Incompability med question

[Glou]

Hello! First time asking here.

I just had a question regarding incompatibility of meds. I was using a peripheral line for a patient. One lumen was getting sodium bicarbonate and the other was getting NS TKO. If I had to give a med that was incompatible with sodium bicarbonate I just clamp the sodium bicarbonate at the IV site and use the closest port of the TKO line flush with 10cc of NS and then give med then flush again then restart the bicarbonate. however this time, I was not as cautious as I usually really am and mixed up my lines. So I clamped the NS line (unknowingly). Paused the bicarbonate. Then flushed from the nearest port 10 cc and gave zofran (incompatible with sodium bicarbonate). I was more than halfway giving this med IV push when I realized I was using the wrong line. So I stopped immediately. Clamped the line. Flushed NS in the TKO and pushed the rest of med in the TKO Line. I changed the whole tubing of the sodium bicarbonate bag. I immediately checked the patient she had no pain. At first the site I thought looked swollen but it seemed fine. I got blood return ( with difficult but there was blood return nonetheless). So I figured it would be okay. I told the next nurse the situation and to keep an eye on it. I texted her if she could let me know if the patient is okay and her arm is fine. During this time I could not sleep when I got home. She texted me a few hours later and told me pt was okay and no issues with her arm. (Sorry this was so long). So I guess my questions are does that mean I no longer need to worry? She would’ve reacted by now right? Like she would have been in pain or her arm would have been infiltrated or extravasated. Does the fact that I flushed 10 cc at the closest port in the sodium bicarbonate line prior to the incompatible med zofran help?

[MunoRN, RN]

I'm not sure what you're referring to by a multi-lumen peripheral IV, some PIVs have two ports, both attached to the same lumen, if you mean a PICC then that would often have multiple truly separate lumens.

Generally though, it's typically considered sufficient to adequately flush a lumen or tubing carrying an incompatible fluid, give the med, flush again, then restart the fluid.  

[Glou]

@MunoRN

Ahh that’s what I meant same lumen but with two different ports!

Thank you for replying! I appreciate it. I guess I just wanted another opinion or some reassurance that one flush was enough to prevent any precipitation or anything like that especially since I did it from the nearest port on the tubing and didn’t disconnect. These thoughts or questions will kind of dwell with me well after a shift so thank you! 

[Been there,done that, ASN, RN]

Sodium bicarb was mixed with Zofran. Many serious interactions can occur. The IV site is the least among them. The physician should have been notified and an incident report written.

The patient needs two separate IV sites.

 

[LibraNurse27, BSN, RN]

I know it's best to disconnect/reconnect IV lines as infrequently as possible, but if you're pushing meds into a line that's not just running saline or another maintenance fluid, I usually disconnect the line, flush the IV, give the med, flush again, reconnect. Maybe if pt is just getting LR or something I'll flush from the nearest port and not disconnect, but not if the line is running a med.

I know it's a small distance from the nearest port to the IV, but, for example, if you flushed a bumex drip that's going 5ml/hr, you would be pushing in the bumex much faster than the rate. I think it's unlikely to cause harm, but for me it helps to just disconnect in order to prevent flushing the med running in the tubing in too fast and prevent mixing incompatible meds. Sounds like your patient is fine though! I would just learn from it and move on = )

[MunoRN, RN]

31 minutes ago, Been there,done that said:

Sodium bicarb was mixed with Zofran. Many serious interactions can occur. The IV site is the least among them. The physician should have been notified and an incident report written.

The patient needs two separate IV sites.

 

From the OPs description they didn't actually mix, the biggest potential effect of the interaction of Bicarb and zofran is that the zofran won't' be effective in an insoluble precipitate, in which case the only reason to notify the MD would be to discuss giving a one-time dose if there's concern the first dose wouldn't have an active effect.  There's no apparent reason for a second IV site.

[Glou]

26 minutes ago, LibraNurse27 said:

I know it's best to disconnect/reconnect IV lines as infrequently as possible, but if you're pushing meds into a line that's not just running saline or another maintenance fluid, I usually disconnect the line, flush the IV, give the med, flush again, reconnect. Maybe if pt is just getting LR or something I'll flush from the nearest port and not disconnect, but not if the line is running a med.

I know it's a small distance from the nearest port to the IV, but, for example, if you flushed a bumex drip that's going 5ml/hr, you would be pushing in the bumex much faster than the rate. I think it's unlikely to cause harm, but for me it helps to just disconnect in order to prevent flushing the med running in the tubing in too fast and prevent mixing incompatible meds. Sounds like your patient is fine though! I would just learn from it and move on = )

Oh I totally understand! In this case, the sodium bicarbonate was at 125 but yes definitely need to consider the rate too and most of all prevent mixing incompatible meds!. Thank you so much for responding btw! Definitely will learn from this to be even more so careful. I generally think I am pretty careful and recheck everything especially making sure nothing is clamped. But I keep reminding myself I’m only human. But my main concern is always the patient. Thank you again.

[Glou]

44 minutes ago, Been there,done that said:

Sodium bicarb was mixed with Zofran. Many serious interactions can occur. The IV site is the least among them. The physician should have been notified and an incident report written.

The patient needs two separate IV sites.

 

Like @MunoRN I don’t think I mixed if I flushed prior and the patient had no reaction fortunately from what I was told by day shift RN at least 5 hours from when it happened. I believe that’s a good sign that everything is OK. There should have been a reaction by then no? But I’m gonna ask her again later. 

I don’t believe I needed two different IV sites. (One less poke for the patient! LOL) I just needed to disconnect/flush before and after instead of just clamping the other port and infusing through the tubing to risk any possibility of mixing incompatible meds.

[Been there,done that, ASN, RN]

If you had two different IV sites, you would not be potentially contaminating the line with the disconnect/ reconnect and flushing. 

" During this time I could not sleep when I got home."  Would have saved yourself a lot of worry, if there was no doubt an interaction could have occurred.