Multiple drip administration

Pediatric Critical Care Columnist · Jan 11, 2012

I know this is a controversial subject and different places have different policies but I work in peds and we can run compatible meds with TPN, we rarely have triple lumens and PIVS never last in our kiddos though they always have them. If this was my patient I would keep the CVP open with a med port so I could give antibiotics and boluses through there. I would do a train with the maintenance at the end (furtherst from the patient) & KVO and then put the other drips from slowest to fastest, closest to furthest away. I would then run the TPN with the sedation and also have a med line there for meds if needed, but like I said at my facility we often run things with TPN and do not keep it as a dedicated TPN line, however we keep a med line attached and keep it a closed system.

This is similar to how we practice on our unit. With some minor differences... Many of our cardiac kiddies will have triple-lumens (our cardiac anaesthetists are pretty slick with the line insertions) and we have a common practice for what we run where. The distal port is always our CVP/push/med port. Medial port gets the amino acids-dextrose solution (once we start it), lipid emulsion and occasionally compatible other infusions although we try very hard to keep our TPN in a dedicated line. If push comes to shove and we have a PIV, we might put the lipids there so that we can run lipid-incompatible meds with the AADS. Vasoactives and compatible sedation will then run in the proximal port. Morphine, midazolam and milrinone are all compatible with epinephrine and norepinephrine so they'll all go together. As for the order of operations, vasoactives go proximal to the patient and if a drive is required due to low flow rates, it goes most distal. It's only sensible to minimize the dead space that a vasoactive drug has to move through to get to its target.

All our vasoactive meds are delivered in 50 cc syringes (except levosimendan) and we don't routinely close the lines before changing the syringes. This means that when we switch the line is open and under gravitational influences for about 1 - 2 seconds. So when switching the syringes I'll always hold the opened line level to the heart so that we don't get fluids running in or out freely but instead the fluid in the open line remains static.
As a result patients remain much more stable on switching syringes compared to others that change the lines well above patient level as they tend to give the patient a bolus of vasoactives. Or the ones that change it at ground level since they will have backward flow and end up with hypotensive patients.
I might have to add that all our syringe pumps are on a vertical stander next to the patient. So I'll usually make sure the vasoactives are in the syringes that are around patient level and not the top or the bottom pumps as I know the routines of some of my colleagues :)

I've never quite thought of it that way, but it does make some sense! We mix our own infusions right at the bedside and vasoactives go in 60 mL syringes. With our "old" syringe pumps, this method could actually save the roller coaster rides for the amusement park. With our "new" pumps, which all of us would like to heave through the wall, we have to double-pump everything that's running with our vasoactives because they take so long to get back up and running. I'll have to try this with our "old" pumps and see what happens.

Seems much simpler to just use a bag and then you never have to stop it.

The only problems with that solution with peds patients is that they're usually fluid restricted so the volume of an infusion on a volumetric pump would be too high and because these kiddies are much smaller reservoirs, the pulse delivery system of volumetric pumps causes pretty significant peaks and valleys in their BP. We even see huge swings in BP from having other infusions running on them into other lumens when the patient is on vasoactives. When that happens then EVERYTHING goes into a syringe.

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.

Absolutely!! Vasoactive meds should never be bolused except in a code situation. The risks are so high as to be unacceptable. (In peds, one could kill a patient that way.) And of course, with their short half-lives they can't really be interrupted either (which is what happens in situations like I've described immediately above... bolus then lag, bolus then lag - VERY bad for neonates!). In adults, a drop in SBP from 110 to 80 isn't nearly the same thing as a drop from 80 to 50 in a toddler.

Guest372004 · Jan 12, 2012

This is what I think. I think you ICU nurses need to start out at (U.S.) $150,000/year starting salary!

BelgianRN · Jan 12, 2012

@Janfrn: I remember those times when we were trying out the new generation pumps. Are you using the Braun ones? Switching a syringe went from 2 seconds to a minute and all our patients started crashing. And on top of that you could barely see what was in the syringe. We had to double up our vasoactives as well. Then our engineers let slip they were planning on buying those pumps. We revolted and one of the pumps ended up "accidentally" falling from the third floor down and was delivered in a million pieces to them with a note stating it would be the fate of all the pumps. Dunno who pulled that stunt but I am eternally grateful to them.

Now we have spacy new pumps but I'm still not clear why we had to switch from the old ones they were fine but heavier. In my experience the less casing the pumps have the more problems you have when bumping into things. I know that crashing into things isn't best practice in the ICU but for some reason the architects of our hospital decided to make the elevator doors (or generally all the doors in the hospital) really narrow so when we go through with a bed we have about 1 - 2 cm on either side of the bed.

The only problems with that solution with peds patients is that they're usually fluid restricted so the volume of an infusion on a volumetric pump would be too high and because these kiddies are much smaller reservoirs, the pulse delivery system of volumetric pumps causes pretty significant peaks and valleys in their BP. We even see huge swings in BP from having other infusions running on them into other lumens when the patient is on vasoactives. When that happens then EVERYTHING goes into a syringe.

I wondered exactly the same thing. Even with our syringe system when patients are really unstable on multiple meds etc infusion of our continuous meds still add up to 1 - 1.2 liter of cristalloids on a 24 hour basis. 3 syringes running at 15 ml/hour add a little over a liter already. Then we start concentrating all the syringes to get the rates down and fluids as well. As I have no practice at all with running the meds via infusion bags I hope some will give some insight, but wouldn't you give even more fluids to a patient? And how do you keep them from getting fluid overloaded?

This is what I think. I think you ICU nurses need to start out at (U.S.) $150,000/year starting salary!

Don't limit it to the US I wouldn't mind that kind of money either.

Pediatric Critical Care Columnist · Jan 12, 2012

Your coworker was a genius, BelgianRN!! We would love it if those Medfusion 3500 pumps would just self-destruct. They actually take up MORE space than our old Alaris Asena pumps, which have been heavily used for about 12 years and are falling apart. But alas, they are what our health system has decided we're to have, because we're going to standard concentrations one of these years. They're supposedly Smart Pumps... with unit-specific libraries. Only problem is that there are separate libraries for PICU and NICU. They don't run their drips the same way we do (and there's no mL/hr setting either!!) and the range of drugs they use is very small compared to ours. The only outward difference is that they're labeled on the back with the unit they belong to. And at our hospital, neonates who go for cardiac surgery come to PICU to recover. So guess what happens when a patient crumps. Oh how did you know?! Of course the only pumps available for our inotropes or antibiotics or other PICU-type drugs are the NICU ones and after 10 minutes of putzing with them trying to get them to work, the nurse gives up in frustration to go scavenging old pumps from other bedsides.

Most of our doorways aren't wide enough.

Fluid overload is a serious consideration for our patients. When a 3 kg baby is fluid-restricted to 50% of maintenance (as all of our cardiacs are post-op) their total fluid intake is only 150 mL in 24 hours (6.3 mL/hr!) ... and it usually will be completely overrun by their infusions. This has us all very worried about what will happen when we're forced to use an arbitrary standard concentration devised by our clinical pharmacy staff. It has the potential to be a disaster.

needshaldol, will you speak to my employer?? :clown:

Esme12, ASN, BSN, RN · Jan 12, 2012

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.

whenever you have titrated drips with a saline timed iv remember whenever you use that line for pushing fast the patient will be bolused with what ever titrated med is in that line. but truely it really doesn't matter where it is on the line just that they are all compatable meds. don't let the other nurses get you down, some nurses are particular where they place their drip. when i worked icu if our preference differed we would just change it, but we tried to all be consistant and compliant with our peers not to cempete with them. just remembe this too shall pass and in a hundred years will this matter? if not....then just ignore the source. i loved icu and so will you. :)

FlyingScot, RN · Jan 12, 2012

We would love it if those Medfusion 3500 pumps would just self-destruct. They actually take up MORE space than our old Alaris Asena pumps, which have been heavily used for about 12 years and are falling apart.

Jan, try clamping more than one of them to an isolette! The old Medfusion pumps had a nice flat clamp. These beasts have this enormous thing that is nearly impossible to use and are fragile as all get out. I had a mission that required 8... (8!!) of them! We could barely get to the baby! Or titrate anything with any ease! I remeber using a lot of really bad language on that trip.

haleyrn36 · Jan 20, 2012

You need to look up the INS (infusion nurses society) They write the infusion nurses standards. (The nurses bible for infusion policy and TJC guidelines) If you become a member, "and I highly recommend it," you will have access to nurses who specialize in infusion therapy. Do not depend on nurses that may be very good, but have old and possibly bad habits. INS has given me a new inside on infusion therapy. I have been practicing infusion therapy for 20+ years. I am a CCRN, CRNI certified and old ICU/ER nurse. If you have questions...and I hear you have many....become a member of the INS and become the best infusion nurse in your facility.

haleyrn36