Iv antibiotic running as primary?

[SquatsNScrubs]

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.

[hawaiicarl, BSN, RN]

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.

Most plain IV bags from the manufacturer typically come with 10% overfill, the problem with this theory is that when the medication is mixed by pharmacy they don't add 10% extra medication.

Cheers

[morte, LPN, LVN]

ah i follow you now

you had me worried...

[morte, LPN, LVN]

Most plain IV bags from the manufacturer typically come with 10% overfill, the problem with this theory is that when the medication is mixed by pharmacy they don't add 10% extra medication.

Cheers

which is why the pharmacy puts on the bag "infuse entire bag", duh. and, the diluent has to be accounted for, as well.

[morte, LPN, LVN]

Most plain IV bags from the manufacturer typically come with 10% overfill, the problem with this theory is that when the medication is mixed by pharmacy they don't add 10% extra medication.

Cheers

if I could give this one 10 thumbs up, I would.

[KeepinitrealCCRN]

They should be run as secondary. I think a lot of people are just lazy.

[MunoRN, RN]

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.

I can understand the Emergency Department doing this.

It defense of my fellow ED nurses it should be pointed out that not every ED nurse thinks it makes more sense to give a patient a partial dose of antibiotic, and since it's the first dose of antibiotic it's actually all the more important to give the full dose.

I timed how long it takes to add the secondary portion of the set-up yesterday and even at a fairly leisurely pace it was 11 seconds.

It's not common practice for floor nurses to toss IV tubing set up in the ED, so long as it was set up correctly, I've never actually seen a floor nurse toss tubing that was just set up just because it came from the ED.

[tigress_8207, ASN, BSN]

At the Hospital where I work we flush the line with at least 20 ml NS so that the patient receives all of their antibiotics.

[Guest219794]

• Nurse A has an order for asa 324 mg. Administers 3 tabs, drops one on the floor and kicks it under the bed.
  
• 
  
• Nurse B has an order for 15 units IV insulin. Draws it with an insulin srynge, transfers to a luer lock, but does not account for the dead space. Inadvertently administers 10 units, throws 5 units in the trash.
  
• 
  
• Nurse C has an an order for 400 mg abx iv. Administers 300 mg, discards 100 mg.
  

Which of these is a medication error? I am thinking all of the above.

• The order didn't specify exactly which method to give a full dose.
  
• 
  
• Everybody give a partial dose.
  
• 
  
• When the medication was studied, those nurses probably gave partial doses, so a partial dose should be fine.
  
• 
  
• My preceptor did it that way.
  

Which of these is a good rationale for giving a partial dose? I am thinking none of the above.

Many nurses are familiar with the concept of a "nursing dose". The nurse believes, maybe correctly, that an incorrect dose was ordered, give a nursing dose, and documents having given the ordered dose. Whether that is right or wrong, at least there is some rationale for independently over riding the order. I don't see any good rationale for discarding a clinically significant portion of an ordered med.

Whether to run primary or secondary is really not the question. The question is how are you going to give the medication ordered, and there are a number of ways to do it, either primary or secondary. As a professional nurses, it is our job to chose the appropriate method.

A better example than the ABX would be a more critical med like fosphenytoin, which can be given in a 50 ml bag. Is there a nurse on this forum that considers it OK to give 3/4 of a dose of fosphenytoin?

This issue has come up a couple of times at work recently, and I was surprised at how common nurses misunderstand stuff like priming volumes, dead space, and residual volume. Thanks to the discussion in this thread, I have read, and learned a bit.

It turns out this lack of understanding is a common source of medication errors, and there is a bunch written about it.

Residual volumes are often overlooked and misunderstood by many nurses, not realizing the serious implications of the inaccurate and incomplete administration of prescribed dosages may lead to suboptimal treatment outcomes or other adverse effects for the patient. When the residual volume is not cleared, it has been reported that a 40% loss of the prescribed antibiotic dose occurs. In your case, it's 50%

An urgent issue came to my notice within the Trust regarding the under

dosing of patients with infusions of IV antibiotics by anything up to 50% of

the prescribed dose.

Thanks to this thread, I have learned something I feel like I should have already. This article helped me.

There has been talk about overfill in this thread. There is an important distinction between pharmacy and commercially filled bags. Pharmacy bags generally contain the entire dose needed, but the volume may be higher than 50 ml, or it might be exactly 50 ml. (or 100, 250...) The key here is that the entire bag must be infused to give the full dose. In a perfect world, the pharmacy will make that clear with specific instructions. I don't know who lives in that perfect world- I don't.

A commercially prepared med bag may have overfill, but the concentration will be as listed. In other words, regardless of whether there is 50 or 55 ml in the bag, 50 ml will deliver the prescribed dose.

[Ms Kylee]

We run as primary.

[emm1256]

In the ED where I work, most loading doses run over 30 minutes. We use a dial-flow to put the meds in, flush the rest of the line with a flush; I never grab a pump unless the abx have to run for longer than 30 min.. Pretty sure the floor nurses hate DialFlow tubing...but At our hospital there are not enough pumps and channels in the ED for every patient to have a pump/multiple channels. It's more of a "Just grab one when you need one" type thing.

[guest940422]

I've worked places that do this and then run a "flush bag" behind the antibiotic for 20 mls. Drives me nuts because I have to make a special trip to hang the flush bag and the pump beeps twice at the end of the infusion (night shift sleeping babies/parents). I tried teaching people how to use a primary NS bag, to flush, pointed out the same bag can be used for multiple antibiotics, showed people how it decreased the number of steps they took to hang a med.... culture wins.

Do your job the best way you know how and don't worry about everyone else. They are practicing under their license and you are practicing under yours. As long as you know you've done right by your patients you're in good shape.

Openly teach anyone who asks about the way you hang your drugs, practice catches on better when people see it than when told to do it.

[mrf0609]

I was taught that even giving any NS or other fluid, as a primary, without orders is administering without orders. I have a few issues with hanging a separate primary line of NS if the patient does not have fluids ordered. First, fluids need to be changed every 24 hours, most of the times when I see people hang a ns primary with an abx piggybank no one ever changes that fluid every 24 hours. The other issue is that many times the patient does not need additional fluids due to other conditions, kidney failure or chf, they do not need the extra fluids given. Often times I find the night nurses tend to hang the small saline bags so that they can run the fluids, albeit slowly, overnight and not have to deal with mapping the patient. Just my thoughts on it, and what I was taught.