IV Question

Castiela · Aug 18, 2017

I think most of fluid bags have a bit more than is states on the bag, which is why there is always a bit left over. You can restore the secondary infusion and add x amount of mls to get the extra stuff.

I was also taught to kink the tube before giving an IVP med, I have no clue about positive pressure or such, however, if you don't, you can see them med go away from the patient if you are pushing hard, and I have never heard of administering a 10 ml saline flush after a med, much less seen it, so I have no idea about the proper practice for that.

DextersDisciple, BSN, RN · Aug 19, 2017

I agree with Castiela on the IVPB scenario. I also have been told that since the IVPB is to gravity (higher than primary line) the Secondary line will continue to infuse until empty but at the rate of your primary line.

I.e. Primary line is NSS running at 10mL/hr and secondary (IVPB) Flagyl running at a rate of 100mL/hr. If there is left over flagyl it will still infuse to gravity but at a rate of 10mL as opposed to 100mL.

I always kink the tubing. The Alaris tubing is not positive pressure. If it was, you would not need to use a clamp to keep it from running all over the floor. Plus if the tubing is kinked, I can visualize the push reaching the pt. I then flush with 10mL NSS syringe before I unkink. This way I am positive the push has reached the pt when I intend it to.This is not always necessary though. Your primary fluids will flush the push through as well.

As for the 10mL syringe flush- I'm going to guess you are referring to an Alaris syringe pump? If it allows you to choose the rate, just do the math to determine rate from duration. 10mL/3-4mins = 2.5- 3.3 mL/min. So rounding to the rate to 3 mL would be appropriate. If you only want flush 3mL you would not select 10mL syringe at all and should be able to selection "basic infusion" and program from there.

Side note - as a student I am very surprised you are permitted to use all 3 of these features let alone without a preceptor at your side!

Anon101 · Aug 19, 2017

Thanks for the response Castiela and DextersDisciple. There's always a preceptor present, but I'd like to clarify a few things. Let's consider the following example:

Ancef 500 mg IV q6h. Supply is Ancef 1 g vial - add 2.6 mL diluent to yield a total of 3 mL for a concentration of 330 mg/mL. Infuse using a 50 mL solution of D5W over 20 minutes.

So I would require 1.5 mL, which would be injected into the 50 mL bag for a total volume of 51.5 mL. In school we learned that when setting up the Alaris pump, we would enter 51.5 mL as the VTBI. However in practice I see that staff normally just go with 50 mL as is set up in the guardrails. Also, when the pharmacy prepares such medications, they also just go with the 50 mL. What is best practice in this case?

Guest219794 · Aug 22, 2017

Hi all, I'm a nursing student on a pediatric unit and have a question regarding IVs. We use Alaris pumps.
When administering a medication (i.e. antibiotic) via secondary line (piggyback), I notice that there's usually always some medication left in the chamber and tubing after infusion is complete and the primary line resumes. Is this normal, if not, why is it happening?
When administering a saline flush via syringe in the pump after medication, I press 'channel select' > '10mL syringe' > basic infusion. Here, it doesn't let me enter the duration for the flush, which I was told should be around 4 minutes. The VTBI also says "ALL" and doesn't let me input 3mL. I can only enter the rate. It would be great if someone can guide me step-by-step on how to run a saline flush via syringe.
When giving IV push med (i.e. antibiotic), my preceptor told me to pause the infusion and kink the tubing prior to doing so. But I've also heard that you don't have to pause the infusion or kink the tubing due to 'positive pressure'. Is this true?
Thanks, I appreciate the help

The fluid left in the secondary line is a common, and bad, practice.

If the bag is labelled "50 mg XYZ", that is what is in the bag. If there was 50 ml in the bag, and 10 ml gets left in the tubing, the pt is getting 40 mg of XYZ.

s a student you will see a wide variety of practice. Be selective, and be sure you understand the practices you adopt. If you ask for a rationale, and are told "well, I was always taught..." smile and nod.

Regarding pinching the line. The lines I use don't allow upward travel, so I don't bother. Even without that, fluid takes the path of least resistance, Given a choice of a stopped pump or an open vein, it is heading for the vein.

LovingLife123 · Aug 22, 2017

I always just add whatever I see the remaining amount to be. It's usually just about 10mL. When it beeps that it's empty, I add an additional 10mL or if it's more and I can clearly see that, I may add 20mL.

We run 25mL flush bags behind our abx to ensure all med in the line and chamber go in. I have never kinked a line when running an additional med in and not sure why you would. It's all going in as both lines should be running at once.

DextersDisciple, BSN, RN · Aug 22, 2017

Thanks for the response Castiela and DextersDisciple. There's always a preceptor present, but I'd like to clarify a few things. Let's consider the following example:
Ancef 500 mg IV q6h. Supply is Ancef 1 g vial - add 2.6 mL diluent to yield a total of 3 mL for a concentration of 330 mg/mL. Infuse using a 50 mL solution of D5W over 20 minutes.
So I would require 1.5 mL, which would be injected into the 50 mL bag for a total volume of 51.5 mL. In school we learned that when setting up the Alaris pump, we would enter 51.5 mL as the VTBI. However in practice I see that staff normally just go with 50 mL as is set up in the guardrails. Also, when the pharmacy prepares such medications, they also just go with the 50 mL. What is best practice in this case?

It's a shame yours aren't already premixed, or maybe I'm just spoiled :) I think 55mL would be safe , it's such an odd number. Or at least do 52mL, you can always add more volume.

MunoRN, RN · Aug 22, 2017

When administering a medication (i.e. antibiotic) via secondary line (piggyback), I notice that there's usually always some medication left in the chamber and tubing after infusion is complete and the primary line resumes. Is this normal, if not, why is it happening?

The secondary will infuse until it reaches the level of the fluid in the primary bag, so if the secondary isn't high enough and the drip chamber or even the bottom portion of the bag is the same height as the fluid level in the primary bag then it will only infuse to that point, the slowly infuse as it continues to match the slowly decreasing fluid level in the primary bag.

Keep in mind that programming a secondary infusion into the pump doesn't cause the pump to pull from the secondary bag, essentially all you're doing is telling the pump to run at a set rate for a set volume, and to then switch back to the primary rate. If you have a primary infusion running at 75ml/hr and hang a secondary to run at 100ml/hr for 50ml, then the pump will run at 100ml for half an hour and then go back to 75ml/hr, if there is still 10ml of the secondary left, it will still infuse but at 75ml/hr.

When giving IV push med (i.e. antibiotic), my preceptor told me to pause the infusion and kink the tubing prior to doing so. But I've also heard that you don't have to pause the infusion or kink the tubing due to 'positive pressure'. Is this true?

If the line is in a pump, even if the pump is off, it will prevent backflow, modern primary tubing also includes a check valve above the pump that prevent backflow, so there is no reason to pinch the tubing above the port.

So I would require 1.5 mL, which would be injected into the 50 mL bag for a total volume of 51.5 mL. In school we learned that when setting up the Alaris pump, we would enter 51.5 mL as the VTBI. However in practice I see that staff normally just go with 50 mL as is set up in the guardrails. Also, when the pharmacy prepares such medications, they also just go with the 50 mL. What is best practice in this case?

So long as there is an primary infusion that will continue after the 50ml volume to be infused is completed, it doesn't matter all that much what volume you put in, just keep in mind the remainder will infuse at the primary rate, which might vary significantly from the prescribed rate for the secondary medication, so generally I set the volume to include overfill and secondary chamber/tubing and primary line volume to ensure that the entire dose infuses at the prescribed rate. Obviously if the primary infusion rate is 100ml/hr and the secondary infusion is to go at 100ml/hr, then it makes no difference.

Guest219794 · Aug 23, 2017

The secondary will infuse until it reaches the level of the fluid in the primary bag, so if the secondary isn't high enough and the drip chamber or even the bottom portion of the bag is the same height as the fluid level in the primary bag then it will only infuse to that point, the slowly infuse as it continues to match the slowly decreasing fluid level in the primary bag.
Keep in mind that programming a secondary infusion into the pump doesn't cause the pump to pull from the secondary bag, essentially all you're doing is telling the pump to run at a set rate for a set volume, and to then switch back to the primary rate. If you have a primary infusion running at 75ml/hr and hang a secondary to run at 100ml/hr for 50ml, then the pump will run at 100ml for half an hour and then go back to 75ml/hr, if there is still 10ml of the secondary left, it will still infuse but at 75ml/hr.
If the line is in a pump, even if the pump is off, it will prevent backflow, modern primary tubing also includes a check valve above the pump that prevent backflow, so there is no reason to pinch the tubing above the port.
So long as there is an primary infusion that will continue after the 50ml volume to be infused is completed, it doesn't matter all that much what volume you put in, just keep in mind the remainder will infuse at the primary rate, which might vary significantly from the prescribed rate for the secondary medication, so generally I set the volume to include overfill and secondary chamber/tubing and primary line volume to ensure that the entire dose infuses at the prescribed rate. Obviously if the primary infusion rate is 100ml/hr and the secondary infusion is to go at 100ml/hr, then it makes no difference.

All of this assumes a setup in which bags are hung at different levels, and gravity rules.

Right now I am working with two kinds od pumps, and eight of the bag is irrelevant- it is essentially done mechanically.

MunoRN, RN · Aug 23, 2017

All of this assumes a setup in which bags are hung at different levels, and gravity rules.
Right now I am working with two kinds od pumps, and eight of the bag is irrelevant- it is essentially done mechanically.

A primary/secondary set-up is by definition a single fluid column with the secondary medication at the top of the fluid column. There are other ways of setting up that are really two primary infusions where one is held while the other is infusing, but this is not a secondary set up, it's two primaries.