Infusing TPN - page 2
I remember all through school having it drilled into my head that TPN was to infuse by itself and never to piggyback ANYTHING else into it. Where I work RN's consistently piggyback numerous drugs... Read More
Jul 20, '03Contact your pharmacy. There are a great many drugs that ARE compatablie with TPN. There are also a few that are not compatablie with TPN. Alaso thirdshiftguy....the pt is going to get the formula with things piggybacked in because you are running it on a pump that will deliver it at the specified rate....what you have to consider is the time and amount that you are delivering you piggyback in....thay will increase the true rate of the fluid going in at the cath. i.e tpn at 75 cc/hr and piggy back at 125 cc/hr = 200 cc/hr delivery at the cath....will the line you are running it through hold up to that kind of rate and how much fluid can the pt tolerate. You may have to ask the pharm to cut back on the dilutent of the piggyback to minimum amts to possibly keep someone from going into fluid overload. esp if they are also getting triples abx's q 6 or even q4.
P.S. any one know the true cost of TPN? I do....you would be surprised at the cost of what it really costs to make vs what we charge....just ask me....
Jul 20, '03The only thing infused with TPN through the same line (piggy backed in) is Lipids. This is to decrease contamination. However, if folks follow their hospital policies for blood draws from a CVAD and flush it appropriately..... well, clotting should not be a big problem. Also, to maintain acuraccy of insusion rate and to make sure that the TPN and Lipids do not remain up longer than 24 hrs, they need to be run via an infusion pump.
I seem to have become the resident expert at my facility on CVADs and just developed an inservice on them, based on research that I have done, hospital policy, infection control and CDC recommendations. You can not go wrong if you stick with the SOP of your facility and maintain aseptic technique.
Jul 20, '03In the large # 1 in the nation cancer center/teaching hospital I worked in.... they NEVER drew blood from a central line.
"It increases the risk of infection." ( Remember these white counts are in the hundreds.)
They had talented & experienced lab persons who could draw blood from a fly...and they utilized feet as lab donor sites also.
Also, most blood draws were in Pedi tubes...."Why fill a 10 cc red top when you can check the lab value just as accurately in a 1 cc red top?"
pH of infusions and compatibility....the docs know this when ordering the medications.
For example, antibiotic levels are checked weekly to ascertain they are in a therapeutic range.
Nothing is ever left to "eyeballing it" when you are working in a world-class hospital.
Everything is confirmed by scientific analysis. (lab analysis) (and documented and placed in the chart/computer records)
For example, a immunosuppressed cancer patient on TPN , lipids, antibiotics.
The doctor who is prescribing KNOWS whether the antibiotics he has ordered are pH compatible. No one would rely on nurses to eyeball the tubing to see if it is compatible.
And assays are done weekly by the lab to confirm the medication is at therapeutic levels in that patient.
Doctors know what they are doing in a first rate hospital and
ASSUME responsibility for the patients' outcome.
If there were a pH compatibility problem and the doctor missed it, the pharmacist would definitely intercede and "catch" it and inform the doctor.
This is not a nursing responsibility. This is between the team of physician and pharmacist. ....with the doctor assuming 90 % of the responsibility.
Which brings me to a question I like to think about......
ask yourself, too...........
What is it that makes a hospital a world class-- "first rate " hospital? What are you doing ...what is YOUR hospital doing that prevents it from being "First Rate?"
What are the obstacles to efficiency that you encounter daily?
In a first class hospital.... efficiency is KEY.
There is never a reason to do anything TWICE.
Jul 20, '03We always check with the unit pharmacist who confirms what is and what isn't compatible with the TPN/PPN solution that is hanging (Pepcid, even certain antibiotics). We always carefully check with the pharmacist and confirm with the drug book AND floor nurse. If lipids are also infusing with the TPN, then NOTHING ELSE SHOULD BE RUN ON THAT LINE.
Jul 20, '03Passing thru please remember not everyone has access to those facilities and I have worked in a purported "world class hospital that should have had those checks and balances in place but they were not truly evidence based.
Where I work ensuring that drug admixtures do not occur is a NURSING responsibility and not a medical one. Unfortunately not everywhere in the world has the same access to resources that your facility does. Sometimes you have to make blanket statements that will ensure maximum safety wherever you are.
Jul 20, '03And I would like to add that no matter how world class, first rate a facility is.....doctors are only human and are prone to making mistakes...which is why we have a variety of qualified medical personnel at work to care for the patients. From the doctors to the nurses to the pharmacist to the lab technicians to the lab personnel that takes and tests each specimenright down to the radiologist and x-ray techs to the nursing assistants......it is a team effort. And while it must be very nice to have access to this technology you speak of....Gwenith is right. Not every place has access to it. I would think that there would be more risk of infection with multi venipunctures than to use good aseptic technique and draw blood off a CVAD and flush it appropriately. Ah, well.......variety is the spice of life and ya can't have everything perfect in life. *sigh*
Jul 20, '03Originally posted by Dplear
Contact your pharmacy. There are a great many drugs that ARE compatablie with TPN. There are also a few that are not compatablie with TPN. Alaso thirdshiftguy....the pt is going to get the formula with things piggybacked in because you are running it on a pump that will deliver it at the specified rate....what you have to consider is the time and amount that you are delivering you piggyback in....thay will increase the true rate of the fluid going in at the cath. i.e tpn at 75 cc/hr and piggy back at 125 cc/hr = 200 cc/hr delivery at the cath....will the line you are running it through hold up to that kind of rate and how much fluid can the pt tolerate. You may have to ask the pharm to cut back on the dilutent of the piggyback to minimum amts to possibly keep someone from going into fluid overload. esp if they are also getting triples abx's q 6 or even q4.
P.S. any one know the true cost of TPN? I do....you would be surprised at the cost of what it really costs to make vs what we charge....just ask me....
This would be true then if you are running on a multi-line pump with both infusions running at the same time. Duh.....I was thinking of piggybacking like an antiboidic that stops the main infusion while it infuses, but on a single-line pump.
I've heard that we charge our patients an outrageous amount of money in the thousands for TPM.....so do tell, what is the cost vs the charge to patients?
Jul 20, '03I agree, but nurses have ENOUGH !! to do.
Why take on chemistry??
How , may I ask, will you know the Pepcid is 6.9 when it should be 7.4??
Or the Flagyl is 8.1 and needs to be diluted to 7.4?
Untamed Spirit....I beg to differ re: multiple sticks vs. a central line for drawing blood, that the multiple sticks could increase infection risks.
Think it through........and the consequences.
What is the consequence at an antecubital site stick of introducing infection?
What is the consequence of infection introduced into the central line?
One is a major pain in the butt , yes, but rarely seen. I've seen two in ten years. Usually iv stiks that are infected are a result of the iv site ...not being changed....has been in too long....nothing at all to do with a blood/lab draw.
The other is life threatening. (The central line blood draw)
I've seen as many as three valves growing...." vegetation."
and by then the patient has bacteremia, septicemia,
can be a day away from shock....
they pull the central line and, SURPRISE ! there's "gunk" on it.
What does the other 5 quarts of blood look like?
God forbid there is a dialysis catheter also..
I personally will request all sticks via skin and all blood draws thru the skin, when I am the patient.
A world-class first rate hospital, "best in the nation" has done the
studies for decades and decided a policy that is in the best interest of the patient.
Why would the nurse re-invent the wheel and say, "well, in my opinion, I think multiple sticks is a higher infectious risk for these patients."
Why not, in your hospital, be an advocate for the patient?
I've gone to many a hospital and refused to allow anyone to draw blood from the patients' central line....and also done a LOT of patient teaching.
I've never had a doctor or administration complain. I simply say,
"This is the policy at ____________."
Why not emulate "the best?" It is foolish to work and learn at a high level of practice institution and then go to Podunk, America
and practice their policies without discussion.
I've never seen a
doctor refuse to try a method that has been accepted and is policy at a more "advanced" hospital. They listen to me.
Patients are real appreciative. They will then tell you of the nightmare situations they have experienced with infected catheters, and stories begin, like,
"this is my third one. (central cath.) I was in ICU for three weeks two years ago, when the second one got infected, etc...........etc.........."
Just go with the research, histories, studies, statistics.Last edit by passing thru on Jul 20, '03
Jul 20, '03I am an advocate for the patient and I can tell you that when I have had a CVAD to draw from, I have never had any of them develop sepsis. I have had multiple patients develop phlebitis and cellulitis from multiple IV sticks. Do not insinuate or assume I am NOT an advocate for my patients, passing.(You know what they say about assuming....) I take great offense to that.
I was not arguing World Class hospital's studies or research results. It was merely my opinion and experience that I voiced. You say that pt's tell of nightmarish experiences from being in "Podunk" hospital as you say. Well...I can countr and say that I have had many a patient tell hellacious stories of "World Class" hospital. No matter where you go....there are going to be positive and negative experiences.
I still say that if you are having pt's with c/o high infection rates with CVADs...then someone is not practicing aseptic technique and they need some good old fashioned counseling and remediation for it's not the procedure placing the patient at risk but rather the practicioner(sp). Aseptic technique is vital to an immunocompromised patient....for they are at a far greater risk of infection than other patients.
I agree to disagree with you but I will not take a thinly veiled insult quietly. I take great pride in providing my patients with competent care and great compassion. I enjoy teaching my patients and I enjoy the adrenaline rush moments. I do not bash your capabilities and skills, please do not attack mine, thank you very much.
Jul 20, '03And Gwenith you are right...a blood culture should never be drawn from an existing line....but a fresh veinipuncture site cleansed with chlorohexadine or betadine and then the blood specimen obtained. Otherwise the culture would not give accurate results and treatment would not be appropriate.
Jul 20, '03TPN on the average costs 28 (twenty eight) dollars a bag to make. The most expensive item in the TPN is the bag itself which goes for around 20-25 bucks. The average charge is around 2000-3000 dollars a bag. Nice profit there.
Jul 20, '03You're exactly right Untamed. You finally hit the nail on the head. I agree 100 %... Yes, it is THE PRACTITIONER.
That is the world-class hospitals' reason for NEVER allowing blood to be drawn thru the central line.
Too much handling, too many entries, too much of everything.
How many have you seen with old dried clotted blood in the caps?
How many have you replaced that looked like that.?
How many have been FLUSHED that looked like that? YUK !!!!
It is a STERILE procedure. A mask should be worn when changing caps, etc, etc. But, who does?
And, the world class hospitals' researchers and administrators know a thing or two about human nature.
They KNOW nurses will contaminate their needles, not set up a sterile field, will withdraw and forget which syringe is their withdrawal syringe and which is for the lab (lab results bears this out.)
And they KNOW nurse's forget to bring a new rubber cap, so they put the OLD ONE BACK ON after it has laid on the sheets or on the table.
Or,..... they simply stick the rubber cap thru the gunk and draw.
There's gotta be 40 ways to contaminate the central line with EACH BLOOD DRAW.
The researcher's simply say.... you and no other nurse will
be 100 % compliant 100 % of the time with each blood draw through that line.....
So, the policy is..... "stay out of it!"
Think about it the next time you draw through the central line...and observe your co-worker. One of you will break
technique and contaminate.
It was the sheer #'s of contaminations and infections that resulted in the alarms going off in the Infectious Disease Department. And , consequently, resulted in the many studies and the ultimate policy.
The researchers did not simply choose "central lines" as a topic for a study.
It was the high rate of infections caused as a result of the central lines. The central lines were identified as THE SOURCE of the infections.
Who goes into the central lines?? Doctors??///no.
Lab techs???? /// no.
The nurses! .... so, who was responsible??
And, who was banned per policy from drawing blood from central lines?
Sorry if I came off sounding like I was bashing your capabilities..or insulting you...
You can take care of me anytime. I'd trust your judgement and skills for sure.
Jul 20, '03Passing thru I will have to disagree that just going by the policy of a "world class hospital" is not enough. I used to wokr in a hospital that not only claimed thsi dsitinction but did have a certain international reputation. I left
I now work in a smaller facility that does not rest on its laurels invests a lot in qualty improvement and is a collaborating centre for the Joanna Briggs Institute. In other words we use evidence based practice for everything. unfortunately the databases for EBD are still growing and there is a lot that is not yet covered.
As for nurses being responsible for drug administration and therefor drug admixtures - yes we are. As an Austrlian nurse our scope of practice seems to be different in many subtle ways to America - this seems to be one of them. We use texts and online referrences to work out what is feasable and what is not. In truth the main thing is "do not admix drugs". We try always to have a secondary drug line. We use quad lumen catheters to ensure that in ICU we will have enough venous access.
Our medical staff do not know what drugs are compatable it is not thier job. If we have a real problem ( and sometimes it does occur we will acess the pharmacy for further information but we don't have pharmacy cover 24/7. Cripes! I have worked in places that don't have MEDICAL cover 24/7!!