Insulin and phenylepherine

[offlabel]

I was advised today that putting insulin and phenylephrine on the same manifold is verboten because of "incompatibility". We run up to six infusions through a manifold with our cardiac surgery patients. As central access can get used up pretty quickly in these patients with other things like volume and blood products, I'm resistant to dedicating an entire lumen of a central line for one drug.

When I research the matter, all I can find is that in animal models, phenylephrine decreases the efficacy of insulin when given at the same time. Nothing at all about line compatibility. So I'm calling BS on that unless someone can produce a real reason to separate the two.

Anyone?

[MunoRN, RN]

Trissels lists 4 studies, which included the finding of precipitate when combined at normal diluations and for normal duration. I usually put the insulin in through the introducer, vasoactives/inotropes run through the medport. This is partly because I start getting the patient ready for the floor as soon as they come out of the OR (I despise having to switch everything over when it's time to transfer), so I put everything that will continue on the floor through the introducer, since that will be all that's left when they go to the floor.

[offlabel]

Trissels lists 4 studies, which included the finding of precipitate when combined at normal diluations and for normal duration. I usually put the insulin in through the introducer, vasoactives/inotropes run through the medport. This is partly because I start getting the patient ready for the floor as soon as they come out of the OR (I despise having to switch everything over when it's time to transfer), so I put everything that will continue on the floor through the introducer, since that will be all that's left when they go to the floor.

Thanks...could you provide the study sources? I'm not familiar with Trissels.

[tcvnurse, BSN, RN]

Why not just run the insulin through a peripheral line? Or, in our ICU for our cardiac surgery patient's once we get them settled we put the propel through the peripheral run the pressers through the VIP port on the swan and the maintenance and Insulin in the white port of the MAC using a y-extension set.

Personally, I always feel like I never have enough access so I like to place another PIV asap when pt arrives from OR if possible.

[MYSTICOOKIEBEAR]

I see patients come out of the OR with insulin in the VIP all of the time. I would, however, advise you to NOT run your insulin with your adrenergic agonists because if you have to give a bolus, you are "punching" the patient with a lot of pressors that they definitely do NOT need.

I usually run my insulin behind my D5W tko that also has antibiotics and lytes piggy backed to it.

[offlabel]

I don't give insulin boluses to patients on insulin drips. I increase the rate if necessary. Besides, between the carrier solution and whatever other drips that are on, there isn't very much of anything in line at any one point in time. I'm not worried about "punching" anything or in advertently decreasing something with a change in rate of something else.

[MYSTICOOKIEBEAR]

I don't give insulin boluses to patients on insulin drips. I increase the rate if necessary. Besides, between the carrier solution and whatever other drips that are on, there isn't very much of anything in line at any one point in time. I'm not worried about "punching" anything or in advertently decreasing something with a change in rate of something else.

Nursing preference or against hospital policy? Our post op cardiac surgery patients have a very tight insulin protocol devolped by our endocrine team in conjunction with our cardiac surgery team that requires us to administer insulin boluses to get blood glucoses

[offlabel]

Nursing preference or against hospital policy? Our post op cardiac surgery patients have a very tight insulin protocol devolped by our endocrine team in conjunction with our cardiac surgery team that requires us to administer insulin boluses to get blood glucoses

Personal preference. There is no evidence that aggressive BG management improves outcomes in cardiac surgery patients. Yes, there is a generally accepted range of optimal BG (I personally use 140-180 in the OR), but titrating an infusion is adequate in all but the most brittle of patients, IME.

[MunoRN, RN]

Thanks...could you provide the study sources? I'm not familiar with Trissels.

I'll see if there is some way to link to it, I don't have access to Trissels at home and I don't access allnurses at work, we also have access to King's which also referenced studies.

I would agree that we often say something is incompatible for various reasons when it actually isn't, but this one appears fairly legit. What the Trissels studies observed was a visible precipitate when they were combined at normal IV infusion concentrations, resulting from combining an acid and a base which produces a salt, making the inactive. EVen that doesn't necessarily mean they really can't go together, since some of these precipitates quickly dissolve again once mixed with blood. Norepinephrine and insulin are also listed as true incompatibilities, although hearts frequently come back with both insulin and levo running together in the same lumen by the anesthesiologist, and both appear to still be working.

[MunoRN, RN]

Personal preference. There is no evidence that aggressive BG management improves outcomes in cardiac surgery patients. Yes, there is a generally accepted range of optimal BG (I personally use 140-180 in the OR), but titrating an infusion is adequate in all but the most brittle of patients, IME.

I also would never bolus or even titrate the drip just to get them below 150, I usually shoot for 140 as the target but the best practice is well establish which is to keep BG