IV Push through cvc with triple lumen

MN-Nurse, ASN, RN · Sep 25, 2011

Help! I am stuck trying to figure out this situation. If a patient needs to be administered Labetolol IV push med through a triple lumen subclavian and all the ports are occupied (Cardizem-yes compatible, Heparin-not compatible, and 0.9 NaCl with 20 KCl-yes compatible) do I need to pinch off all three lines before administering the med, or just the tubing of the port that I am using? I am going to use the 0.9 NaCl with 20 KCl port and I know I need to pinch that line, but do I also need to pinch Cardizem and Heparin's tubing???
Thanks!

I always stop the unused lines and run one or two flushes in the line I am using if any of them are incompatible.

CrazyCatLadyRN, BSN, RN · Sep 25, 2011

can you be running the heparin through the same cvc anyway? on my unit I am pretty sure we always have to use a whole separate IV access site for a heparin drip. Never stop the heparin! We just had an in-service on heparin drips on my floor. When I had a picc pt once, the fluids and antibiotic ran through that and then we had a separate IV for the heparin. No risk of having to ever stop it.

ksl777 · Sep 25, 2011

hmmm, ok, i will have to find out about the heparin situation. but thank you both for your help!

wooh, BSN, RN · Sep 25, 2011

I've always been taught that the lumens of a CVL or a PICC are like completely separate access points for the purpose of running things in. It's like your medial port stuff will come into the vein HERE and then a little ways down your medial port will come out and then head down to the end where your distal port is going to come out. Nothing mixes until it's all being mixed up in the bloodstream.

Now for drawing blood FROM the CVL/PICC, I've been taught to stop all the lines, since you're pulling your blood from that area and don't want your hyperal that's going in the medial port sucked back up through the distal port as you're drawing electrolyte levels. But that's based on common sense, and I would be interested in hearing from a IV expert on if that's supported by evidence.

Reno1978, BSN, RN · Sep 25, 2011

The three lumens remain separated and whatever is infusing in them enter the bloodstream thru different exits on the catheter. So as long as you're pushing compatible drugs through the same lumen, you're safe.

Reno1978, BSN, RN · Sep 25, 2011

can you be running the heparin through the same cvc anyway? on my unit I am pretty sure we always have to use a whole separate IV access site for a heparin drip. Never stop the heparin! We just had an in-service on heparin drips on my floor. When I had a picc pt once, the fluids and antibiotic ran through that and then we had a separate IV for the heparin. No risk of having to ever stop it.

Heparin has a tendency to be incompatible with many other intravenous infusions. If you have access to run your heparin gtt exclusively, do it. However, heparin can certainly be ran through a multiple lumen catheter in its own lumen while other incompatible infusions are running in their own lumens.

CrazziiRN913, ADN, BSN · Sep 25, 2011

I agree with Wooh...I was also taught the same thing about where the med comes out into the blood stream with a CVAD...I believe that's the point of them to 1. They last longer than a regular IV, and 2. You can run incompatible things simultaneously, because inside the cath that's inserted each port is really a separate tube that let's the med out at different points so it doesn't mix!

313RN, BSN, RN · Sep 25, 2011

If it's a true triple lumen cath then get a stopcock and run the cardizem and 0.9 into the same lumen. Then you have a free lumen for pushes.

You can also hook up a pressure set to the now open lumen, again using a stopcock and now you have a place for pushes and you can use the pressure set for all your lab draws very easily.

nerdtonurse?, BSN, RN · Sep 25, 2011

Since heparin can infuse in such small amounts, we usually run it with a maintenance line (not sure, it's not like the line's going to clot off, geeez...). So I'd move the heparin to infuse with the NS + 20KCL, that way keeping a line open for anything else the doc might decide to use. We had a pt in ICU one time that had a triple lumen in the subclavian, one in the femoral, and we had them all full with every pressor we'd ever used (Dob, Dop, Levo), Heparin, Integrilin, Diprivan, pretty much continuous KCL and Mag riders, plus just about every antibiotic in the house on rotation... It's never a good sign, when even the MD in infectious disease looks at a handful of cardiologists and shakes his head, going, "it should be working, but it's not...".

Never, ever, get an infected heart.

papawjohn · Sep 25, 2011

Well KSL777, I'm trying to imagine the situation that has you posing this question at like 0100. (Of course -- where you're at, maybe it's 4pm! But the time-heading says 0139.) And I imagine you've just finished your shift and you had a push to give to a patient who really needed that med -- but his only access was a Triple Lumen Central IV. You looked at the meds and fluids flowing thru that line and said to yourself 'where do I put this?'

Because you had labeled the lines, right? That's basic! Don't stand at the bedside and wonder 'is that the Norepinephrine?' Very important!

And because you'd made yourself aware of incompatibilities, eh? You said that and I'm very impressed! I've stood before that huge chart with all the drug names along the top and along the left hand side and tried to find the right intersection to see the C or the I or the X. It's not easy when your patient needs the med and it's in your hand and there are like a million little boxes on the chart and you want to be right!

Then you walk over to your patient and each lumen of the TLC has one IV line running to one pump. Each pump might have a med (Norepinephrine, Diltiazem, what-have-you) or it might have maintenance fluid with piggy-backs. OMG!! Is the med compatible with Zosyn? Or Mag Sulfate?

Such a world of decisions!!

Here's what I've done. First, be sure of the maintenance fluid and it's compatibilities. Run that into the DISTAL Port (which is the one "DISTAL" to you -- the port farthest from you and farthest from the patients skin). Then all the drips that are compatible with that, hook to a stop-cock and put them between the maintenance fluid and the distal port. If there are 2 or 3 or 4 drips, put the 2 or 3 or 4 stopcocks in a chain with the distal port at one end and the maintenance fluid at the other.

This actually has a name; it's called a "manifold". Anesthesiologists use this system in surgery. It's whats between the fuel injector of my car and the intake valves of the cylinders. You're not doing anything new or amazing. But you're making everything clear and organized.

You will find that you will know exactly what is going into your patient and where -- which is a real accomplishment, believe me! And you will find that all the compatible things are flowing neatly together and that you might have a 'hep-lock' port on that Triple Lumen to use for nothing but 'pushes'.

So you have all the vaso-pressors running into one 'manifold', say. And all the maintenance and antibiotics running into another. OK? And you have the third port for pushes. And you have a push that is NOT compatible with the other meds hanging. So you're uncertain -- should I push this med in or do I need to stop the incompatible ones -- even flush the lines! -- and then give the push?

Ahh -- stop and think: what is the major buffering system of the body? When I was in Nursing School (and dinosaurs roamed the earth) it was the BLOOD. So you are actually 'pushing' this med into a BUFFERED mixture of (incompatible) meds and blood.

Believe me, the blood will take care of it 9,999 times out of 10,000.

The 'incompatibility' issue occurs in the IV tubing. Not in the central venous circulation.

So label your lines and put them into compatible 'manifolds' if necessary. And do not be afraid to mix them in the blood of your patient.

So says your old Papaw.

ksl777 · Sep 25, 2011

wow, that's great! thank you so much. i love the idea of the manifold. and that is true, i do have to keep in mind that everything is buffered by the blood. thanks for such a great response papaw :)