ICU Nurses - IV Carrier Rate for Infusing Pressors

Published

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 fluid 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?

Specializes in CVOR, CVICU/CTICU, CCRN-CMC-CSC.
I am surprised your facility doesn't have a set written protocol for pressor administration. It is very rare for me to see pressors not going through multi-lumen x-ray verified central line. Our pressors come weight based, premixed, and verified by pharmacist for each PT in a 100 ml/bag. We are required to print out the specific pressor administration policy and hang it on the IV pole/pump with 2 RN verification and signing. It has start rate and increase rate till desired effect achieved plus max rate and absolute max rate. Every titration increase must be documented along with current set of vitals till stable goal reached. There is nothing left to individual RN interpretation in administration- as it should be.

Same here, except on night shift. We mix our own gtt's with 2-RN verification. Everything else stays the same though. All our pressor orders come with parameters and are infused through a central line.

Up Vote Up Vote ×
Specializes in ICU, CARDIOLOGY.

what did the physician order? IV fluids are medications that should have an order. If there is no order or an order you feel needs clarification or if you feel the pt condition requires a change of rate, CALL THE DOCTOR FOR AN ORDER. I do not think this should be something nurses should be doing as a "standard protocol". This is a medical decision with nursing input.

Up Vote Up Vote ×
Specializes in Critical Care.
what did the physician order? IV fluids are medications that should have an order. If there is no order or an order you feel needs clarification or if you feel the pt condition requires a change of rate, CALL THE DOCTOR FOR AN ORDER. I do not think this should be something nurses should be doing as a "standard protocol". This is a medical decision with nursing input.

When used to facilitate the administration of ordered medications, fluids are not actually considered a medication, they're technically classified for that use as a device. If you have an order for an IV push medication, would you feel the need to call the doc for an order for a flush?

Up Vote Up Vote ×
Specializes in PACU.

Pressors on a seperate lumen.

Up Vote Up Vote ×
When used to facilitate the administration of ordered medications, fluids are not actually considered a medication, they're technically classified for that use as a device. If you have an order for an IV push medication, would you feel the need to call the doc for an order for a flush?

Exactly!! In addition, with very critical patients, certain practitioners leave standing criteria to guide fluid administration and pressor titration. Those who have not worked in very critical areas may not have experienced this.

Up Vote Up Vote ×

We have an order set to use for carrier fluids. My hospital, like yours, also prefers the carrier fluid to be separate from the maintenance fluid. I usually Y-in pressors to the carrier fluid line, or use a stopcock.

Up Vote Up Vote ×
what did the physician order? IV fluids are medications that should have an order. If there is no order or an order you feel needs clarification or if you feel the pt condition requires a change of rate, CALL THE DOCTOR FOR AN ORDER. I do not think this should be something nurses should be doing as a "standard protocol". This is a medical decision with nursing input.

Incorrect. Most ICUs have policies and guidelines for this sort of thing.

Up Vote Up Vote ×
Specializes in Critical care.
I'm guessing your open hearts come back with an IJ or other central line? Ours come back with IVF through a manifold to a central line at 60mL/hr and orders to keep total infusion volume (including all gtt's) at no more than 100ml/hr. Post extubation (usually 6 hours post-op), policy is to drop the IVF to 20ml/hr. If a gtt doesn't play well with the others, it gets its own port and carrier at 10mL/hr, if gtt volume

One of our rationales in keeping the carrier at speed is to be able to titrate our gtt's with a faster response. Titrating a levophed gtt at 4mL/hr with a 20mL/hr carrier and about 15 mL of line from pump to vena cava will take about 45 minutes for the titrated levo rate to actually reach the patient. This opens the potential for some serious tail-chasing and over-titration. Having the carrier rate at 60mL/hr will allow the titrated volume to reach the body in a mere 15 minutes to allow finer control. Of course, once extubated, the carrier is dropped to 20mL/hr and we have to account for that increase in time when we manage titrations.

ETA: I realize the OP doesn't need the drawn-out rationale - I'm leaving it up for the benefit of new ICU nurses who may have questions about titration.

I'm not following this logic (45mins from pump to vena cava) the drug from the bag to y-site/manifold/pt access is of the same concentration, thus a change in rate has only the drug half-life to wait to see a change. The only change in any one drug's concentration is AFTER a y-site/manifold with other fluids running into same pt access lumen. Not accessing the most proximal port in a carrier line for your slow running vasovasoactives will avoid what you describe. A properly set up manifold (string of stopcocks) is only about 3ml at most...it's this volume that will affect the speed at which a rate change reaches the pt.

Up Vote Up Vote ×
Specializes in Cardiac/Transplant ICU, Critical Care.

Assuming that the patient in question has a Mac Cordis with a SWAN threaded through, it takes 1.5mL of any fluid from the VIP to the blood stream. They usually come out of the OR with a driver of 20mL/hr, but I usually take this off as soon as they get in the room as long as they are decently stable on drips. Now if the patient is extremely hypotensive and we are starting levo, I usually crank it up to 20-30 mcg/min to "drive" it in and once I see the maps bounce back I very quickly scale it back.

It always annoys me when a patient's condition is rapidly deteriorating and we are going baby steps up on the pressors. I usually hit them full blast to get a good buffer zone and wiggle room and then cut back as needed. If they are pretty stable on their drips and the total rate is >10mL I usually don't even mess with a driver.

Up Vote Up Vote ×
+ Join the Discussion