NEW NURSE-antibiotic administration

Sour Lemon · Aug 28, 2018

Hi all I am a new nurse and have a couple questions regarding antibiotic administration. When hanging an antibiotic (when there are not continuous fluids already running) I have been taught to hang the antibiotic as a secondary with NS as the primary. When programming the pump (we use Alaris), can you just program the NS as you would the same volume and rate as the antibiotic and not program the antibiotic as a secondary because the antibiotic will flow down to the primary line with gravity? Then after that you would go back to volume to be infused and add more. Is this technique correct? Is the whole point of hanging the antibiotic as a secondary with NS so the line doesn't run dry?
Thanks!

I don't understand the specifics of what you're trying to do, but it sounds wrong. Program the primary at a KVO rate (30ml/hr is typical) and the antibiotic as a secondary at the rate it's ordered to run. Nothing should be running to gravity unless it's ordered to be administrated that way. Also, anything that's unclamped and not on a pump can "back up" into something else that's hanging/running.

Do you have a preceptor? Don't be afraid to ask for clarification of anything from someone you actually work with. It's usually easier to understand things like this in person.

MiniPaige · Aug 28, 2018

So correct me if I'm wrong, but you're asking if instead of programming a secondary infusion (IV piggyback), just change the primary infusion rate to the abx rate and then just open the secondary abx line so it will passively flow with the primary IVF?

If that's correct, then I would say you're making more work for yourself and potentially harming the patient. We don't us Alaris at my hospital, but from what I'd gather by doing this technique, you'd basically be bolusing the patient with small amounts of NS and the amount of the abx that would run with the NS would be extremely minimal. There have been more than one time that I've walked into a patient room after hanging a PB abx and for some reason the pump didn't start the secondary IVF. So the pump was running the primary IVF while the secondary tubing was wide open, however the abx bag was still full and I didn't note any gtts from the abx bag into the secondary tubing fluid chamber. *I am by no means an expert in how IV pumps work to differentiate primary/secondary IVF* However from what I have gathered from my experience, the pump needs to force the secondary fluid to run, otherwise you'll just be giving the patient small boluses of the primary IVF with maybe minuscule amounts of the secondary abx running passively through the line.

So from my experience, it would just be a bad idea. From potentially harming the patient (i.e. potentially not keeping a therapeutic level of abx/giving mini boluses that aren't medically indicated), to potentially getting in trouble for basically giving unordered mini boluses of the primary IVF (which remember is a med and there is a reason the MD ordered it for your patient at the rate/amount they did), as well as just making more work for yourself. Plus, the 10 extra seconds to program the secondary infusion aren't that big of a deal anyways.

KelRN215, BSN, RN · Aug 28, 2018

Why would you do it that way? Just program the secondary line to run at the prescribed rate and program the primary line to run KVO. I don't think it would work the way you are asking about doing it since the flow is being managed by the pump, not gravity.

MunoRN, RN · Aug 28, 2018

There's not necessarily a reason to enter separate primary and secondary infusions into the pump if you're just using a primary bag of NS to prime, backprime, and flush the line. When you enter a secondary infusion into a pump all you're doing is telling the pump to run at a different rate for a certain volume and then change to a different (primary) rate. I gather Alaris uses some confusing terminology when referring to primary and secondary infusions, but so long as we're referring to the proper definition of a secondary infusion which is a solution y'd into a primary line above the pump where the secondary is hung higher in the fluid column than the primary.

If you want the pump to alarm for infusion complete after both the secondary and flush from primary bag then you only need to tell the pump to run for the volume of the secondary bag and sufficient volume to flush the line which can be done just programming a primary infusion. The reason you may want to still program the antibiotic as a secondary is that in some pump libraries the antibiotic will only show up under the secondary infusion programming, so using just the primary program may not utilize the pump library guardrails.

MunoRN, RN · Aug 28, 2018

So correct me if I'm wrong, but you're asking if instead of programming a secondary infusion (IV piggyback), just change the primary infusion rate to the abx rate and then just open the secondary abx line so it will passively flow with the primary IVF?
If that's correct, then I would say you're making more work for yourself and potentially harming the patient. We don't us Alaris at my hospital, but from what I'd gather by doing this technique, you'd basically be bolusing the patient with small amounts of NS and the amount of the abx that would run with the NS would be extremely minimal. There have been more than one time that I've walked into a patient room after hanging a PB abx and for some reason the pump didn't start the secondary IVF. So the pump was running the primary IVF while the secondary tubing was wide open, however the abx bag was still full and I didn't note any gtts from the abx bag into the secondary tubing fluid chamber. *I am by no means an expert in how IV pumps work to differentiate primary/secondary IVF* However from what I have gathered from my experience, the pump needs to force the secondary fluid to run, otherwise you'll just be giving the patient small boluses of the primary IVF with maybe minuscule amounts of the secondary abx running passively through the line.
So from my experience, it would just be a bad idea. From potentially harming the patient (i.e. potentially not keeping a therapeutic level of abx/giving mini boluses that aren't medically indicated), to potentially getting in trouble for basically giving unordered mini boluses of the primary IVF (which remember is a med and there is a reason the MD ordered it for your patient at the rate/amount they did), as well as just making more work for yourself. Plus, the 10 extra seconds to program the secondary infusion aren't that big of a deal anyways.

The pump doesn't control which bag the infusion in coming from, it's the physics of the fluid column you're creating by hanging the secondary bag higher than the primary that determines this. It is possible for the secondary to unclamped and hung correctly and still not have flow coming from the primary and not the secondary, typically due to the connection where the secondary Y's into the primary where it's doesn't fully open the Y port valve.

Oncnurse555 · Aug 28, 2018

Thanks all for the responses. I do have a preceptor who is experienced and this is what I have been taught. What I've gotten from this is That when hanging a IVPB higher that's the bag that will be taken first due to the force of gravity. Bc of this, i program the antibiotic as the primary even though it's hung as an IVPB to the saline. I then go back and add VTBI so the antibiotic is all used and there's a small flush of NS once the antibiotic is done and the primary bag is pulled from. I then get an alarm Tha\T' the infusion is done bc i programmed only for the amount and time of the antibiotic. I only use the saline for priming and backpriming and a small flush at the end. I was more so curious if other people have done this.

Night__Owl, BSN, RN · Aug 28, 2018

The pump has no idea which tubing is primary or secondary. You have to lower the primary bag with the hook, so that the secondary is higher up, so it will flow in first by gravity. If you were to hang both bags evenly, the pt would be getting roughly 50% abx and 50% base fluids until both bags were empty.

That said, I usually set the base rate to KVO, then program the secondary for the antibiotics. That way my Alaris pump doesn't start beeping the minute it is done. If it runs for an hour, I can come in about an hour and ten minutes later and take it down, without it bothering my patient.