IV Insulin and Cardizem

[NurseBettyICU, ADN, BSN]

Pt only has 1 IV currently. Insulin gtt infusing. Can another compatible medication be Y'd into this Insulin tubing?

Same scenario, but Cardizem infusing (instead of Insulin). Can another compatible med be Y'd into the Cardizem?

I overheard a nurse say that NEVER should any other med be running with Cardizem or Insulin bc it would push the Cardizem or Insulin into the patient too fast.

Side note: pts are in ICU on continuous cardiac monitoring (Cardizem), BSG is being checked Q1 hr (Insulin).

[JKL33]

On 2/21/2020 at 1:06 AM, NurseBettyICU said:

I overheard a nurse say that NEVER should any other med be running with Cardizem or Insulin bc it would push the Cardizem or Insulin into the patient too fast.

How would that work?

[Rose_Queen, BSN, MSN, RN]

There are a few resources you can go to for accurate info on what drugs can or shouldn't be run together. There are several drug guides online, and your facility may link directly to their preferred one- mine links to Lexicomp right from the EMAR. Secondly, are there procedures/protocols/policies that your pharmacy maintains on what is acceptable? And thirdly, you can always reach out to a pharmacist at your facility with questions.

I would take what the other nurse said with a grain of salt. You would be using two channels on a pump or two pumps, and each medication would have its rate controlled by a pump. I'm not seeing how having multiple meds running like that could lead to one med being pushed too fast.

[adventure_rn, MSN, NP]

Maybe I'm misunderstanding. You can definitely y a drip in with another compatible drip and it shouldn't cause too many problems (unless they're running at dramatically different rates, in which case you may see a bump in the initial med when the y'd in drip is started).

However, you can run into big problems if you're y-ing bolus meds in with your drips (even if they're compatible). Every time you give a bolus med with a drip, you're going to bolus a bit of the drip (unless the rate of the bolus med is exceedingly slow, i.e. the same rate as a drip would run). This isn't a huge deal for certain drips (i.e. sedation for intubated patients), but it can cause major problems with vasoactive drips and potentially with insulin.

When you're starting/stopping a bunch of meds/drips running alongside other drips, the rate with which the med actually reaches the patient can be very inconsistent, which leads to fluctuations and swings in whatever metric you're checking (BP, glucose, etc.) The biggest safety issue is that you may end up overcorrecting or undercorrecting the drip based on the inconsistent values you're getting.

[adventure_rn, MSN, NP]

1 hour ago, adventure_rn said:

Maybe I'm misunderstanding. You can definitely y a drip in with another compatible drip and it shouldn't cause too many problems (unless they're running at dramatically different rates, in which case you may see a bump in the initial med when the y'd in drip is started).

However, you can run into big problems if you're y-ing bolus meds in with your drips (even if they're compatible). Every time you give a bolus med with a drip, you're going to bolus a bit of the drip (unless the rate of the bolus med is exceedingly slow, i.e. the same rate as a drip would run). This isn't a huge deal for certain drips (i.e. sedation for intubated patients), but it can cause major problems with vasoactive drips and potentially with insulin.

When you're starting/stopping a bunch of meds/drips running alongside other drips, the rate with which the med actually reaches the patient can be very inconsistent, which leads to fluctuations and swings in whatever metric you're checking (BP, glucose, etc.) The biggest safety issue is that you may end up overcorrecting or undercorrecting the drip based on the inconsistent values you're getting.

Still thinking about this topic an hour later...

In this situation, there's an even further cause for concern if you're using a drip where you can bolus the pump off of the drip (for instance, if you've got an insulin or sedation drip running, and you have the ability to bolus your insulin/sedation off of that pump). It's totally fine to do this if the drip is running alone. However, if the drip is running with other drips, or even with other meds, the bolus off of the drip is going to cause the rest of the drips/meds downstream from the y-port to be bolused as well.

For instance, let's say you've got an insulin drip running with a 4-hour long potassium supplement. If your blood sugar is high and your provider wants you to increase your insulin drip rate and give a bolus off the insulin drip pump, you're going to end up bolusing your K+ as well (which could potentially kill someone).

I guess my point is that you can run drips with other drips/meds in a bind, but you have to be thoughtful about what you could potentially be bolusing and how that would affect your patient.

[adventure_rn, MSN, NP]

On 2/21/2020 at 9:46 PM, JKL33 said:

How would that work?

On 2/22/2020 at 12:32 PM, Rose_Queen said:

I would take what the other nurse said with a grain of salt. You would be using two channels on a pump or two pumps, and each medication would have its rate controlled by a pump. I'm not seeing how having multiple meds running like that could lead to one med being pushed too fast.

You are correct that each pump/channel controls it's own med. However, the problem that the OP described occurs further downstream from the pump.

Let's say that you've got a drip (insulin, cardizem, epi, whatever) which is supposed to infuse at 2 mL/hr. The entire length of the tubing has been primed with this drip solution and is currently infusing into the patient.

Now let's say that you attach a bolus med at the y-port which is supposed to run at 100 mL/hr over 20 mins. Everything above the y-port (at the level of the pump) will be unaffected. However, everything downstream from the y-port (the entire priming volume of the tubing below the y-port plus the priming volume of the catheter/PICC line itself) is going to be 'flushed' into the patient at 100 mL/hr by the med. In this example, if the volume of the tubing/catheter downstream from the y-port is 1 mL of insulin/card/epi, you've taken a volume of drip medication that was meant to run over 30 minutes flushed it into the patient in a matter of seconds.

Effectively what will end up happening is that a large volume of the drip will reach the patient all at once, then it will level off and reach an equilibrium. Once you stop the drug, the amount of drug reaching the patient will rapidly drop off for a bit but eventually reach an equilibrium.

Yes, it's true that the pump controls the total volume/dose of the med reaching the patient overall. However, y-ing in additional meds/drips downstream will affect the rate at which the drug actually reaches the patient minute-to-minute. So in the example I laid out, over the course of an hour, the patient will receive the correct total amount of the drip drug. However, the dose will reach the patient way too fast when the bolus is started, and then way too slow once the bolus is stopped. This can be a big problem with drips, since the whole point is that they're being run continuously.

This ends up being a huge problem with pressors (hence why we almost never give bolus meds with pressors). When you bolus a med with a pressor, your BP shoots way up. This is to be expected, but some providers (especially residents) freak out and want to lower the pressor dose. At the same time, your bolus med stops, and the amount of the drug reaching the patient rapidly decreases (on top of the fact that you've just decreased your total pressor drip dose). Consequently, your patient's blood pressure bottoms out.

[murseman24, MSN, CRNA]

Just Y the meds low in the tubing using a few 3-way stopcocks or adding a connector with multiple ports as close as possible to the IV. The issue is that if there is a large amount of say, insulin in the IV tubing, and then you start another med that infuses quicker than the insulin, the insulin in the tubing downstream from the other med will infuse at the rate of the added med (until the insulin in the tubing is exhausted).

[JKL33]

^ Yes. And unless you are y-ing at a relatively high port, it seems likely that the amount of insulin we're talking is ~ 2-3 units or so, depending on concentration of insulin gtt (usually 1:1)... so it's just a matter of how many mls of fluid is needed to prime the tubing from the port in question to the patient; 3 mls from port to patient = 3 units insulin, etc. If you y-in right at the patient/site it would be a fraction of a unit.

[Lipoma, BSN, RN]

Or better yet...place another IV. Working in the ER I've sent patients up with 2-3 peripheral IVs.

If pt is a hard stick, get the resident to drop an EJ or central line.

[InHisImage, BSN]

I agree with everything adventure_rn has said.

As an ER nurse, I would never run anything, compatible or not, with cardizem let alone insulin!

Even if technically compatible, my hospital has policies against running certain IV meds together, and both insulin and cardizem are not to be run with other drips, so you should check your hospital’s policies first.

Finally, I don’t see how an ICU patient can get by with only one IV. IMO, and standard practice at my hospital, is for all ICU patients to have at least one IV that is not in continuous use (running NS would be the obvious exception) when they have a continuous drip(s) running so that emergency meds, scheduled IVPs, or PRNs can be pushed without disturbing the drips and running into the same complications that adventure_rn described.

[murseman24, MSN, CRNA]

On 2/24/2020 at 7:39 PM, InHisImage said:

I agree with everything adventure_rn has said.

As an ER nurse, I would never run anything, compatible or not, with cardizem let alone insulin!

Even if technically compatible, my hospital has policies against running certain IV meds together, and both insulin and cardizem are not to be run with other drips, so you should check your hospital’s policies first.

Finally, I don’t see how an ICU patient can get by with only one IV. IMO, and standard practice at my hospital, is for all ICU patients to have at least one IV that is not in continuous use (running NS would be the obvious exception) when they have a continuous drip(s) running so that emergency meds, scheduled IVPs, or PRNs can be pushed without disturbing the drips and running into the same complications that adventure_rn described.

I generally agree with you, and when possible to have an extra IV running to give antibiotics and other drugs is usually required/essential. However, in the interim it is perfectly safe to run these drugs together with a maintenance fluid as long as they are EXTREMELY close to the insertion site. The variation in dose is minuscule, on the order of a quarter mL. Pressors, cardizem, insulin, will all not effect the patient with this amount of drug.

But yes, to reiterate, you will most likely need to get another IV asap. Until you are able to accomplish this, you can use these drugs as long as they are right next to the skin.

[InHisImage, BSN]

5 hours ago, murseman24 said:

I generally agree with you, and when possible to have an extra IV running to give antibiotics and other drugs is usually required/essential. However, in the interim it is perfectly safe to run these drugs together with a maintenance fluid as long as they are EXTREMELY close to the insertion site. The variation in dose is minuscule, on the order of a quarter mL. Pressors, cardizem, insulin, will all not effect the patient with this amount of drug.

But yes, to reiterate, you will most likely need to get another IV asap. Until you are able to accomplish this, you can use these drugs as long as they are right next to the skin.

I realize that you aren't entirely disagreeing with me and I also understand that certain circumstances may dictate that certain meds be run together, but I don't care to belabor the point because I believe that enough has been said on the topic for the OP to make her(?) own decision about how to practice; however, there is difference between what is permissible and what is wise.

I will also reiterate that the OP's workplace policies may very well support what she overheard other nurses saying on the subject and that should be the first consideration driving her decision. If there is nothing in writing, IMO the nurse manager should be consulted, not only for clarification, but for CYA...just in case. In the meantime, it is also my opinion that a nurse should err on the side of caution when whenever possible until a definitive answer can be obtained.