IV push failure - how I am failing

[Brandazzle1]

I am new to the hospital environment and brand new to IV meds so when my preceptor said it was a mistake not to pause the heparin drip before doing an IV push dose of morphine I expressed understanding and told her I never knew that. I honestly don't remember learning that in nursing school so she told my boss and now they've added another week of orientation for safety concerns.

I am terrified they're going to fire me. I already had an extra week of training to hone my time management skills and then I do this! I just worry that there are other deficits in my education that will lead me to endanger a patient or get fired and I'm 37 weeks pregnant so I'm about to go on leave without really being on my own. I just feel like I'm failing and the preceptor says I didn't seem to understand how serious this mistake was. She's right. I didn't. I don't know what I don't know, you know? Are there other things specific to IVs that I should be aware of before I kill someone?

[SassyRN_972]

I don't think there is any obvious reason to use a separate IV access, what are you basing that on?

It's typical in the ICU setting to have more than one IV. It was very common where I worked.

[MunoRN, RN]

I'm thinking all the reasons that they listed. You don't think it's convenient to have more than one IV access when you have abx that have to go in intermittently? Typically if you have a heparin infusion going, say for a NSTEMI, you would want to have another iv already in place anyway in case the first infiltrates so that you can simply switch the heparin gtt over instead of having turn the infusion off while looking for a new iv site. I'm thinking you must have misunderstood their post.

I also remember the days when it was just sort of routine to have extra IV's in place for unspecified "convenience" reasons, that's not really considered good practice anymore. IV starts are not without risk to the patient, and to justify that risk there needs to be adequate reason to support it's necessity. Just because the patient is on a heparin gtt, which is the reason given earlier, does not come close to justifying the need for a superfluous IV access.

[OhioCCRN, MSN, NP]

I think my point is pretty obvious...

Heparin is a continuous gtt

If you need to keep interrupting it for other medications, it is time to start another line.

[MunoRN, RN]

It's typical in the ICU setting to have more than one IV. It was very common where I worked.

It used to be common in my ICU as well, but we've learned to keep our practice current.

[MunoRN, RN]

I think my point is pretty obvious...

Heparin is a continuous gtt

If you need to keep interrupting it for other medications, it is time to start another line.

Are you under the impression that interrupting a drip, with a half life of more than an hour, to push a med over a couple of minutes is of any clinical significance?

[OhioCCRN, MSN, NP]

Are you under the impression that interrupting a drip, with a half life of more than an hour, to push a med over a couple of minutes is of any clinical significance?

Methinks you are trying to blow this out of proportion.

I stated my point. It is excellent practice where I work ( top 5 U.S. hospital) so I will hardly stoop to defend my practice to an anonymous person on the net.

Have a nice night!

[dream'n, BSN, RN]

OP, I'm struggling about how to explain this without confusing the heck out of you. You know to check compatibility, but that's just one thing. Now think about your Y-port. From the Y-port to the actual vein are several mL of medication in the tubing. Certain drugs, including Heparin usually run at a very low rate per hour. For instance Heparin may run at around only 9 mL/hour (which is actually hundreds of units/hr). Therefore, if you push a drug from the Y-port you will be giving a bolus of Heparin essentially, as the Heparin from the Y-port to the vein is being pushed through quickly. To avoid this; pause the IV, disconnect, and push your drug from the J-loop of the IV. Does this make sense?

[Nonyvole, BSN, RN]

Being totally honest here - my research skills are failing me this morning. I blame the paint fumes because I'm repainting my home office and primer stinks. What research is out there speaking against multiple PIVs? Muno, is it your hospital's policy against it, because I know at my facility we're required to have two PIVs placed for any STEMIs and to try to get two PIVs on codes. Not at work to look it up for the official verbage.

Although, yes, emergent situations vs. non-emergent situations, and what the doctors think about putting in a central line vs. having us simply start a second PIV...

[psu_213, BSN, RN]

Being totally honest here - my research skills are failing me this morning. I blame the paint fumes because I'm repainting my home office and primer stinks. What research is out there speaking against multiple PIVs? Muno, is it your hospital's policy against it, because I know at my facility we're required to have two PIVs placed for any STEMIs and to try to get two PIVs on codes. Not at work to look it up for the official verbage.

Although, yes, emergent situations vs. non-emergent situations, and what the doctors think about putting in a central line vs. having us simply start a second PIV...

Obviously if a patient has multiple incompatible drips going, has a significantly unstable condition (STEMI, shock, etc.), no one (almost no one?) is going to argue against multiple lines. I don't want to put words in Muno's mouth, but I think the point is it is not necessary nor best practice to have a second line "just in case." I'm not a big fan of absolutes, so to say one ALWAYS starts a separate line when there is a heparin gtt. is dogmatic and it is overkill. Where I work, our heparin is compatible with dilt (apparently it is not in all hospitals, depending of the supplier). It would be silly to say the patient MUST have a second line just because they are on both dilt and heparin gtts. (And just because a highly ranked hospital does something a certain way, that does not mean it is the best way to do something.)

[Nonyvole, BSN, RN]

Obviously if a patient has multiple incompatible drips going, has a significantly unstable condition (STEMI, shock, etc.), no one (almost no one?) is going to argue against multiple lines. I don't want to put words in Muno's mouth, but I think the point is it is not necessary nor best practice to have a second line "just in case." I'm not a big fan of absolutes, so to say one ALWAYS starts a separate line when there is a heparin gtt. is dogmatic and it is overkill. Where I work, our heparin is compatible with dilt (apparently it is not in all hospitals, depending of the supplier). It would be silly to say the patient MUST have a second line just because they are on both dilt and heparin gtts. (And just because a highly ranked hospital does something a certain way, that does not mean it is the best way to do something.)

Ah, good point. Obviously, the paint fumes have also affected my logic...so shutting up on this particular concept until neurons start firing again. Thanks. :)

[MunoRN, RN]

Methinks you are trying to blow this out of proportion.

I stated my point. It is excellent practice where I work ( top 5 U.S. hospital) so I will hardly stoop to defend my practice to an anonymous person on the net.

Have a nice night!

There certainly are some situations where two IV's are warranted, but that need should be based on an actual rationale and just being on a heparin drip by itself is not a rationale. Just blindly doing something because it seems to be what others do is not a rationale either. While I can appreciate the quality of the hospital you work for, that quality doesn't somehow negate the need to have an understanding of why you are placing a second IV. For instance, is the patient receiving incompatible medications? Are they on a drip where the half-life and clinical effects prevent the ability to to use the same IV? etc.

[calivianya, BSN, RN]

There certainly are some situations where two IV's are warranted, but that need should be based on an actual rationale and just being on a heparin drip by itself is not a rationale. Just blindly doing something because it seems to be what others do is not a rationale either. While I can appreciate the quality of the hospital you work for, that quality doesn't somehow negate the need to have an understanding of why you are placing a second IV. For instance, is the patient receiving incompatible medications? Are they on a drip where the half-life and clinical effects prevent the ability to to use the same IV? etc.

I'm honestly curious, because your hospital's policy strikes me as a little scary. I get that there are risks to inserting peripherals for sure, but if you have a patient receiving a heparin drip because of a MI, that person has the chance to code. How does your hospital justify the risk of only having one IV, which could blow quickly or infiltrate during a code? It's never pretty when the code teams shows up and the only access available is defunct. I feel like risking being unable to push ACLS drugs in an emergency is a lot bigger of a risk than inserting an extra peripheral.

Do you have another method to quickly establish access? We have an EZ-IO drill, as an example, but IOs come with higher risks than PIVs, so we tend to put in extra IVs so we won't get in a situation where we have to insert an IO in an emergency. We have had physicians put in lines during codes as well, but that takes time and time is brain in a code.