Multiple Drip Management tips/tricks

Nurses General Nursing

Updated:   Published

Specializes in ER, CVICU, Nursing Student Instructor.

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Hi all! Working on a project and gathering some tips/tricks/wish you had knowns for a) ICU drips and b) managing multiple drips. For example, Amio must be on a filtered line, Albumin needs the vent open and can spike with a needle to help air flow, etc. 

Thank you! 

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Stopcock Manifolds

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

Off the top of my head (these are things that have all come up on ICU orientations in my unit over the past couple years- not trying to be condescending on any of them, sometimes people really just don't know):

-ativan and nitro drips are hung on nitro tubing.

- Propofol, albumin (and anything in a glass bottle), needs the vent open on the tubing in order to run.

- Bicarb WILL beep "air-in-line" more times that you can imagine and many of those bubbles will be smaller than you can actually see. Amiodarone will do the same. (the small bubbles, even visible ones, will not harm your patient, you would have to run nearly an entire line of air into your patient to risk harm from an air embolus)

- You can't piggy back onto blood or TPN/PPN. Priming your blood line with saline first and then the blood- this is something that will be guided by your hospital policy. There isn't any published data to support why it's primed with NS rather than the blood itself. 

- A-lines are NEVER for infusing medications.

- Lexicomp compatibility is a great tool, take the moment to use it and if you have 7+ drips just print a copy to pass along. Protonix drips are notoriously incompatible with everything and ketamine and versed have more incompatibilities than many others.

- Watch your extravasants and know your unit/hospital policy on running things through midlines. (Just because a doctor says pressors can go through a midline doesn't make it acceptable, they don't know the policies)

- You're NEVER going to push potassium.

- Remdesevir may be considered a chemo hazard at your facility.

- Albumin may require informed consent at your facility (and may be contraindicated for Jehovah's Witness patients, they should be aware it is human albumin)

- When titrating pressors unless specified in an order (which we all wish it always was) the last on should be the first titrated off. Also when levophed reaches about 10-14 mcg/min, non weight based, consider asking to add vasopressin, especially if it's currently running through a peripheral site. If your patient is experiencing reflex tachcardia with levophed, inform provider and they may switch to neosynephrine.

- Always double check your secondary tubing clamp is open when you hang it on your KVO/ primary.

- Propofol tubing is changed every 12 hours. If you have to daisy chain your drips, it should always be the drip closest to the patient otherwise you're contaminating all the other tubings that aren't changed every 12 hours. 

- I second Wuzzie's manifold suggestion but I know that my hospital won't use them and it was sited, by someone, that they can be inaccurate. I still don't see how it's worse than a daisy chain where your patient might not get a new med for hours, or get bolused when another infusion is added. 

- Green caps on all central line ports.

- Always label your tubing at least with the date. A day change sticker without a date isn't sufficient.

-I'll come back if I think of anything else.

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Specializes in ER, CVICU, Nursing Student Instructor.

Thank you so much! This is exactly what I was talking about. I appreciate it. 

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13 hours ago, JBMmom said:

Off the top of my head (these are things that have all come up on ICU orientations in my unit over the past couple years- not trying to be condescending on any of them, sometimes people really just don't know):

-ativan and nitro drips are hung on nitro tubing.

- Propofol, albumin (and anything in a glass bottle), needs the vent open on the tubing in order to run.

- Bicarb WILL beep "air-in-line" more times that you can imagine and many of those bubbles will be smaller than you can actually see. Amiodarone will do the same. (the small bubbles, even visible ones, will not harm your patient, you would have to run nearly an entire line of air into your patient to risk harm from an air embolus)

- You can't piggy back onto blood or TPN/PPN. Priming your blood line with saline first and then the blood- this is something that will be guided by your hospital policy. There isn't any published data to support why it's primed with NS rather than the blood itself. 

- A-lines are NEVER for infusing medications.

- Lexicomp compatibility is a great tool, take the moment to use it and if you have 7+ drips just print a copy to pass along. Protonix drips are notoriously incompatible with everything and ketamine and versed have more incompatibilities than many others.

- Watch your extravasants and know your unit/hospital policy on running things through midlines. (Just because a doctor says pressors can go through a midline doesn't make it acceptable, they don't know the policies)

- You're NEVER going to push potassium.

- Remdesevir may be considered a chemo hazard at your facility.

- Albumin may require informed consent at your facility (and may be contraindicated for Jehovah's Witness patients, they should be aware it is human albumin)

- When titrating pressors unless specified in an order (which we all wish it always was) the last on should be the first titrated off. Also when levophed reaches about 10-14 mcg/min, non weight based, consider asking to add vasopressin, especially if it's currently running through a peripheral site. If your patient is experiencing reflex tachcardia with levophed, inform provider and they may switch to neosynephrine.

- Always double check your secondary tubing clamp is open when you hang it on your KVO/ primary.

- Propofol tubing is changed every 12 hours. If you have to daisy chain your drips, it should always be the drip closest to the patient otherwise you're contaminating all the other tubings that aren't changed every 12 hours. 

- I second Wuzzie's manifold suggestion but I know that my hospital won't use them and it was sited, by someone, that they can be inaccurate. I still don't see how it's worse than a daisy chain where your patient might not get a new med for hours, or get bolused when another infusion is added. 

- Green caps on all central line ports.

- Always label your tubing at least with the date. A day change sticker without a date isn't sufficient.

-I'll come back if I think of anything else.

Good point about the albumin maybe needing consent. We give albumin out like candy bars but it’s part of their consent they sign on admittance. Thanks for all the tips! 

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Sometimes I follow nurses with a real skill for neatness. A manifold with neatly labeled lines all untangled and easy to use is a thing of joy. For teaching, include a picture of the ideal setup. 

I have floated a lot the the cardiothoracic ICU lately. Those patients have more drips running than anywhere else. The other night I had to change out all the tubing for three pressors, heparin, sedatives, fentanyl, saline lines, arterial line, and  all the manifolds and claves. Earned my pay that night. 

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24 minutes ago, RNperdiem said:

The other night I had to change out all the tubing for three pressors, heparin, sedatives, fentanyl, saline lines, arterial line, and  all the manifolds and claves. Earned my pay that night. 

I worked PICU and experienced the same when it came to numbers of drips (add Potassium/Calcium/Sidenafil/Lasix among other things to that as well). The way we managed it is when it was time to change out we got an entire second set of pumps. Spiked the new bags with new tubing, put on the new pumps, labeled and connected to a new manifold. Let it run for 30-60 minutes depending on the slowest drip rate into an empty IV bag (we had an adapter for this) then just changed at the site. Everything was already run through so no BP drops whith pressor sensitive patients. 

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.
On 6/7/2022 at 1:03 PM, RNperdiem said:

The other night I had to change out all the tubing for three pressors, heparin, sedatives, fentanyl, saline lines, arterial line, and  all the manifolds and claves. Earned my pay that night. 

That is SO frustrating. I can't think of a night I've had that many lines to change, but things have changed over the past couple years in my unit and attention to detail has fallen by the wayside more often than it should. I've often had most, if not all, lines in a room running expired or unlabeled. Trying to time all of them to change and minimize waste is difficult in an eight hour shift and sometimes impossible. But it does feel very satisfying to walk  in to a pile of spaghetti and walk out with a neat and nicely labeled set up. And it saves SO much future time when things are put together nicely. Your coworker that followed you was lucky!

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