IV scenario

chuckc, BSN, RN · Mar 24, 2006

Thank you all for your input! This is from Nursing 106 class that starts Monday. I was just looking ahead, I will find out what the answer is in a couple of weeks, I was just trying to figure it out beforehand. Keep those answers coming!

danfif · Mar 25, 2006

Hum,,,,I think that I would hold the TPN, flush line with 10cc NS, hang the 80mg of Gentamycin, which should be mixed in a 50ml bag of NS, and instill that over 30 minutes. When the Genta is done, I would flush again with 10 of NS, hang my 500mg of Vanco, which should be mixed in 100ml of NS, and run it over 60 minutes. I might add, that I would change my tubing, and not run the Genta and the Vanco through the same line.

My thought pattern is this; 1. Sure don't want to stop the Blood for an hour and a half because of the 4 hour time window to infuse the unit. 2. Lipids, if I remember correctly, have to be run in over 10 hours, so you don't really want to delay them any longer than you have to. 3. This leaves the TPN as the likely one to hold, and use that port for this infussion.

Holding TPN for 1 1/2 hours should not cause this patient any problems what so ever. The more important issue is getting these antibiotic's into the patient in a timely manner.

And lastly, the thought of starting a peripheral (sp) line to run these antibiotics is tempting, but it is my guess that this patient is; A. A very hard stick. B. Very sick, they just don't give everyone a triple lumin central line for the heck of it. C. At high risk for additional infections, ie: the Gent and Vanco.

Ok, that's how I see it anyway, and Please correct me if I am off base!

Peace Out,

Dan

Crocuta, RN · Mar 25, 2006

Why bother...the antibiotics will only be run over half hour probably. There should be plenty of residual left in stomach to cover that short time. I say just stop TPN, for the half hour then resume after antibiotics have run. If not sure how much is in stomach just do a quick check for residual.

TPN's going into a vein. I don't think that the stomach and residuals come into play here.

nursenatalie, ADN, RN · Mar 25, 2006

Ok, this illustrates how different things are in facilities. We always run TPN and lipids in same port (dedicated) with lipids connected below filter. I would not interrupt TPN. We use mostly triple lumens, dont know why you would reserve these for the very sick...most people have the potential to become very sick.

bren3299 · Mar 25, 2006

TPN's going into a vein. I don't think that the stomach and residuals come into play here.

That comment had me a little startled as well!

Bren:uhoh21:

tridil2000, MSN, RN · Mar 25, 2006

Hum,,,,I think that I would hold the TPN, flush line with 10cc NS, hang the 80mg of Gentamycin, which should be mixed in a 50ml bag of NS, and instill that over 30 minutes. When the Genta is done, I would flush again with 10 of NS, hang my 500mg of Vanco, which should be mixed in 100ml of NS, and run it over 60 minutes. I might add, that I would change my tubing, and not run the Genta and the Vanco through the same line.
My thought pattern is this; 1. Sure don't want to stop the Blood for an hour and a half because of the 4 hour time window to infuse the unit. 2. Lipids, if I remember correctly, have to be run in over 10 hours, so you don't really want to delay them any longer than you have to. 3. This leaves the TPN as the likely one to hold, and use that port for this infussion.
Holding TPN for 1 1/2 hours should not cause this patient any problems what so ever. The more important issue is getting these antibiotic's into the patient in a timely manner.
And lastly, the thought of starting a peripheral (sp) line to run these antibiotics is tempting, but it is my guess that this patient is; A. A very hard stick. B. Very sick, they just don't give everyone a triple lumin central line for the heck of it. C.At high risk for additional infections, ie: the Gent and Vanco.
Ok, that's how I see it anyway, and Please correct me if I am off base!
Peace Out,
Dan

dan, you can not stop tpn without tapering it. if your tpn ran out, and you did not have a new one, you are to indeed hang d10 to prevent hypoglycemia, which can occur within 20 minutes of an abrupt hault of tpn.

http://www.nmh.org/nmh/homecare/parenteraldischarge.htm

i agree about the pt probably being a hard stick, so my first choice would be to ivpb the lipids and run the gent in the free port, followed by the vanco. if not, a new line would have to be considered.

sometimes we really do have a lot of meds and face these little dilemmas every now and then.

NessaNurse · Mar 25, 2006

Finish the blood 1st. Vanco can actually run w TPN and lipids, they are compatible, not sure about GEnt, call pharmacy. TPN and lipds can also be run together. If you must adminster abx at same time as blood (*i usually dont). Dont rub blood same time as vanco. Redmans could look like trnafusion reaction and vice versa (not exactly but it could look similar)

clee1 · Mar 25, 2006

Why bother...the antibiotics will only be run over half hour probably. There should be plenty of residual left in stomach to cover that short time. I say just stop TPN, for the half hour then resume after antibiotics have run. If not sure how much is in stomach just do a quick check for residual.

Huh???

TPN.... residual in stomach???? How does THAT happen?

danfif · Mar 25, 2006

Ok, I stand corrected on a couple of things. Yes, as stated in other posts you can run the lipids in with the TPN, just do it below the filter. This would free up the third port and allow the Abx's to be run as stated.

As far as triples being reserved for the very sick, that isn't quite what I ment. For the most part your average hospital patient isn't going to be recieving IV meds for the duration of time that would require or warrent insertion of a central line. I wish they all had them, trust me, but for the most part an 18 or 20 G works fine for the average patient.

Dan

mendu · Mar 25, 2006

Anybody interested in helping with scenario question? The patient has a central line with TPN infusing at 75cc/hr. Intralipids are infusing int the second lumen and blood is infusing into the third lumen. You have an order to infuse Gentamycin 80 mg IVPB and Vancomycin 500 mg IVPB, both at 08:00 AM. What would you do? Thank you to all that reply:idea:

i will graduate in may so i am still nursing student but from my recent clinical experience and knowledge: proximal lume - blood infusion, blood draw, meds administration; midle lumen - tpn and meds administration; distal lumen - CVP volume, viscous fluids and tpn (that what i was thought); though it is ok to ad intralipid to tpn so we have second line open; then retime gen and vanco - they have drug-drug interactions: if given together may increase ototoxicity and nephrotoxicity (both drugs adverse effects so as a nurse we want to avoid it), then vanco need to be infused over 60 min at least and gent over 30 minutes; third lumen for continue blood infusion, draw blood for antibiotic serum or others as ordered; hope this help, looking forward to other members input; good luck with your study;

WVUturtle514 · Mar 25, 2006

TPN in the stomach? That must be some pretty bad central line placement....

First of all, TPN is only infused through central lines, hence one of the reasons for the patient having a central line. Therefore, I would think your first option would be to start a peripheral IV or (if the patient is a super hard stick) find someone who can start a peripheral IV to administer the antibiotics through. Once a line is used for TP, it is only to be stopped and used in an emergency. Depending on the lipid you have running (i.e. Propofol) it would probably not be good to stop this either. Since I've never seen such a thing as "emergent" antibiotics, and since this person is receiving blood products, I would consider the blood a priority over the abx. Therefore, the abx should be infused once the blood is finished if you were unable to get peripheral access. Start with the Gentamycin (over 30 min) so that the patient will at least get some abx in their system, then infuse the Vanc (over 1-2 hours).

BTW, these are my boyfriend's thoughts (he's an ICU nurse) so I was merely typing.....hehe.....

bren3299 · Mar 25, 2006

I am surprised you have never heard of "emergent" antibiotics. Where I work bacterial meningitis, sepsis with shock starting or in full swing are but 2 reasons that IV antibiotics should not be delayed by hours. Depends if these are initial doses and what the back story is. Granted it is not the same urgency as when someone needs drugs during an arrest but I know some ID docs that would string you up if you didn't treat those antibiotics with the respect they deserve as "life-saving" in certain scenarios.

Bren