Multiple drip administration

[Sugarcoma]

I recently had a pt. with multiple drips through one triple lumen central line. I am new and recently off orientation where I had multiple preceptors who each told me something different. I have searched both allnurses and google for an answer to my question but have not really found anything.

In my situation the pt was on levo, vaso, fentanyl, diprivan, epi, 0.9 maintenance as well as receiving boluses of 0.9 and albumin, and multiple ABX piggybacks. We were also treating according to CVP so I needed to keep that port open. The pt. also had TPN so that took up another port. I had one lumen to run all the other meds through so I made a bridge, grouped my vaso actives together and then plugged them into the bridge according to rate. I was taught by my main preceptor to place the most turbulent or highest flow rate, closest to the pt. which I did. Several coworkers argued with me and stated you should place the slowest drip rate closest since the higher rate meds would "push" the slower rate meds in. I have only found one article online regarding this issue and it basically said that placement of medication on a multi infusion set can affect the rate of delivery to pt. It listed a formula where you need to know the dead space and resovoir of your IV tubing etc, but it didn't give any real answers just concluded this was an area where further study was warranted.

I ended up doing the following: TPN in one lumen, Bridge on the other with 0.9@ 150 first, diprivan @ 50mcg second, Fentanyl at 50mcg third, Levo @ 50, fourth, EPI fifth and Vaso @ 0.04 last with a 0.9 chaser at KVO rate. I used my CVP port since we were measuring hourly for boluses, ABX, and pushes.

How do you guys place your meds? And do you have any resources with rationale? I have looked in my AACN book, my critical care references, and unit policies with no success. My rationale for following my preceptors methods was that she had the most years of experience.

[Perpetual Student]

I prefer to have vasoactive drugs and sedatives connected as close to the patient as possible, ideally with a maintenance fluid pushing 'em along. That way when I make a dose adjustment it will affect the patient as quickly as possible.

[Esme12, ASN, BSN, RN]

And we need to remember not everyone responding is from the US as there are other countires here with different laws, policies and equiptment.

[MunoRN, RN]

By "Bridge" I'm guessing you mean what is called a manifold where I work. It makes no difference what order you connect them. Same with piggybacking one fluid into another line, once the connection is made it becomes a y-splitter, it makes no difference if you connect the tip of line A into the distal port of line B or vice-versa in terms of fluid flow.

[Reno1978, BSN, RN]

I ended up doing the following: TPN in one lumen, Bridge on the other with 0.9@ 150 first, diprivan @ 50mcg second, Fentanyl at 50mcg third, Levo @ 50, fourth, EPI fifth and Vaso @ 0.04 last with a 0.9 chaser at KVO rate. I used my CVP port since we were measuring hourly for boluses, ABX, and pushes.

I don't see a need for the 0.9 chaser connected to your vaso. Although it infuses at a small rate, you have your 0.9 @ 150ml/hr running behind it which will help deliver it to the patient faster.

[Sugarcoma, RN]

We also plug a chaser line into the last connection when we build bridges. They are multiple stopcocks connected to each other. I found a picture of something very similar here:http://img.hisupplier.com/var/userImages/2011-07/15/171552101_Three_way_Stopcock_s.jpg

So I was able to pick my former preceptor's brain a little bit for rationale. She told me the reason she sets it up with the fastest med first is because that is usually your maintenance fluid, which is usually 0.9 and because it is positioned on the stopcock first you can use it as a push line without worrying about what is compatible with what, if you have to push something fast.

[mvanz9999, RN]

By "Bridge" I'm guessing you mean what is called a manifold where I work. It makes no difference what order you connect them. Same with piggybacking one fluid into another line, once the connection is made it becomes a y-splitter, it makes no difference if you connect the tip of line A into the distal port of line B or vice-versa in terms of fluid flow.

Wow. The first person that states what I think! It makes no difference, in general, what order you connect your drips. People are fond of stating that the fastest fluid in the back of your other connections will make them flow faster and at a more consistent rate. However, it really makes no difference. The higher flow rate fluid in the back isn't pushing anything. Think of your maintenance fluid like a river. It's flowing at a fast rate, regardless of where you add something (front or back). It gets watered down and carried along with the river regardless of where you add it.

[Reno1978, BSN, RN]

She told me the reason she sets it up with the fastest med first is because that is usually your maintenance fluid, which is usually 0.9 and because it is positioned on the stopcock first you can use it as a push line without worrying about what is compatible with what, if you have to push something fast.

That sounds dangerous. If you used that first 0.9 line to push an IV medication, you're bolusing the patient with all of the vasoactive medication in the line ahead of that connection, and you will have to worry about compatibility unless you shut off all the stopcocks to your medicated drips, and flush it with saline before and after your push...but again, that's an awful idea to bolus anything through your lumen with vasoactive drips infusing.

[Sugarcoma, RN]

that sounds dangerous. if you used that first 0.9 line to push an iv medication, you're bolusing the patient with all of the vasoactive medication in the line ahead of that connection, and you will have to worry about compatibility unless you shut off all the stopcocks to your medicated drips, and flush it with saline before and after your push...but again, that's an awful idea to bolus anything through your lumen with vasoactive drips infusing.

i'm sorry, i mis-typed. it would actually be positioned last on the stopcock, or closest to the patient, with the drips behind it. because i am new and do not have much compatibility memorized i always try to keep an open lumen in case i have to push something fast. if i cannot do that, i will use the cvp port. i am going to continue this practice.

wow. the first person that states what i think! it makes no difference, in general, what order you connect your drips. people are fond of stating that the fastest fluid in the back of your other connections will make them flow faster and at a more consistent rate. however, it really makes no difference. the higher flow rate fluid in the back isn't pushing anything. think of your maintenance fluid like a river. it's flowing at a fast rate, regardless of where you add something (front or back). it gets watered down and carried along with the river regardless of where you add it.

this is what i initially was thinking myself. that because the medication is being delivered at a controlled rate via an infusion pump, position on the bridge wasn't an issue but my preceptor and coworker's felt otherwise. it really doesn't seem to matter how i set things up. it seems like the nurses who follow me always find fault with my set up. lol. i guess that is nursing.

[Sugarcoma, RN]

If anyone is interested I found another article online regarding this issue on the website anesthesia-analgesia.org. Interesting reading.

http://www.anesthesia-analgesia.org/content/109/4/1147.full.pdf

[Reno1978, BSN, RN]

I'm sorry, I mis-typed. It would actually be positioned last on the stopcock, or closest to the patient, with the drips behind it. Because I am new and do not have much compatibility memorized I always try to keep an open lumen in case I have to push something fast. If I cannot do that, I will use the CVP port. I am going to continue this practice.

I understand that - there is still vasoactive medication between that point and where the lumen empties into the patient. If you do not have a free line available for emergency drugs, which is sometimes the case, the best choice to have to "give something fast" would not be the line in which vasoactive drugs are infusing. Just my 2 cents.

[ShaunES]

cvp is useless to assess volume status and you should ignore it; better yet, put your vasoactive medications on the distal lumen and you have another free lumen.

last or first it doesn't matter, there's going to be a good whack of medication in the actual catheter itself that you will bolus if you put anything on it.

our standards are: vasoactive medication on its own lumen unless paired with other vasoactive medications.

(does central venous pressure predict fluid responsiven... [chest. 2008] - pubmed - ncbi for my cvp claim; "

the pooled area under the roc curve was 0.56 (95% ci, 0.51 to 0.61)"; may as well flip a coin.)

[Sugarcoma, RN]

cvp is useless to assess volume status and you should ignore it; better yet, put your vasoactive medications on the distal lumen and you have another free lumen.last or first it doesn't matter, there's going to be a good whack of medication in the actual catheter itself that you will bolus if you put anything on it.our standards are: vasoactive medication on its own lumen unless paired with other vasoactive medications.(does central venous pressure predict fluid responsiven... [chest. 2008] - pubmed - ncbi for my cvp claim; "

the pooled area under the roc curve was 0.56 (95% ci, 0.51 to 0.61)"; may as well flip a coin.)

thank you for the link, very interesting!