Hanging 0.9 w/ antibiotics on pts with no IVF ordered.

[dudette10, MSN, RN]

Here's what I do and why, and I would like to know if anyone else does it this way or if there are any drawbacks I haven't thought about.

I hang a small bag of 0.9 as primary--100 ml, if we have it in stock, or 250 ml, most often in stock. I prime the primary line with the 0.9, then backprime the secondary line abx. I then set the pump for the primary at 50 ml/hr with 18 ml VTBI, because that is the volume that most most primary IV tubes hold based on my research. I set the secondary to the rate recommended for the abx.

Here's my rationale. For 50 ml bags of abx, using a primary line to infuse means that the patient will get only 32 ml per infusion! Even if we set the VTBI at 50 ml, the pump will stop because of air in the line at the point of the pump. By the end of three doses, infusing the abx as primary means that we will have "skipped" an entire dose!

I also like the fact that you can backprime for each new dose in the same tubing or for new abx with new secondary tubing. Much, much faster.

Am I missing something here? I can't figure out why my coworkers always hang the abx as primary. I've asked, but I just get a shoulder shrug as a response.

[Morainey, BSN, RN]

I usually hang the same 100 ml minibag of NS, prime the tubing with that, and then attach the secondary line which I have primed with antibiotic. I usually set the pump for a 25 ml NS flush, and then start the secondary line of antibiotic at whatever rate it's supposed to be at, so that when the antibiotic is done it flushes the line. Usually no problems unless my VTBI for secondary is under/over, but this doesn't happen often if it's something premixed by pharmacy.

[MN-Nurse, ASN, RN]

Am I missing something here? I can't figure out why my coworkers always hang the abx as primary. I've asked, but I just get a shoulder shrug as a response.

I enter an order (under the MD ordering the abx) for a 250ml saline bag and enter the note "For flushes/KVO during Abx administration. Not for continuous infusion." I usually set the primary to run about 25 ml at 100/hr after the piggyback runs. It appears on the MAR, works with barcoding and keeps the books cooked.

I don't backprime, just prime the secondary before hanging it as a piggyback.

One nice advantage to this is that when you have to hang another NS compatible med, you have a nicely primed set just waiting there for you. Easy to switch back and forth. It also allows you to easily give a bolus with the same set or run a concurrent continuous infusion if needed.

[2bTraumaRN2008]

That is hospital policy for us!! We are not allowed to hang straight abx without NS flush bag, and the reason is......the EXACT reason you stated - the pt will NOT get the full dose of abx!! And, we do not need a doctor's order to do so since it is our practice.

[rn undisclosed name]

The hospital I am at does not do flush bags. It drives me crazy. It is their culture. I keep meaning to bring this up to ID and see what their thoughts are on it.

I've brought up this exact issue to my educator and the other educator on the floor was appalled and said we couldn't do that cause most of our patients are cardiac patients and could get fluid overloaded. Umm, I think not!

[LynnLRN]

I agree with you, if the abx is primary then the pt misses a big dose of the med especially when it is only a 50ml abx. Most of my coworkers prime it this way also. The only time I really see it without the flush is when pt's come from ER.

[BacktoBasics]

We just use 1 pump. 1 primary NS at KVO and Abx piggybacked with "secondary tubing" (it's only like 5 ml's).

Or in your case, you can just run the Abx as primary, set your pump to infuse 32ml. When its finished, hang a 50ml NS in place of the Abx and set it to infused for 18mls. 1 pump, 1 less tubing needed, smaller flushed NS amount and line is flushed.

[Gold_SJ]

Here we prime the line with the ivab/Saline mix (in 100ml bag) Run it and have VTBI at 75mls. Then pump beeps we stick up a flush and run that through 30mls so the client gets the entire IVAB.

We generally have seperate lines for IVABs compared to a piggy back or we use a burette.

For children of course it's a whole different kettle of fish.

[Cuddleswithpuddles]

Has anyone else noticed that a lot of IV pumps nowadays leave a lot of medications in piggybacks even if there is a primary bag? I notice a LOT of piggybacks from previous shifts with a good bunch left. I consistently have to program VTBI as 15-20 cc more than what is in the bag.

[BacktoBasics]

Has anyone else noticed that a lot of IV pumps nowadays leave a lot of medications in piggybacks even if there is a primary bag? I notice a LOT of piggybacks from previous shifts with a good bunch left. I consistently have to program VTBI as 15-20 cc more than what is in the bag.

It's not a pump issue. It's overfilled for a reason. You take a 50ml IVPB, and add 15ml of medication. You end up with 65ml's total (essentially).

[MPKH, BSN, RN]

I was taught to always have a primary line when hanging ANY IV medications...the same way you always have a primary line when hanging blood and blood products. This is the first time I've heard of running IV antibiotic as a primary line. Is it commonly done?

[Anna Flaxis, BSN, RN]

It's been a couple of years since I've worked the floor, but we weren't allowed to hang fluids without a doctor's order, even to use just as a KVO or a flush. In the ED, we typically run NSS wide open, unless it's a pediatric patient or a medically fragile adult, or if the fluids contain K+, so in most cases, antibiotics are the primary on the pump, Y-sited into the NSS which is free-flowing.