Help! Question about triple lumens...

miko014 · Aug 30, 2007

First of all, if you have checkoffs on this, I think you should have the information available to you somewhere (books, notes, etc). I don't like doing other people's homework for them. I'm not trying to be mean, but how will you learn to do this stuff if you don't do the legwork now? Besides that, if we tell you what we do, and it is different from what your instructor taught you, will she be cool with "oh well that's what they said to do on allnurses"?

That being said, I have no problem with a push in the right direction . Use your common sense here. You know that you have three different lumens available. If the med you need to give (in any form) is not compatible with the MIV that is running, can you give them together through the same lumen? If it is compatible, no problemo, right?

As far as flushing and things, that is based on hospital policy and you will need to look that up. For example, where I work, we no longer flush anything with heparin (unless it is an IP that we are de-accessing). But other facilities do. For that, you'll need to go on whatever the instructor taught you. Now, for compatible IVPB, is there a need to flush? For a non-compatible IVPB, what is the other option (besides running it through the MIVF that you know is not compatible)? And think about this: what is the point of having more than oine lumen available? Think it through and you will do much better on your checkoff than if we were to sit here and give you instructions to memorize.

Good Luck! :nurse:

Atlnurstudt · Aug 30, 2007

I know that the meds won't mix in the lumen of the triple lumens, but will they mix when they enter the blood stream and then react? I did some more research on the web and it seem that the point of triple lumen is to be able to administer incomp. meds in critical care and trauma and if they're administering TPN. I know the protocols will differ on amount to flush and amt and if to heparinize. These will be given to us in check offs. Unfortunately we were taught this for only a short 5 minutes or so (for me almost 2 years ago) and our lab manuel doesn't go over it at all, except to say that agencies will differ on their protocols. I'm assuming if there is a primary infusing and your med is a push and is comp. that you could just pinch the primary, swab, push med., then unpinch. If the med is uncomp. now I'm thinking that you would just swab, flush, push med, flush and hep. lock. to the other non-blood port (not distal). If it's an ivpb I'm thinking to not bother piggy backing it into the infusing fluids but to just set it up with primary tubing to the other non-blood port, flushing before and after it's done and then hep. lock according to protocol. If the ivpb med ordered is not compatible then I'd do the same thing. Does this sound right? I'm just nervous about the non-compatible meds mixing somewhere after they leave the catheters.

Oh, and please do not assume I have not exhausted all of my resources. Our instructors unfortunately are not perfect (nor available 24/7) and this was just a gray area for many students!!! I have maintained a 4.0 through the program and will hopefully, if I pass this check-off , graduate summa cum laude in December.

My weakness is the hands on stuff, however, and since we only have 3 total check-offs in our entire BSN program I get super nervous, (yeah I think it should be more that that too)!!! I'd rather be taking boards on Friday!!!!

Thanks for your help...hopefully you'll let me know if I'm on the right track...

Carrie

TazziRN, RN · Aug 30, 2007

Think about it this way: if the pt did not have a triple, but say had two periph lines, and you give incompatible drugs in the separate lines, they would also mix in the blood stream, no? Using that train of thought, could you give incomp. meds in separate lumens of a triple?

And don't be too harsh on Miko.....lots of students come here wanting us to do their research for them, and to be honest your request sounded like that.

Atlnurstudt · Aug 30, 2007

Yes, I understand the concept, and I've got my answer, I guess, but still, in triple lumens it seems like the meds hit at the same point in the catheter on it's way to the heart, here's a picture:

http://connection.lww.com/Products/taylor5e/documents/Ch46/jpg/46_010.jpg

How can the medications not mix in there when they meet in the catheter once the three lumens come together as one. Am I smoking crack here???

"Think about it this way: if the pt did not have a triple, but say had two periph lines, and you give incompatible drugs in the separate lines, they would also mix in the blood stream, no?"

But here they are being infused into totally different veins, not the same one.

Ugh...

Sorry, I like to know the nitty gritty and I'm not happy until I understand not just the answer but the why...

Carrie

Oh, and thanks...btw, those who don't want to help, don't have to respond

TazziRN, RN · Aug 30, 2007

But here they are being infused into totally different veins, not the same one.

Sez who? I've started many a duplicate line in the same vein, just higher or lower than the first one.

azhiker96, BSN, RN · Aug 30, 2007

The meds don't meet in the catheter. A triple lumen has three exit sites, the proximal, medial, and distal. The blood flow in the superior vena cava should be more than adequate to mix/disperse each drug before it meets the next one.

On the other hand, I recently saw a FDA warning against treating Neonates with rocephin if they are receiving calcium containing fluids, even if given in separate lines. http://www.fda.gov/medwatch/safety/2007/safety07.htm#Rocephin

deeDawntee, RN · Aug 30, 2007

The tip of the triple lumen is in the superior vena cava and the blood flow there is so fast and turbulent and there is so much of it that compatibility at that point is NOT an issue. I always had questions about medications that were hard on veins being injected directly into the heart through a central catheter...how was that a good idea? I always wondered. The answer is the same. Even with chemo drugs that are very caustic the VERY best place to infuse them is right above the heart itself, the blood flow is such that the heart is protected. It seems counterintuitive, but it REALLY is the very best place to infuse.

The problem with compatibility is that if the two meds come directly in contact, precipitates can form (white snow-like particles) that can cause problems in the vasculature. If you ever inject an IV push and see white particles forming, stop pushing!! In the ICU if we had a lot of IV pushes or piggy backs that were incompatible with the MIV, we start a carrier (NS) at a tko rate so that you aren't repeatedly locking with heparin and then pushing it through a short time later. That is left up to nurse's discretion. The rule of thumb is if you had 4 iv pushes in a shift that required heparin locks, it was best to start a carrier to avoid all that heparin infusing into the systemic circulation.

Good luck and relax. You will do fine.

Atlnurstudt · Aug 30, 2007

The tip of the triple lumen is in the superior vena cava and the blood flow there is so fast and turbulent and there is so much of it that compatibility at that point is NOT an issue. I always had questions about medications that were hard on veins being injected directly into the heart through a central catheter...how was that a good idea? I always wondered. The answer is the same. Even with chemo drugs that are very caustic the VERY best place to infuse them is right above the heart itself, the blood flow is such that the heart is protected. It seems counterintuitive, but it REALLY is the very best place to infuse.
The problem with compatibility is that if the two meds come directly in contact, precipitates can form (white snow-like particles) that can cause problems in the vasculature. If you ever inject an IV push and see white particles forming, stop pushing!! In the ICU if we had a lot of IV pushes or piggy backs that were incompatible with the MIV, we start a carrier (NS) at a tko rate so that you aren't repeatedly locking with heparin and then pushing it through a short time later. That is left up to nurse's discretion. The rule of thumb is if you had 4 iv pushes in a shift that required heparin locks, it was best to start a carrier to avoid all that heparin infusing into the systemic circulation.
Good luck and relax. You will do fine.

Wow. Thanks so much! Now my stubborn brain is happy. I just can't take something and do it "just because". I don't think that's good practice, esp. when you graduate and are responsible for lives under a license you worked so hard for. (Trust me when I say that a lot of nursing students have no idea "why" you do something, they just know to do it). I always want to know the why, which should be the norm.

So...

Are the medications just going through there so fast that it normally isn't an issue even for the small time they are together in the catheter after they meet, inside the body? They don't have time to react with one another and then they hit the heart and are quickly dispersed? Because like the pp said about the rocephin and calcium, and there is apparently some problems also with dilantin, there seems to be some problems happening, albeit rare. Is this right??? I'm doing my preceptorship in the PICU so I'm sure I'll learn a lot about this stuff. Good info on the carrier line and heparin. I was wondering if it would be better to set up IVPB to primary if possible in order to avoid heparin depending on the client and situation. I think I was told by someone you'd just infuse your IVPB on one of the other lumens (at least for check-offs, though I think either would be acceptable in practice, assuming the IVPB is compatible?).

Carrie

Oh, and you should teach/precept...you explained that nicely.

Atlnurstudt · Aug 30, 2007

Ahhhh....my answer (I think):

http://www.icufaqs.org/CentralLines.doc

So the part where the three lumens appear to join actually still consists of three lumens wrapped up all in an outer plastic, or whatever material, tube? Makin' sense now...distal, medial, and proximal, get that too now. Yea. Not that this now has anything to do with check-offs, but it was irking me. I just didn't understand how the device was actually made...it's not like we dissect them in lab, and believe me, they didn't go over the anatomy of a triple lumen. We just went over the different types of central lines.

Lets all celebrate so I can stop bugging you!

Carrie

deeDawntee, RN · Aug 30, 2007

Wow. Thanks so much! Now my stubborn brain is happy. I just can't take something and do it "just because". I don't think that's good practice, esp. when you graduate and are responsible for lives under a license you worked so hard for. (Trust me when I say that a lot of nursing students have no idea "why" you do something, they just know to do it). I always want to know the why, which should be the norm.
So...
Are the medications just going through there so fast that it normally isn't an issue even for the small time they are together in the catheter after they meet, inside the body? They don't have time to react with one another and then they hit the heart and are quickly dispersed? Because like the pp said about the rocephin and calcium, and there is apparently some problems also with dilantin, there seems to be some problems happening, albeit rare. Is this right??? I'm doing my preceptorship in the PICU so I'm sure I'll learn a lot about this stuff. Good info on the carrier line and heparin. I was wondering if it would be better to set up IVPB to primary if possible in order to avoid heparin depending on the client and situation. I think I was told by someone you'd just infuse your IVPB on one of the other lumens (at least for check-offs, though I think either would be acceptable in practice, assuming the IVPB is compatible?).
Carrie
Oh, and you should teach/precept...you explained that nicely.

Thank you!! Yes, you've got it. As far as peds is concerned, I have no experience. Yes, I would say that IVPB to primary is preferable to avoid too much heparin. Also you may want to consider the fact that when you run an IVPB for that period of time the MIV does not run, unless you set your pump to run concurrent. So if the patient receiving the full volume of the MIV is an issue, it is best to run concurrent, but this is fairly rare. (One case would be in sepsis). In most cases we do not worry about that. Just remember that when you add up your I&O that during that hour (or however long) to count input accurately. To tell you the truth, it is a pain to run just a IVPB through a lumen in practice, because you will have to be there when it runs in or the pump will start beeping. That is why many of us will use a carrier, so that we have some leeway as to when we need to be there to lock the infusion. (does that make sense?)

You are going to be an awesome nurse!! Wow, talk about critical thinking!! I am truly impressed!! Keep asking your questions, they are awesome!!

miko014 · Aug 30, 2007

Oh, and thanks...btw, those who don't want to help, don't have to respond

Does that refer to me? Because I was trying to help you. Just telling people answers does not teach them anything. I know that you are just trying to understand, and you are doing a great job with your critical thinking skills. But do you realize how many students come on here and ask for help with homework? I do give you a lot of credit for being honest though...sometimes people just post the entire question (or questions) word-for-word right off their asignment. I never said that what you asked was not acceptable, and I tried to help you. Actually your post right after mine was very good. I wasn't around when you did it, or I would have responded again, but I think everyone else got it covered. Good luck on your checkoffs.