Iv antibiotic running as primary?

Nurses General Nursing

Published

Perhaps I am overthinking this, but alas...

I've recently noticed on my floor patients who are not receiving continuous IV fluids having IV antibiotics run as the primary on the pump. No small bag of normal saline is being used as the primary with the antibiotic as the piggyback. There is approximately 13mL in the distal primary tubing. This means that a patient who is receiving a 50 mL antibiotic is missing out on almost a third of their dose left behind in the tubing...right?

I am relatively new at my facility and am unsure how to go about this. If I see an antibiotic being run as the primary, I will swap the old abx bag for a 100 mL bag of NSS and run the abx as the secondary.

Should I send an email to my manager? I can't find a policy regarding this.

Specializes in Critical Care.
ah i follow you now

The way you described it in your previous post is exactly how I would normally do it when there is no continuous fluid ordered, just with the clarification that I would set it that way while using a primary/secondary setup.

I can understand the Emergency Department doing this.

Specializes in ED, Cardiac-step down, tele, med surg.

We do this in the ER all the time. It drives the floor nurses nuts. If you will be giving multiple doses on the floor, it makes sense to run it as a secondary. It makes it easy for the next nurse to reuse the tubing and prime it from the primary bag. In the ER because our patient will be going up and out of the department, it's often easier to run an antibiotic as a primary. The floor will toss all of our tubings anyway and start over.

very confused.

if you have 15ml of tubing, and a 50ml bag, thats precisely why you would set the VTBI on the pump to 60 or in this case 65. Unless your pumps switch to KVO mode after infusion or something. Ours dont.

There are still pumps in use that use gravity, or a height difference to determine which bag is piggyback. In that case, setting the volume at 65 will cause it to infuse 50 ml from the higher 50 ml bag of ABX, then 16 ml from the lower bag of NS.

How is the abx ordered? Our are all ordered IVPB, so to me that means if I run it as primary I'm not following the order as written. I would hang it piggyback even if I had a choice, for the reason many others have noted, and so that I can back flush and use the same set up for other IVPBs ordered instead of starting over with a new primary line if not compatible. It's annoying when the nurse before me runs as primary and runs the line partially dry.

Two points:

1 - Typically, most of the leftover, unfinished medication in any given infusion is in the drip chamber rather than in the more distal tubing. In effect, this means that you can hang an antibiotic as a secondary and still have more unadminstered medication afterwards if the drip chamber is full than you would have left if you had administered it as a primary infusion but run the line dry to the point of the air-in-line detector. Hanging the saline bag substantially lower than the secondary medication is important if you intend on adminstering more of the dose than you would otherwise.

2- It is often difficult or impossible to know the exact conditions in which various drugs were administered during the clinical trials that guide and justify their usage. If the antibiotic was administered during clinical trials in such a way that some of the initial dose was often left in the tubing, and that clinical trial still demonstrated optimal effect, it's not at all obvious that jerryrigging the infusion to ensure every drop gets to the patient is actually beneficial in the first place.

A related issue:

In some places there is unnecessary difficulty (time-wasting hoop-jumping) required to set up an IVPB because when the medication and route (IVPB) are ordered, this doesn't generate anything in the eMAR or the dispensing machine that accounts for the flush fluid. A separate order entry is required for that or else requires an override in order just to get the flush bag out of the dispensing machine. It's not too big a deal I guess, once the flush/primary set-up is in place, but I'm guessing it is a decent factor in flush sets that never get set up to begin with.

Regardless, this could be easily made less of a run-around by having a PRN or nursing protocol order for IVPB flush set that could be utilized at the initiation of orders for intermittent IVPB meds and/or whenever there is a need for a new flush bag.

Specializes in Cardiac Stepdown, PCU.

Maybe it's just where I work but most bags of fluids we get account for the iv line. Like, when I'm hanging zosyn, there's 110mL in the bag. Granted, I've always hung with a flush but i wouldn't see this as an issue if there's extra fluid in the bag.

It's super annoying to deal with antibiotics ran as a primary. I always run antibiotics as a secondary. Makes so much more sense and makes infusion management easier overall. Some nurses are just lazy and run everything as primarys.

Specializes in Med-Surg, CVICU.

Thank you everyone for your replies! I work on an adult med-surg unit, so we use plum pumps for all IV medications.

All IV meds, whether it is an antibiotic, keppra, electrolyte, etc. are always ordered "IV"...not specifically IVPB.

I concur from the responses that it makes more sense to hang these meds as a secondary infusion, particularly if they are going to be given q4/q6/q8 or if the patient is receiving several different types of antibiotics or other medications.

I will check with my manager when I work next and get his input.

Thanks to everyone again!

Maybe it's just where I work but most bags of fluids we get account for the iv line. Like, when I'm hanging zosyn, there's 110mL in the bag. Granted, I've always hung with a flush but i wouldn't see this as an issue if there's extra fluid in the bag.

Yes, I am pretty sure our bags are mixed with overfill for this very reason.

Specializes in Critical care.

Always run ABx as a secondary/piggy back set, for several reasons, as previous posters mentioned. People who don't do this are either lazy, or the hospital is super cheap and trying to save money.

1. The full dose isn't given - as previously mentioned up to 15 ml will stay in the tubing.

2. Drug stability - most of our ABx are stored in the fridge because they are only stable at room temperature for a limited time. So if the nurse hangs a daily ABx, leaves the set up for the next day and gives the next days dose that med has been sitting at room temperature for ~23 hours.

3. Compatibility - If you are using the same primary set for all of your antibiotics you could run into reactions when the drugs mix, as you can't back flush the set like any sensible nurse would who set up a secondary set.

Cheers

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