ICU Nurses I Didn't Know You Could Do This???

CrufflerJJ, BSN, RN, EMT-P · May 20, 2012

Also the middle lumen is used for what?

Whatever your little heart desires.

If you're running into a "line" shortage, either check drug compatibility on your spiffy PDA (yes, I'm old fashioned), phone, or you can even call pharmacy.

We tend to run most pressors together. Bicarb can be finicky with some pressors, but not others. I try to leave my last lumen for use with a less than critical med. If you have to interrupt a bicarb drip for half an hour, generally there's little harm done (your mileage may vary).

Creamsoda, ASN, RN · May 20, 2012

Yeah you can pretty much run most pressors together, just double check compatibility. If its compatible, run em together! Bicarb is not compatible with a lot, but sometimes it is.

FlyingScot, RN · May 20, 2012

My manager comes in and gives us some tips. He basically stacked three- 3 way ports together one for each pressor on a main line of normal saline and connected it to one of the triple lumens and a heplock to the other end, then connected each pressor to a port.

This is called a "manifold" and you can stack as many stopcocks as you want as long as the drugs are compatible.

MikeRNWI · May 20, 2012

Yep sometimes in the ICU you need a long chain of stopcocks to manage everything. Last weekend I had a patient on with a triple lumen and a IJ dialysis catheter for CVVH. Had so much that we even had to stopcock things into the Dialysis venous return line as well. Sometimes you just have to verify what's compatible and form a chain. The only thing to be aware of in that case is if anything gets bolused, everything gets bolused for a short time...

Candyn · May 21, 2012

HI MikeRNWI,

Sorry I am a new grad, is it ok to bolus every for a short time? That will be all the vasopressors and bicarb??? Interesting....

Biffbradford · May 21, 2012

Just don't hook up your CVP to that port too, or you can bolus your patient with XYZ when ever you flush it. :clown:

BelgianRN · May 21, 2012

As others have said most vasopressors/inotropes are compatible so we infuse them via a single lumen on the central line and dedicate this line as the hemodynamic line. Since most of the sedatives we use are compatible we infuse them on a single, but different lumen on our central line and dedicate this as sedation line. Both lines are sacred and won't be used for anything but continuous meds to avoid unnecessary pushes of both.

To answer your question Mike it isn't okay to bolus with your vasopressors and inotropes. It leads to major swings in your hemodynamic profile. Very seasoned nurses/MDs will do this on occasion and make and educated guess that a 0,05 - 0,2 ml of the entire mix will increase BP just by enough. Although I have done this successfully in the past I still prefer to just keep upping the doses for desired effect or give them a bolus of a single pressor via a dedicated bolus line.

I found that when you infuse bicarb quickly it generally leads to a swing in BP anyway since you tend to push your pH towards a more normal value and the effect of your vasopressors and inotropes potentializes since they are not very functional in acidic environments. And generally patients with multiple pressors are in some degree of metabolic acidosis.

MikeRNWI · May 23, 2012

I agree with BelgianRN. You dont want to bolus your pressors. If your patient is requiring increasing doses of these medication, it is doubtful a transient dost such a as a bolus will be helpful in the long term. Once the bolus wears off, you lose its effect and have dangerous hemodynamic swings. It is much safer to simply increase the dose.

My comment was implying that if you stopcock together, say, your pressors and midazolam for sedation, that if you give a bolus of midazolam, you will also give a very small bolus of vasopressor (whatever is in the catheter at that time). Sometimes you have no choice but to connect multiple drips together, but its always important to remember everything that you have connected in that line.

manager123 · May 23, 2012

"Sometimes you have no choice but to connect multiple drips together, but its always important to remember everything that you have connected in that line".

Seriously, don't even attempt to rely on memory. The nurse that follows you will curse you to hell and back when they come on and spend 20 minutes trying to figure out what line is what, especially if the patient starts to dump. This is when that paper tape comes in really handy. LABEL each of your tubings with the drug name near the connection to the manifold connection. You can see in a heartbeat what is running through there especially if you need to push a med in a hurry.

Creamsoda, ASN, RN · May 24, 2012

"Sometimes you have no choice but to connect multiple drips together, but its always important to remember everything that you have connected in that line".
Seriously, don't even attempt to rely on memory. The nurse that follows you will curse you to hell and back when they come on and spend 20 minutes trying to figure out what line is what, especially if the patient starts to dump. This is when that paper tape comes in really handy. LABEL each of your tubings with the drug name near the connection to the manifold connection. You can see in a heartbeat what is running through there especially if you need to push a med in a hurry.

Or if god forbid...and you know of course none of US would do this, BUT say the previous nurse forgot to order a new bag and your levo runs dry and you got 4 pressors going and the other nurse didnt label anything and your pressure suddenly tanks because your pump is beeping "air in line. You want to be able to mix that bag up ASAP and prime that line up quick and know at which hub to disconect it from so you can flush the air out and get it going again. Also having a obvious label for a med line is nice too (like where your NS/maintenance is running) so you know imediately where you can push your drugs.

armyicurn · May 24, 2012

I would second what Creamsoda said. I make it a habit to ensure I have enough reserve in the bags and never punch the total volume to be infused on the pumps. I have been put on the spot by other incompetent RNs with this. Everything hits the fan 10 minutes after shift change when the pump goes nuts only for you to discover that you have run dry.

Also, if you have a half fast pharmacy section, order that pressor ahead of time. My pharmacy where I am currently stationed rates way below subpar and I have confronted the pharmacist on duty many times. It is an ongoing battle.

I also carry a card the size of the hospital badge with all the drips std and max concentrations. I carry this card along with the other 500 plus cards of nonsense the hospital wants us to carry. It has come in handy many times where I had to mix my own drips at the bedside. Pharmacy was too slow for me to wait on them and I do not do dead patients. I recreate this card every time I go to another hospital where the ICU protocols on pressors and such are different from the previous one where I was stationed at.