IV Pump VTBI and Rate

[Elm12]

Hi Everyone, 

I am currently in nursing school and I have a few questions about calculating the VTBI and the pump rate. 

1. I often see nurses hang an antibiotic of 50 mls and they program the VTBI for 40 or 45 mls to make sure the line doesn't run dry. I understand that concept but isn't potentially missing 10 ml's of an antibiotic important? Can you not program the VTBI for the whole 50 mls, or is it better to do 40/45 because of it running dry or possibly causing an air embolism? 

2. How do you know the ml/hr rate for each antibiotic? Does it tell you somewhere in the chart what to run each specific one at? I have looked in my drug guide and don't see this information. I do know how to calculate a ml/hr rate with this formula: volume (mL) divided by time (min), multiplied by 60 min over 1 hour, but are you given the time to be infused, or is it just assumed it's always over 30 minutes? 

3. Can you reuse IV tubing for different antibiotics? I see this all the time and I thought you should only do that if it is the same antibiotic. If you can do this, how do I know the two different antibiotics are compatible because some of the first one is usually still in the line? 

Thank you for any guidance you can give. 

[Been there,done that, ASN, RN]

You have many good questions. These questions are for your instructor. Don't forget to use the pharmacy for a resource.

[Elm12]

Thank you for your input @Been there,done that and for your response! I do agree that these are questions for my instructor and I have asked them to two different instructors and a few nurses on the floor. These have been my responses: 

1. I have been told to program the antibiotic short by 10 mls. No one can give me a solid answer if the dose not given is important overall. The reason I'm really asking is  because I had a patient ask me about the 10mls he wasn't getting on his 50 ml antibiotic and he mentioned that over 5 doses he was missing a full dose of the antibiotic. 

2. I have been told it depends on the antibiotic what to program it at, when I asked how do I know, I was told you'll learn — from where or whom, I am unsure. 

3. Our instructors taught us to never use the same line on different antibiotics but I realize textbook nursing is different from real-life nursing. For example, I always ask my preceptor if I need new tubing or if the antibiotics are compatible. She always says no to new tubing and that they are compatible. I asked her how I can find this info out and she said didn't answer me. 

I graduate in December and I feel frustrated by how much I don't know, the gatekeeping of knowledge by my preceptor, and the lack of clarity from my instructors. I just want to be a safe nurse and not cause patient harm. I guess I'm just overthinking it. 

 

[londonflo]

You are asking very important practice-based  questions. I so appreciate asking these questions and can understand if you are puzzled by the answers,    
1) you learned in your dosage and calculations class work that adding a dry powder (antibiotic) into a fluid increases the volume. For example 50 ml of NaCl or D5W increases that volume to 50 ml +. A piggyback tubing package says what volume is necessary to prime, depending on the brand. Look at the paper that comes with the tubing. You will need to leave that amount in the tubing. After a while you will see the same antibiotics and will see amount is left in the bag after filling the new tubing and running the IV med. That becomes your practice wisdom...and when you work you will see the same ATB over and over.

2) it is not necessary to change tubing when hanging a compatible antibiotic. It fact it is contraindicated.
 Look for a good handbook for this or call pharmacy. In fact you do NOT want to change  (open the system) when you do not have to. It is a basic principle of infection prevention. You are in a tough position with your preceptor. Don't rock the boat but I do have to ask why isn't your instructor hanging IVs with you?

and textbook nursing is not different than actual nursing...that's just a phrase used by RNs who cut corners, RNs who bristled when authority told them how to do something because they don't like authorities, RNs who think they know better than anyone, RNs who can't remember how to do something and don't want to admit they don't, and a thousand other reasons.

best wishes on your continued education. I am so glad to read of you asking these questions and not carrying forward the cliche ( this is the real world...forget the 'teaching world'.) idiots say that

I had an RN family member say something about an MD resident when she disliked what he said. My sister said "he's read too many books!” I thought "huh?” I still can't figure out what she thought was wrong with his practice - he read too many books? Versus how else should he learn?

[Elm12]

Thank you, @londonflo, for your thoughtful comment. I really appreciate you taking the time to answer my questions. Your answers are very helpful! 

1. Yes, that makes so much sense. I'm going to start looking at the tubing to see how much it takes to prime them and will look at how much, if any, is left in the antibiotic bag. I dislike there being extra medication in the antibiotic bag that the patient doesn't receive! But you're right, knowing the sweet spot of having a full line with all the medicine out of the bag takes practice wisdom, which I hope to cultivate! 

As an aside, these antibiotics are running as an intermittent primary with 2-3 doses given over 12 hour shift. The extra antibiotic that stays in the line is then given when the next antibiotic is hooked up to the pump, hours later. They run on the primary line with no other fluids. I don't know if this makes sense, but to me, it would seem that if we used a small 50-100 ml bag of NS we could back-prime the antibiotic, then run the antibiotic for the full volume, and then flush the line with NS with the amount that's left in the line. That way they could get the whole dose at once. 

2. Thank you for clarifying that it's best practice to not switch secondary lines! The infection prevention aspect makes so much sense! I also found in my drug guide that they do list y-site compatibility for antibiotics, so thanks for pointing me in that direction! 

At this point, I am only with a preceptor on the floor. He is a good nurse, but has made it abundantly clear that he didn't want a student and is bothered by questions. I did have one instructor in first semester that did follow us into rooms and help us with everything — they were my favorite! However, I was so new at that point I hadn't even thought about the nuances of IV medication administration, so I didn't ask at that time. For the remainder of my clinicals, my instructors assumed that we knew how to do these things at this time and they sat in a room and did other work for the duration of our clinicals. We were pretty much at the mercy of any nice floor nurse who offered to help. Many of my fellow students did get to do externships in the Summer at bigger teaching hospitals and learned a lot! However, I was unable to do that and have little clinical experience compared with them. 

I also agree that textbook nursing shouldn't be different than real-life nursing! I really enjoy evidence-based practice and always want to embrace it, even if it means updating a method of my nursing practice. I like to understand the why behind doing things, not just because this is how its always been done. 

Thank you again for your advice and input — it is much appreciated! 

[nursej22, MSN, RN]

Aye, yi, yi, I am sorry you are not getting the support you deserve. 

Not all antibiotics and or their diluents are compatible. There should be some sort of reference available to you to check. Where I used to work, there was link on the EMR to double check, or pharmacy would help. Here is an example of one I found on line:

https://www.lachuletadelfir.com/wp-content/uploads/2018/07/Y-site-Compatibility-General.pdf

Also, at the place I used to work, if there was no primary infusion, the policy was to set one up as you described above, and run every IV as a piggyback. And all of our doses came labeled with the correct infusion rate. Thank you pharmacy! 

[Elm12]

Thank you, @nursej22! Very helpful! I am going to print out the chart you linked. I don't have badge access to the computers yet, but I will also see if the EMR has a medication checker, too. That's so nice that the doses came labeled with the infusion rate! Thanks again for your advice! 

[PAB]

Where I work it is considered a med error to leave anbx in the line. They should always be set up as piggy back and now we have smart pumps who can alert you if something seem off. The full amount or even 20 -30cc over (check the tubing volume) should be administered to clear the line. You can set the pump to return to the primary line for the flush and then do a final manual flush (for line patency)when you disconnect.  The pharmacy is your best resource if you are alone and wonder about compatibility. It is best practice to not break the line when possible if that is feasible. You can back prime also because with this safe set up you know all the anbx has been administered. It has been my experience that the MAR describes clearly the rate and dosage so always follow that when calculating and of course continue your independent double check. You will occasionally find errors and I usually notify the pharmacist so I can admin safely.
Find a kind and safe way to follow other leaders on the unit so you can get a better experience and you feel grounded when you are on your own.

[mdsRN2005, ASN, BSN, RN]

londonflo said:

and textbook nursing is not different than actual nursing...that's just a phrase used by RNs who cut corners, RNs who bristled when authority told them how to do something because they don't like authorities, RNs who think they know better than anyone, RNs who can't remember how to do something and don't want to admit they don't, and a thousand other reasons.

 

Fully agree!  There may be some things that are practically different in practice, but the basic concepts and principles don't go away.   Keep this in mind when what you see doesn't match what you've learned.  For example, if you learn with paper MAR but most hospitals have eMAR, that's a practical consideration.  As is differences in supplies, etc.  However, if it violates a core principle, that's a different story.  I once went with a nursing student and a fellow RN coworker to put it a catheter.  The RN contaminated the sterile field and the student called her out on it.  She then made a comment about "real world nursing vs textbook nursing".  I took the student aside afterwards to explain that she (the student) was right and to disregard what the RN had told her.  I then told her what I did differently to prevent the mistake the other RN made.   I was so glad I spoke with her because she said she was wondering if sterile technique was just something she was taught in school that was not really followed in the real world!  I assured her that is not the case!  
 

You asked a lot of great questions.  Please continue to do so, as well as to think analytically and question what you are told. During your remaining clinicals (and especially as you transition into practice), try to find mentors who do things correctly and enjoy teaching.  They will be invaluable!  
 

I'm sorry you've gotten stuck with a preceptor that isn't interested and instructors that sit at the desk.  I'd add to the previous comment that an instructor telling you "I don't know" is a cop out unless followed by "let's find out". Sorry you haven't gotten the support you need.  Hope it gets better!  But I'm glad you have found this site, there are many nurses on here who enjoy teaching and have a wide array of experience.  No substitute for a good instructor but a great resource nonetheless!