IV Piggyback: Benefits of Its Administration

This article will provide an overview of the IVPB, what it is, the equipment needed to administer one, how to set one up, and other basic guidelines for IVPB infusion.

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IV Piggyback: Benefits of Its Administration

The intravenous piggyback (IVPB) infusion is a method of giving intravenous (IV) solutions to patients. IVPBs are smaller doses of medication that "piggyback" off the central IV line.

Table of Contents

What Is an IV Piggyback (IVPB)?

Nurses have used IV piggybacks since the 1970s as the standard medication administration method of antibiotics. An IVPB is usually a smaller volume of fluids than the primary IV fluid infusion. The IVPB is set up and administered by a trained nurse. IVPBs are given intermittently over minutes or hours, once or multiple times daily. Using an IVPB, the nurse can infuse multiple medications and IV fluids into a patient, and it does not require multiple IVs, which is safer and more comfortable for the patient. 

When to Use an IV Piggyback?

IVPBs administer smaller doses of medication, including antibiotics, electrolytes, and other medications that require multiple doses through IV lines to the patient. The IVPB method of administration allows the nurse to flush the IV tubing to ensure that the patient receives all of the medication and that none is left in the IV line. 

Differences Between IV, IV Push, and IVPB

There are different methods of giving IV medications. Each form of administration is essential for the nurse to know.   

  • Nurses infuse large volumes of fluids such as Normal Saline, Lactated Ringers, and Dextrose 5% in water through IV tubing via a catheter placed inside a vein. This method allows for volume replacement when patients are sick or have decreased blood volume. 
  • The IV push method is similar to IVPB. It is a way to give medications in smaller doses and allow less fluid use if the patient is fluid overloaded. In addition, using the IV push method enables you to provide medicines over a shorter time.
  • Another way to infuse smaller amounts of fluid is to use the IVPB method. This method ensures the primary fluid restarts after the IVPB completes the infusion. 

IV medication instructions direct nurses to infuse the medication over a specific time. The decision of which method to use depends on the IV solutions and the dose and volume the nurse will infuse. Infusion pumps allow the nurse to time the IVPB infusion. Pumps also enable the fluid to switch back to the primary fluid without the nurse having to change the tubing physically.  

IVPB System Equipment and Overview

IV medication administration is one of the main tasks for nurses. The nurse should know how to set up the IV lines for primary and secondary infusions. IV line setup is taught in nursing school and during orientation to the unit. The nurse should not be afraid to ask for help to set up infusions properly. 

The equipment needed for setting up an IVPB infusion includes the following:

  • Clean Gloves

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  • Alcohol Pads

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  • Flush Syringe

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  • Primary Tubing

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  • Primary Fluids or Flush Bag

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  • Secondary Tubing

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  • IV Pole with Infusion Pump

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While collecting equipment and medications, nurses should also check the IV line compatibility of the IV solutions they will administer to the patient. Medication compatibility is also important. IV medications and fluids must be compatible when hung to avoid complications. Hospital systems commonly use Lexicomp to check IV medication and fluid compatibility. The pharmacy is also a great resource for checking compatibility. 

IVPB Labeling

Labeling medication bags, flush bags, primary tubing, and secondary tubing is essential. Protocols are in place in hospitals instructing how long IV tubing can hang and how to change it out. Most hospitals have medication and tubing stickers for labeling, and nurses should follow their hospitals' protocols. The nurse should write the date and time they hung the tubing and medication on the label and when to change it. Some hospitals have color-coded tags for different days of the week.

Step-by-Step Process

The nurse should explain the IVPB procedure and obtain consent from the patient before hanging the IVPB medication. In addition, before administering the medication, the nurse should check the "Five Rights of Medication Administration": 

  1. Right Patient
  2. Right Medication
  3. Right Dose
  4. Right Route
  5. Right Time 

The nurse should also inspect the IVPB solutions' color, clarity, turbidity, and if there are any particulates. After these steps, the nurse should wash their hands and don clean gloves. 

Hanging and Connecting the IVPB

  1. Assess the patient's IV site or central venous catheter for patency using a flush syringe to aspirate blood and flush the line. 
  2. Be sure to close the roller clamp on the IV tubing.
  3. Spike the IVPB solution with the secondary tubing using an aseptic technique. Squeeze the tubing chamber to release the solution. 
  4. Scrub the Hub of the primary tubing port directly above the infusion pump with an alcohol pad for at least 15 seconds and connect the secondary tubing.  

Back Flushing the IVPB    

Secondary or IVPB should hang above the primary fluids to allow gravity to help infuse the medications. Backflushing the tubing prevents complications caused by air left inside the tubing and clears the medication from the tubing between doses.

To backflush the IVPB, lower the IVPB below the primary fluids and allow the primary fluid to fill the secondary tubing up to the secondary tubing chamber. 

After adequately checking the medication and patient and setting up the infusion set, the nurse programs the infusion pump to deliver the IVPB as directed and to switch to the primary fluid after completing the IVPB. 

Occasionally IVPBs are not run with a flush and can be set up like a primary infusion. 

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After the IVPB 

After infusing the IVPB, the nurse allows the line to flush additional fluids into the patient to ensure the line is clear and the patient has received the full dose of medication. The nurse then disconnects the tubing from the patient's IV catheter and applies sterile caps to the IV tubing and the patient's IV catheter. 

Original Allnurses Post

Quote
Question:

I am a new grad trying to survive every week. I know it may sound dumb but need clarification on IVPB and primary infusion.

Answer:

The IVPB is a smaller dose of medication, usually antibiotics, that you administer with the primary fluids. Primary fluids are usually large doses, 500mL or more, of Normal Saline, Dextrose 5 or 10% in water, or Lactated Ringers. When programmed into the infusion pump, the primary fluids will stop while the IVPB runs and restart when the IVPB bag is empty.

Question:

so let's say if a pt does not have any continuous fluid order and has a new ivpb order of 25 ml/hr. With 250 or 500ml of NS as primary, what should I put for rate and vtbi? Does it have to be 25 ml/hr for rate so the ns can be infused at the same rate for the rest of abx in the tubing and how much for vtbi..? I have seen nurses just putting random 10-35 vtbi and it just really confuses me every time.. please correct me if I am wrong and how much do you guys usually put for vtbi and running rate for primary infusion? 
thank you 

Answer:

The reason for the 250 or 500mL of NS as a primary is to flush the line after the IVPB to ensure that the patient receives all of the medication and to clear the line if you can use the secondary tubing setup for multiple doses. Primary IV tubing holds approximately 25mL of fluid. If this tubing is not flushed, the patient does not receive around 25mL of the medication, which can be an entire dose, depending on the medication. A good rule of thumb is setting the pump for 50mL at 100mL per hour, a standard IV rate that will clear the line in 30 minutes.

References

  1. Lee, R., Tran, T., Tan, S., & Chun, P. (2021). 602. Intravenous push versus intravenous piggyback administration of cephalosporin antibiotics: Impact on safety, workflow, and cost. Open Forum Infectious Diseases, 8(1), S403–S404. doi: 10.1093/ofid/ofab466.800  
  2. Rahbar, A., David, J., Promlap, J., Hara, J., Zitek, T., & Lee, P. (2021). 178 Safety comparison of antibiotics administered via intravenous push versus intravenous piggyback to adult patients in the emergency department. Annals of Emergency Medicine, 78(4), S71. https://www.annemergmed.com/article/S0196-0644(21)01030-1/fulltext
  3. Wolters Kluwer. (n.d.). Lexicomp trissels IV compatibility databases. https://www.wolterskluwer.com/en/solutions/lexicomp/resources/lexicomp-user-academy/trissels-IV-compatibility-databases
  4. Gorski, L. A., Hadaway, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., Meyer, B. M., Nickel, B., Rowley, S., Sharpe, E., & Alexander, M. (2021). Infusion therapy standards of practice, 8th edition. Journal of Infusion Nursing,44(1S Suppl 1), S1–S224. https://doi.org/10.1097/NAN.0000000000000396
  5. Martyn, J. A., Paliadelis, P., & Perry, C. (2019). The safe administration of medication: Nursing behaviours beyond the five-rights. Nurse Education in Practice, 37, 109–114. https://pubmed.ncbi.nlm.nih.gov/31132586/  
  6. Institute for Safe Medication Practices. (2020, December 3). Hidden Medication Loss When Using a Primary Administration Set for Small-Volume Intermittent Infusions. https://www.ismp.org/resources/hidden-medication-loss-when-using-primary-administration-set-small-volume-intermittent

 

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Kellie Norris

About Kellie Norris, MSN, RN

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You should run the primary line at the same rate as the secondary as this will allow consistent medication administration.

As for the volume you should program enough that the volume from the proximal ysite through the entire IV line.

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.
3 hours ago, chare said:

You should run the primary line at the same rate as the secondary as this will allow consistent medication administration.

I'm not sure what secondary medication is being run at 25/hr, but you will often have multiple secondary medications throughout a 24 hour period. Antibiotics can run anywhere from 33/hr (cefepime) to 200+/hr (vancomycin), so you're not going to have your primary fluids at the same rate. We generally run a KVO at 10/hr. That means there will be antibiotic in the lower part of the primary tubing that infuses slower than the antibiotic rate but that's generally less than 10cc of the total infusion so it's not going to matter much. 

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4 hours ago, chare said:

You should run the primary line at the same rate as the secondary as this will allow consistent medication administration.

As for the volume you should program enough that the volume from the proximal ysite through the entire IV line.

Thanks! if the pt does not have fluid order and if he or she may have risk of fluid overload can I set the vtbi as 30ml and then disconnect it?

1 hour ago, JBMmom said:

I'm not sure what secondary medication is being run at 25/hr, but you will often have multiple secondary medications throughout a 24 hour period. Antibiotics can run anywhere from 33/hr (cefepime) to 200+/hr (vancomycin), so you're not going to have your primary fluids at the same rate. We generally run a KVO at 10/hr. That means there will be antibiotic in the lower part of the primary tubing that infuses slower than the antibiotic rate but that's generally less than 10cc of the total infusion so it's not going to matter much. 

Thank you! so like you said if there are multiple abx ordered at the same time 33/hr and 200/hr what do you usually put as rate and vtbi for primary? (in case there is no option for kvo?) 

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16 minutes ago, chare said:

When most people think of an IVPB they think of an intermittent medication that is going to infuse over 1 - 2 hours, which is the scenario described by @Sunflowerr7761 in her or his original post.  Again, in the scario described in the original post in which the patient doesn't have IV fluids running and the fluids are started for the sole purpose of administering the IVPB the rate should be the same rate as the medication being infused, with sufficient volume to completely clear the primary line, and then taken down until needed again.

In the scenario of prolonged or continuous infusion of antibiotics you describe, I doubt many would consider this an IVPB based on the continuous infusion ...

... especially as you are connecting this distal to the pump.  And, dependent on the rate the antibiotic is infusing it is possible that you aren't going to need a carrier fluid.

if the pt has continuous/prolonged abx infusion every few hours do I have to change the vtbi every time when I change the secondary? How much do you set for primary rate and vtbi if there are multiple abx running in different rates and different amounts? sorry for asking bunch of questions and thank you so much for reply

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Specializes in Med-Surg.
4 hours ago, chare said:

You should run the primary line at the same rate as the secondary as this will allow consistent medication administration.

As for the volume you should program enough that the volume from the proximal ysite through the entire IV line.

Good answer.  I never thought of it like this and will do it.   I usually just flush at 125 cc/hr for 25 cc's.  

Our pharmacy asks that we run Cefepime over 4 hours so it's 25 cc's hour where I work.    

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1 minute ago, Sunflowerr7761 said:

if the pt has continuous/prolonged abx infusion every few hours do I have to change the vtbi every time when I change the secondary? How much do you set for primary rate and vtbi if there are multiple abx running in different rates and different amounts? sorry for asking bunch of questions and thank you so much for reply

Rereading @JBMmom's post, I believe I misread "anywhere from  33/hr (cefepime) to 200+/hr (vancomycin)" as hours that the medication was to infuse (which didn't make sense), rather than infusion rate (which does make sense).  This highlights the importance of using the correct terminology).

As for changing the VTBI, yes, this should be changed every time you hang a new bag to ensure the patient will receive all of the ordered medication.

And, never be "sorry" for asking questions.  If you ever find yourself on a unit where asking questions is discouraged or frowned upon, it is time to seek employment elswhere.

Best wishes.

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

Maybe I misunderstood the original post. If you have a one time order for a medication then there isn't a reason to hang it as a piggy back on non-ordered fluids. You would just hang it on primary tubing and if the volume is very small you could flush with 25 cc from a saline bag after infusion and disconnect.

Most of our patients don't have an order for a KVO. But if there is more than one antibiotic ordered, or the patient has multiple electrolyte replacements, etc. We will hang a flush bag on primary tubing that is generally running at 10/hr. I don't change the rate for that primary to match any infusion because the volume left in the tubing is pretty small. And I'm not hanging anything at a y-site unless it's because potassium is infusing and the patient has discomfort with it, a y-site connection wouldn't be a piggy back because then both fluids are running at once. 

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2 minutes ago, JBMmom said:

Maybe I misunderstood the original post. If you have a one time order for a medication then there isn't a reason to hang it as a piggy back on non-ordered fluids. You would just hang it on primary tubing and if the volume is very small you could flush with 25 cc from a saline bag after infusion and disconnect.

Most of our patients don't have an order for a KVO. But if there is more than one antibiotic ordered, or the patient has multiple electrolyte replacements, etc. We will hang a flush bag on primary tubing that is generally running at 10/hr. I don't change the rate for that primary to match any infusion because the volume left in the tubing is pretty small. And I'm not hanging anything at a y-site unless it's because potassium is infusing and the patient has discomfort with it, a y-site connection wouldn't be a piggy back because then both fluids are running at once. 

I don't know if it is the unit policy but the nurses I have been following hang primary ns even with one time order abx or anything IVPB order. I was told to use two different channels when running potassium to ease the discomfort. Do you do like that? Or is there any way I can do with potassium using one channel? and thank you so much 

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