Heparin gtt Through Mannifold

[nursingstudentwannabe, BSN, RN]

Hello! I recently had a patient who was on a heparin drip (daily Xa draws, no rate changes). The patient had one IV access when I took over the assignment. The heparin was going through a mannifold with NS running through the middle of the mannifold. About an hour in to my shift, I had to hang IVPB remdesivir. I only had the one IV access, so I asked my manager if it was OK to hang the remdesivir onto the NS running through the middle of the mannifold. He said it is generally avoided if you have other options, since running something at 200 mL/hr boluses the heparin in. The previous nurses had been hanging any IVPBs on NSS running through middle. 

Originally, I decided to put the remdesivir on standby, as I planned to go in to get a new IV on this patient (he was COVID-19 btw). However, another patient (also COVID-19) started trending some really high BPs and had some stroke s/s. I needed to take him to CT to r/o stroke. Plus, my third patient was set to upgrade to ICU, so I also had to call report & transfer him as well. I decided to go ahead & just run the remdesivir for my other patient before I left the floor, figuring I wouldn't have any time to get in a new IV. (I feel horrible about this now) 

About 3 hrs into my shift (2 hrs after giving remdesivir), I went in to give insulin to the first patient. I noticed he had a really large black-purple bruise on his RLQ. The patient told me it was because he was getting his insulin through his abdomen, but I checked his chart and almost all of the nurses had been giving him his insulin through his arms. I immediately paged the provider about it. They did a CT of abdomen, and it showed a large anterior abdominal wall hematoma. We stopped heparin drip and held on his other blood thinners. 

The thing is, I'm terribly worried that I did this or at least played a part in him bleeding. Maybe he was being bolused w/ heparin because of all the IVPBs he was getting through the mannifold the last several days? Is 2 hrs enough for someone to get such a large bleed? I didn't want to run the remdesivir in with the heparin, but in the moment, it felt like I didn't have any other option. Was this a big lack in nursing judgement on my part, because I certainly feel like I did something wrong! I plan to speak with my manager about it again tonight. 

Anyway, sorry for the long rant here. I hope it makes sense! Thanks in advance for any tips!

[chare]

5 hours ago, nursingstudentwannabe said:

[...]

The thing is, I'm terribly worried that I did this or at least played a part in him bleeding. Maybe he was being bolused w/ heparin because of all the IVPBs he was getting through the mannifold the last several days? ...

[...]

Your patient was not being bolused with heparin because you were running piggybacks on the saline line.  If your heparin infusion is running at 10 mL/hour, it will only enter the manifold at 10 mL/hour, regardless of how fast everything else is running.

What will happen is that the small amount of heparin in the manifold and IV distal to where the saline enters the manifold will infuse at the faster rate.  Then, when the piggy back completes the small amount of heparin distal to where the saline enters the manifold will infuse at the slower rate.  However, the amount of heparin infused during the time the piggyback is infusing will equal the amount of heparin that would infuse during the same time period if just the saline was infusing.

[Guest219794]

Chare has it right.

Assuming the primary line is the saline.

The problem comes up if you have a highly concentrated drip, running slowly, and you tap into it.  Lets say you are running something at 3 ml/hr, and your manifold, or Y-site, is in a spot in the line with 3 ccs in it.  Patient is ordered a bolus of a compatible solution, and you plug that into your medication.  They will get whatever is between the manifold and them- in this case 1 full hour of medication in a few seconds.

Don't do that.