Infusing TPN

passing thru · Jul 20, 2003

You'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.

YUK !!

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...

I wasn't.

You can take care of me anytime. I'd trust your judgement and skills for sure.

gwenith, BSN, RN · Jul 20, 2003

Passing 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!!

New CCU RN · Jul 20, 2003

I have to feel bad for your poor patients passing thru at this "world class hospital" as you poke them q2-q4h bc they are on cvvh .. their arms must be a mess!!!!!!!!!

That is absurd not to draw through a central line...... and sorry that your world class nurses have infected lines at your world class hospital, but at other places... that isn't the case.....

P_RN, ADN, RN · Jul 21, 2003

PassingThru I assume you mean MD Anderson?

Where can we read this protocol?

My cousin with Hodgkins disease died as a result of sepsis of a central line. She had previously been treated there.

nowplayingEDRN · Jul 21, 2003

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 !!!!

I have seen a few like this and changed them, STERILELY I might add but not enough to merit going into crises mode over using the CVAD as it was intended....to infuse multiple meds and draw blood.

They KNOW nurses will contaminate .............And they KNOW nurse's forget

It is so typical of those that live in glass houses to throw stones. Doctors and other medical professionals are so quick to point the finger of blame at the nurse. Yet they forget that without the skilled hands of the nurses caring for these patients the mortality rates would be much higher....they are not taking into consideration that the very spot the CVAD is placed affects whether it clots or not and they are not taking into consideration that not every patient has impeccable hygeine and that there are patients that feel compelled to touch and manipulate lines, dressings and the like. All these things directly affect CVADs....from clots to infections and other complications.

Again, I can see using extra precautions but it is unethical in my book to perpetually perform venipuncture every 2-4 hours on a patient that has a perfectly functional CVAD that is designed for just that use....and it is down right cruel and unnecessary to put a patient through such discomfort when there is no need to.

I accept your apology and I thank you for your vote of confidence in me and in my judgement. rest assured, if you were in my care it would be nothing short of World Class care you recieved.

And yes, Gwenith and P_RN....a World Class facility can not rest on it's laurels alone...for the are still run and staffed by humans and even World Class staff can make mistakes. I will stand my ground.....there is no substitute for good aseptic technique and following the hospital SOPs.

SharonH, RN · Jul 21, 2003

As it has already been pointed out, many meds can be piggybacked throught the same line as Hyperal but it is the Lipids which are incompatible with other medications. If you only have one one lumen on your central (or peripheral) line for whatever reason, you simply need to shut off the lipids, flush the line real well, and you can run most anything with the Hyperal. If you are using a pre-mixed bag of Hyperal/Lipids together, obviously that cannot be done. If you have more than one lumen, it is preferable to simply run your other meds through the other lumen.

Edited to add: The Hyperal should not be interrupted due to the risk of hypoglycemia so you should take care as to how you secondary meds are run with it.

Originally posted by passing thru
You'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.
YUK !!

There's gotta be 40 ways to contaminate the central line with EACH BLOOD DRAW.

That's pretty sad. The overwhelming majority of nurses I work with are simply too professional to be so sloppy and careless.Yes, there will always be an exception because we are human. It sounds like these people dropped the ball. They needed to re-educate their nursing staff instead of simply making allowances for gross incompetence leading to discomfort for the patient.

Tweety, BSN, RN · Jul 21, 2003

Originally posted by UntamedSpirit
And 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.

Interesting, because when we have a febrile patient that requires blood cultures we always draw one of the two blood cultures from the line, this is a good indicator if the cause of the fever is an infected line.

gwenith, BSN, RN · Jul 21, 2003

It is very possible that our TPN solution is formulated somewhat differently to yours as well. We have bags of "premix" which as well as the dextrose/amino acid combo often has a list of added trace elements and vitamins.

We also can get and have used a premix with the lipids mixed into the bag - sort of looks like you are running custard:)

Tweety, BSN, RN · Jul 21, 2003

Original response removed.

I didn't realize one had to wear a mask when changing caps for drawing blood. I don't except when I change the dressing, then I can honestly say I wear a mask. I always bring fresh caps, and three individual flushes.

We have pretty good luck with our world class nurses because I rarely see clotted up central lines as Passing Thru described.

They do get infected, but usually those are the ones that stay in for way to long, like weeks on end.

While I agree that drawing blood increases the risk of infection, using good technique, it should be no more of a risk that haning a piggyback med q8h.

If I have a central line, I insist you draw blood from it and spare me the stick. (But I have ropes for veins and wouldn't agree to a central line in the first place.)

The question is this world class facility with it's world class reasearch hiring world class nurses?

Tweety, BSN, RN · Jul 21, 2003

Originally posted by gwenith
It is very possible that our TPN solution is formulated somewhat differently to yours as well. We have bags of "premix" which as well as the dextrose/amino acid combo often has a list of added trace elements and vitamins.

We also can get and have used a premix with the lipids mixed into the bag - sort of looks like you are running custard:)

I'm not sure how our TPN is mixed. It comes up from the pharmacy based on what the MD ordered or what the pharmacist ordered. Usually it's a pharmacist managing the TPN forumula's, most of the docs write "pharmacy to manage TPN, etc.". They daily fill out a TPN order.

We then match the label on the TPN with the additives etc., with the MD's order. We don't do any calcuations whatsoever, does that set us up for liability? Obviously if we notice the pharmacist writes for 2 million units of insulin and the bag says 2 million units and we hang it we are liable.

gwenith, BSN, RN · Jul 21, 2003

I have a feeling that when we get down to the variances we will find we have been talking about different formulations. Obviously if the bag of TPN has added whatevers in it it will change what it will be compatable with and make compatablity determination more difficult.

SharonH, RN · Jul 21, 2003

Originally posted by 3rdShiftGuy
Original response removed.

I didn't realize one had to wear a mask when changing caps for drawing blood. I don't except when I change the dressing, then I can honestly say I wear a mask. I always bring fresh caps, and three individual flushes.

We have pretty good luck with our world class nurses because I rarely see clotted up central lines as Passing Thru described.

They do get infected, but usually those are the ones that stay in for way to long, like weeks on end.

While I agree that drawing blood increases the risk of infection, using good technique, it should be no more of a risk that haning a piggyback med q8h.

If I have a central line, I insist you draw blood from it and spare me the stick. (But I have ropes for veins and wouldn't agree to a central line in the first place.)

The question is this world class facility with it's world class reasearch hiring world class nurses?

Exactly. Something's not right here. I know there's a shortage but is is really that bad out there. There are a myriad of other tacks they could have chosen to address a problem of infected lines and poor technique including re-education of nurses, designating nurses to do it(i.e. RNs only, IV team, etc), or making the residents do it. Any of those would have been preferable to making the poor patient bear the consequence of incompetence of both nurses and management.