with my other patient) I favor putting the bolus on the pump (999ml/hr) to ensure it does all infuse because the pressure bag will need pumped up after about 300cc infuses.

[ladymacgyver]

I try to use the pressure bag in emergent situations. A pump running at 999cc/hr will take one hour to infuse one litre and I usually want a bolus to infuse faster than that. A pressure bag pumped up to 300 mmHg usually can infuse a litre bag in about 15 min.

[Cook26]

delphine22 said:

S/n from my studying, AACN says the best place to infuse a bolus is not through a CVC but through a large gauge short-length peripheral catheter. Something else for me to chew on!

This would be based on Poiseuille's law. Flow rates are directly proportional to the fourth power of the inner radius, and inversely related to the length of the tube. It gets complicated, but basically means that a large, short PIV flows faster than a central line, and a central line flows faster than a PICC.

[delphine22]

I try to use the pressure bag in emergent situations. A pump running at 999cc/hr will take one hour to infuse one litre and I usually want a bolus to infuse faster than that. A pressure bag pumped up to 300 mmHg usually can infuse a litre bag in about 15 min.

My thoughts exactly and that's why I started this thread. I got a 500cc bolus in, by gravity without a pressure bag, through a 20g in the forearm in about 15 minutes. If I'm trying to raise blood pressure I don't wanna wait for the pump.

[WarEagled]

60cc syringe and push. Peds. Use more than one access at once if you've got it and need to.