Iv antibiotic running as primary?

[SquatsNScrubs]

Perhaps I am overthinking this, but alas...

I've recently noticed on my floor patients who are not receiving continuous IV fluids having IV antibiotics run as the primary on the pump. No small bag of normal saline is being used as the primary with the antibiotic as the piggyback. There is approximately 13mL in the distal primary tubing. This means that a patient who is receiving a 50 mL antibiotic is missing out on almost a third of their dose left behind in the tubing...right?

I am relatively new at my facility and am unsure how to go about this. If I see an antibiotic being run as the primary, I will swap the old abx bag for a 100 mL bag of NSS and run the abx as the secondary.

Should I send an email to my manager? I can't find a policy regarding this.

[RNrhythm, BSN, RN]

It's been the expected practice at every place I've worked to hang antibiotics as a secondary even if there are no primary fluids ordered.

Same here. Maybe a few times a year I will run across an existing IV pole setup where the ABX is primary but I suspect it came up from the ED that way.

[KelRN215, BSN, RN]

Some IV pumps are the type you can just screw a luer-lock syringe onto, thus, you can easily give a flush of whatever amount you want to. The ones I've used like this were PLUM, I think.

The hospital I worked at also carried 25 mL bags of normal saline. If a patient was on IV antibiotics only, no fluids, and it was something that came in a bag instead of a syringe (this was pediatrics), we spiked the bag as primary and spiked a 25 mL normal saline bag when the antibiotic was done to flush the line/ensure that the full volume of antibiotic in the tubing got to the patient. The same tubing was used for 96 hours.

[AceOfHearts<3]

One of the hospitals I worked for actually sent an email telling us that we needed to run at least a 13ml flush to ensure the full amount of the medication was received. If the line isn't flushed the patient doesn't receive the full dose. It dosen't concern me as much with electrolytes when the levels are normal and we are just boosting them and we'll recheck the levels (I still hang a small flush bag). It's a big pet peeve of mine when done with antibiotics and other critical meds like keppra and even blood products-I want the patient to get th full amount because they obviously need it.

[Ddestiny, BSN, RN]

At our facility all patients automatically get an order for a PRN 30-50mL of NS to use as a primary behind any antibiotic, antiseizure med, etc. We program our pumps to infuse the flush at the same rate as the secondary med. If you have somebody that has a LOT of various secondary meds that they're getting each day then you can also use a 250cc bag instead of a 100cc bag.

I feel like the rationale for why to do this has been covered well by other folks. From a purely nurse-oriented view of it, it takes a little longer to set up initially but after that you can quickly change between multiple meds off of the same primary setup. I also set my serial K+ infusions on a secondary so that I have a little "cushion" in between doses. My goal is to not flush the entire 30cc in between, but there is never exactly 50cc or 100cc of fluid in the bag, there's usually a little more. But even if I do happen to get the entire flush behind the K+ then it's easy to "back prime" the secondary tubing and hang the next. In the case of giving K+ every hour until you reach a certain dose, I usually don't purposefully flush the entire line with the 30cc of NS until after the last bag of K+.

[humerusRN]

Working in pediatrics, you can imagine the amount left in the tubing when you're tiny to begin with can be a big deal. As a result, I would say 75% of our antibiotics are given over a syringe pump, with a flush behind. (Regardless of IVF running)

[elijahvegas, ASN, RN, EMT-P]

set the pump to account for the fluid left in the tubing..

50ml bag of abx

VTBI 55-60

[MunoRN, RN]

set the pump to account for the fluid left in the tubing..

50ml bag of abx

VTBI 55-60

The pump isn't going to sense air and then keep pumping the air in order to empty the tubing. The pump will stop once it gets air, and there's typically 15ml or so left in the tubing below the pump.

If you've got a primary/secondary setup then that would work since once the secondary (antibiotic) empties then the line will pull from the primary bag to infusing the medication remaining in the primary tubing.

[Rose_Queen, BSN, MSN, RN]

Some IV pumps are the type you can just screw a luer-lock syringe onto, thus, you can easily give a flush of whatever amount you want to. The ones I've used like this were PLUM, I think.

Yes, that is what we have.

[Guest219794]

I am a very new nurse so I have very limited experience but where I work we never hang antibiotics with fluids unless both are prescribed. It seems the providers at my (and apparently your) facility do not think it is super important that the patient receives that last 13ml.

Unless you know of (or are willing to conduct) specific studies that demonstrate better patient outcomes when IV antibiotics are run secondary to fluids I personally would not worry about it.

Also, if the patient has a condition like CKD or CHF, additional fluids could possibly exacerbate their condition.

Just my 2 cents, curious to see what others think though...

Obviously there are some instances in which 13 ml is not as much of a concern. But, there are plenty of instances in which it is.

Let's take a drug, 400 mg in 50 ml. If you leave 13 ml behind, you are giving roughly 300 mg.

It seems the providers at my (and apparently your) facility do not think it is super important that the patient receives that last 13ml.

Actually, the provider thinks you are giving the 400 mg she ordered, and that you documented giving. The provider expects you, as a professional to know how to give the medication ordered. That is why the order doesn't read "400 mg rhinocorocillin IV, or as much is convenient".

There are many ways to give the full dose, IVPB being just one of them. Giving 300 mg rhinocorocillin when 400 mg is ordered is a medication error, even if it is a common practice where you work.

Unless you know of (or are willing to conduct) specific studies that demonstrate better patient outcomes when IV antibiotics are run secondary to fluids I personally would not worry about it.

There were studies. That is how the 400 mg was decided on the dose. I am confident there are no studies that show the efficay of the 25% of any drug left in the line.

[elijahvegas, ASN, RN, EMT-P]

The pump isn't going to sense air and then keep pumping the air in order to empty the tubing. The pump will stop once it gets air, and there's typically 15ml or so left in the tubing below the pump.

If you've got a primary/secondary setup then that would work since once the secondary (antibiotic) empties then the line will pull from the primary bag to infusing the medication remaining in the primary tubing.

very confused.

if you have 15ml of tubing, and a 50ml bag, thats precisely why you would set the VTBI on the pump to 60 or in this case 65. Unless your pumps switch to KVO mode after infusion or something. Ours dont.

[MunoRN, RN]

very confused.

if you have 15ml of tubing, and a 50ml bag, thats precisely why you would set the VTBI on the pump to 60 or in this case 65. Unless your pumps switch to KVO mode after infusion or something. Ours dont.

If you've got a 50ml bag and 15ml of tubing, then you've got 35mls in the bag after priming the tubing, assuming you are priming it without letting a single drop come out the end of the tubing while priming it. For most pump manufacturers, the tubing can be placed in the pump anywhere between the upper and middle ports, which is usually about 15ml of tubing below the pump. Since the pump will stop once air reaches the pump, the volume of the tubing below the pump will be left uninfused when using a primary-only setup.

[elijahvegas, ASN, RN, EMT-P]

If you've got a 50ml bag and 15ml of tubing, then you've got 35mls in the bag after priming the tubing, assuming you are priming it without letting a single drop come out the end of the tubing while priming it. For most pump manufacturers, the tubing can be placed in the pump anywhere between the upper and middle ports, which is usually about 15ml of tubing below the pump. Since the pump will stop once air reaches the pump, the volume of the tubing below the pump will be left uninfused when using a primary-only setup.

ah i follow you now