ICU Nurses - IV Carrier Rate for Infusing Pressors

[rebrrn]

Hello everyone!

Perhaps some of my ICU nurses from across the globe can help me out on this one. The hospital I work at is trying to develop many process improvements and I am trying to help my co-worker out on this topic: How fast should we be running IV Carrier Fluids for infusing pressors? At this hospital we always run our Carrier fuild with pressors while our standard IV fluids infuse in a separate line. Mainly our emergency line. We find that many of our heart/surgical patients come out of the OR with the carrier IV rate going at 100cc/hr. This is not always appropriate for some patients. And this hospital likes the carrier rate to be separate from the IV fluids. Does this make sense? For example: Fresh heart surgery comes out with IV fluids going at 100cc/hr and then an IV carrier rate going at 100cc/hr. Now the patient is receiving double the IV fluids than ordered. So then the nurse cuts the carrier fluid down to 30ml/hr. Now, the pressors aren't reaching the patient as fast which could lead to hypotensive events. Another issue we are faced with is not having a clear cut order for how fast our carrier fluid should be infusing So my questions is, does anyone work in a hospital that has a policy or order set that pertains to this dilemma? Or how does your hospital handle this issue?

[MunoRN, RN]

There's no one-size-fits-all rule for this, where I've worked it's nursing judgement since basically what you're doing is managing how drugs are infusing which is within a nurse's scope.

I think many nurses are under the false impression that when they change the rate on the levophed, for instance, that the amount of levophed entering the patient changes at the same time. You have to consider the volume of fluids between where the levophed plugs in, and where it actually empties into the bloodstream. If there is 10mls of volume between the levophed port and the end of the lumen, and the new levophed rate plus the other fluids pushing it is only 30mls/hr, then that increased dose of levophed won't actually hit the patient until 20 minutes after you changed the rate on the pump. Putting a carrier fluid behind it will produce less lag time, the amount that carrier should be at depends on various things; how labile is their BP? How large are the swings? What else is in the line? Fluid status?

The most common thing we use pressors for sepsis, and it's uncommon not to being giving some amount of continuous volume while on pressors for sepsis, so I usually run an NS at 50ml/hr behind the pressors since I will always be giving at least 50ml/hr in volume. I then run a titrated fluid in another lumen, so if I want my NS at 150/hr, I run the second lumen NS at 100. This way I can make large changes in the rate and even bolus without affecting the pressors.

For open hearts it's a bit more difficult. For one thing they typically come back with these large volume daisy chains that everything is plugged into, ideally you want minimal volume between where your vasoactive gtts, inotropes, etc plug in. Despite the fact that they often desperately need volume, the surgeons would prefer we give no volume at all if we can get away with it, so I try to get away with 20 or even 10mls/hr, although depending on how quickly rate changes actually need to make it to the patient, a carrier rate might have to be 50mls an hour or more.