alibee 4,070 Views
Joined: May 18, '11;
Posts: 48 (35% Liked)
; Likes: 34
Registered Nurse; from
2 year(s) of experience
Surgical/Stepdown, Home Care
Religion and religious beliefs have always been respected in many arenas worldwide.
And for that I'm grateful. I agree with the ruling.
9-11 patients is insane. Whoever is dictating those ratios is just asking for patient complications and deaths. It's just not humanly possible to adequately care for that many patients. I'd be looking for another job. In the meantime, make sure you have malpractice insurance. A hospital tha is willing to take such risks with its patients doesn't care about its staff.
If you can't backflush secondary lines between potentially incompatible IVPB meds - are you then changing the J-loop and IV catheter between every incompatible med?
No, you flush between meds when pushing into a saline-lock, right? So, if the problem doesn't exist in the J-loop and cath, then why would it anywhere else.
Munro and redhead,
I have seen lines of where residual of incompatible medications have been problematic for patients.
Seriously, lol how are you scientifically defining "half-hearted." The calcium and ceftriaxone event in babies (see below) is at odds with your dubious null hypothesis.
Also, in many places, the secondary line is to be brought up ^, while the primary line is to be brought down V, if intermittent. Now where there are many controllers or pumps, the pump to the primary line is set at a particular rate, if continuous. So if the secondary medication is running in at the lower port on the line and at a slower rate, wouldn't this pretty much prevent any backup into the primary line. As far as the primary line, lower down, if the the primary continuous infusion is running and the secondary port is lower down, then the primary IV solution will continuously be pushing it along the IV. It is at a continuous and controlled amount, not at a guess of something that may or may not be "half-hearted." See what I mean? Physics will prevent a stagnate residual accumulation, so long as there is no serious issues of viscosity or differences in pH compatibility or other issues and problems regarding incompatibility--which begs the question, why add on something to the primary line a medication is considered incompatible, to whatever degree, at all?
As far as compatibility between various meds going into the secondary line, my concern then has more to do with the secondary line and what it means in terms of an acceptable level of back-flushing and residuals within that particular line and port connection. So, me? I'd first want to know if the medication I'm riding into to the primary line is truly compatible with the primary IV solution. OK, that's a no brainer. Then I want to know about any medicines I would be giving back-to-back and their compatibility. For God's sake, many of the compatibility charts or compatibility information shows "unsure or unknown" for certain agents and compatibility. We take enough chances with them, and we take enough changes in practice in general. People get busy. Crap happens. To me, if something is questionable, I would much rather pull a separate line and be safe and be down with it. Again, I'm not saying use a separate secondary for each antibx or med. I'm down with that if it's compatible with both the primary--any primary additives, and any other consecutive secondary meds. Damn, I don't think that is being at all unreasonable.
Fortunately, with kids that are on multiple infusions, they usually have multi-ported lines. But there are times it gets tricky, and in general, it's a much more anal world, b/c too much can go wrong and there are multiple other issues. I think working pediatric critical care has overall made me a safer nurse as compared when we could be more like "cowboys" in adult critical care. Sure, more autonomy, but when I think back, it was more unnecessary risks we were taking with the adult patients.
Anyway, back to the issue:
It's not just an issue like with Dilantin or Diazepam, however, where precipitate in the line or the catheter or port of the a particular line can cause big problems. That's bad enough, b/c it's not so easy to just stick a new line in a patient. If you have ever witnessed it, you know what a problem it is.
It's the fact also that some meds have bad sequelae in people b/c of issues s/a how are the agents combined, what is the combination in line of the primary infusate, and the fact that multiple meds for IV PB in one line can build up as residuals. Maybe some adults can tolerate this, but some can't and certainly children may not. There are also issues with certain meds where they are formulated in non-aqueous solvents to allow dissolution of a substance that is poorly water soluble substance in a small volume. For such formulations, dilution of the non-aqueous injection vehicle with water or saline may
precipitate the drug.
But from a chemistry and pharmacological standpoint, there are a number of other reasons why we shouldn't mix incompatible agents, and where we well may not know what substance or amount of the substance could potentially be a problem.
Not too long ago there were found to be problems with IV cefriaxone and calcium administration in neonates and children. This was reported in association with deaths in infants and children by a French agency. So, these meds are now to be given with separate lines, and in children, no one should be giving an electrolyte without a two RN or RN-MD check anyway--so when you check the calculations, you should also be checking what is running where and with what. There was thereafter a stoppage of these meds in any same line in adults as well, however, I believe they are doing the secondaries again in adults, b/c there were no cases of it being a problem in adults. *shrug* Whatever.
To me, it's an issue of potentially problematic chemistry, and it's not worth it.
Here's another consideration. In the use of multiple meds in a line, leaving various amounts of different residuals can add to the break down of the plastics in the IV line. This could also lead to problems for the patient, if not in the short-run perhaps in the long-run with continued use.
As far out as that may seem to some, it just makes NO sense risk the potential problem by using the same line for medications that are incompatible, even if there is back-priming.
The questions become 1. Was the back-priming done with a sufficient volume each time? and 2. What of residuals at port points? Can anyone be sure that this will not be problematic for a patient?
No one can be sure of these things, even if there were more evidence-based studies. Why? Well there are too many variables, and the problem of added medications (multiples) only adds to the uncontrollable variables. Studies where this could be tested sufficiently are beyond problematic for numerous reasons.
The first rule in medicine is "Do no more harm." This is just as true in nursing and allied health. Therefore, I state, again, that using a line with drugs that are incompatible, even if flushed through, is potentially problematic, and the benefits of doing this do not outweigh the potential risks.
What is controllable is sound technique when adding to a line.
In general, again, I say there is no problem IF meds are compatible. So by all means, limit the needless risks associated with contamination with those meds and back-flush where and when appropriate.
It's never, however, appropriate in my practice to mingle incompatible meds. Again, the question is, can we be sure the incompatible medication was appropriated diluted by the back-flush from the primary fluid? And are we even sure the primary fluid is compatible with all of the particular secondary meds?
Acids and bases being what they are, I 've seen crystalization set up in ports. To me, it's not worthy having to potentially stick a person again, just b/c I 'd didn't feel like getting a new and separate line for the incompatible medication, or b/c I was worried about the $2 or $3 bucks spent on procuring and using a separate line. The benefits don't outweigh the risks to me for anything that is listed as incompatible with anything else that was given through it.
So short of any hard data, which again, would be very difficult to come by, even with multiple studies, I'm going with that with the least probability of causing a problem, and then I will use good aseptic technique for the incompatible line, and then call it a day. Sue me.
Here's what the following expert infusion nurse shares in terms of things in general--secondary lines and back-priming:
"Backpriming a secondary set to use it for multiple meds is an acceptable practice as long as any medication in the primary fluid is compatible with the secondary med. Leaving the secondary set attached to the primary set is much better practice because you are not manipulating the tubing on both ends with each dose. —
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website Lynn Hadaway Associates, Inc.
Blog Lynn Hadaway Associates, Inc.
Office Phone 770
I'm cool with what she is saying, with the added exception of not risking trouble with anything that is incompatible with the other previous meds infused. Is that overkill? I don't know. You decide for your own practice. Just as easy and safe to get a separate line for that med that is incompatible with the previous med I've given through the line. And it's definitely a No-No if there is incompatibility with the primary fluid in the same IV line. Shoot, I'd be more comfortable flushing sterile NSS after the previous med and then moving to the incompatible one; b/c at least then I have the physics of flushing the whole secondary line. If the primary was stopped during infusion, I'd flush where the secondary went in too.
I swear, I think half the time some of these angios or other lines like PICC, etc become problematic at the site because of all the various crap we are giving, how often we are giving it, and how we are giving it. Vessels are sensitive. They aren't like top line copper tubing or even tough PVC. They are made up of collagen for heaven's sake.
Also with regard to Lynn the infusion nurse above, it seems clear to me that that would also apply to compatibility with any added electrolytes and other substances in the primary infusion, no? People can miss this stuff though.
Also even for back-priming, what I have read is that if multiple meds and antibiotics are used in a secondary line intermittently, the secondary then should be changed every 24 hours. If you use one line and back flush, and disconnect after each infusion, this is also considered "primary intermittent." If it is connected intermittently to a primary then it is considered a secondary intermittent & changed every 24hr.
Aside from the issue of your particular views and judgment in terms of how you want to practice, whenever in doubt, it always pays to give pharmacy a call, and refer as well to the P&P for the unit or floor, and then too, stay on top of drug safety alerts. This another reason why nurses need their smart phone or smart devices for clinical use in the hospital. You can't always get to a free computer on your floor or unit.
Also, the hosptial, unit, or floor policies are not always right up-to-date. (Not to get off topic, but this is something I always use, legitimately so, against the argument of having smart phones or smart devices in the hospital.) So my first step, other than my own smart device, is to call pharmacy, while I'm also looking up the unit standard P&P.
All places should teach new nurses to do this upon unit/floor orientation.
Guess my, lol, "authority" (such as it is ) is bunk though, even though it's based on 10+ hospitals--99% of them being teaching/university based hospitals, as well as >20 years CC experience.
No, it is NOT recommended ANYWHERE that you use the same line for an agent that is incompatible, period, end of story.
Isn't that a given? Several people have made this point but I figured that nurses were using new tubing strictly for that reason to begin with. It sounds like some people here are saying that it's okay to use the same tubing even if the solutions are incompatible because the backpriming should take care of it. What's the verdict?
When folks are saying "backprime several times" do you mean to reinstill the secondary line with primary solution, wait for it to infuse, and repeat? That DOES sound time-consuming.
Someone can backprime all you want, the spike still has the previous med on it. Are the backprimers looking up compatability or just assuming since they backprimed it is as good as new? At my facility, if I heard that someone was using the same line for each PB, I would start to question their nursing standards. I have never looked at the P&P regarding this because I never thought it was an issue. Definitely food for thought.
I use the same secondary tubing for all piggybacks, unless they aren't compatible. Backprime.
I thought it was so strange my 2nd nursing job to see 10 different secondary tubings hanging on the IV pole. A lot of people don't want to change their habits.
Backprining is common and is acceptable.
Umm this is THE norm on med-surg units with ratios as high as 1:7.. I would KILL for 1:4..
I had a visitor say once, "We should get the nurses to give massages." I looked at her and said, "I think the nurses need the massages. Sorry, I'm not trained for that."
Me to Pt: Anything else I can get for you before I leave
Pt gf who is not sick at all: I need a sprite
Me: Vending machines are in the hall
The look on her face was like I killed her puppy. If you are not the pt, you rarely get anything from me. The cafeteria is open til midnight and the vending machine is 24/7
I found with those type of family members, I would try harder to turn the lights on whenever I could. I'm sorry, but you arent the pt so I really dont give a flying fornication about your sleep. At least when you act that way towards staff. I'm worried about me and the pt safety and frankly, you camped out there with your crap everywhere bothers me. I have to lunge over you, which you complain about, trip over your computer cable, which you complain about, then get to the pt and check them, only for you to complain that you arent sleeping. Seriously shut up.
your post is greatly entertaining. please do not go into this field.
My rent is more than that, my car payment is way too high, i pay all my utilities myself and I buy just about whatever I want. Now add a daughter to the mix, I dont think I could do that without sacrificing some for me, which is what kids are about right? So i say yes you can.
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