Multiple IV's question

[hollyberry678]

I had a pt who was has a DL subclavian Hickman. She has TPN/Lipids running into one port. The other port has Maintenance NS TKO, and has various piggybacks during the day (most of them K replacements 4x 10 MEQ to replace her lab K of 3.4), but also Zosyn and vanco.

She had been running low grade temps, and all cultures came back negative, so the Dr's were thinking the catheter was infected. To try to save it, they ordered the QD vanco to be divided up (into two bags) and running continuously into both ports 24 hours/day. they asked me if there was any problem with this. I said 'compatibilty perhaps?' they then said if there were a compatibility issue that I should stop the one while an incompatible med was running, and run the other on at twice the rate until the IVPB was finished.

Pharm sent up two 100 ml bags. I went to the pharmacist and asked how to infuse- she divided up 100 ml by 24 hours-- approx 4.1ml/hr (for each bag)

Pt had triple Baxter pump-- 1 TPN, 1 Lipds, and 1 NS. I ordered another, they were out, so had to settle for two singles.

Set up each 100 ml vanco to the singles at 4.1 ml/hour, got extension tubing to get another port after the filter on the TPN. Then added the other bag to the maintenance.

The next day, both pumps looked like they had been infusing at 4.1 ml/hour, but the bags didnt look like they had been....slighlty fuller than I would have expected.

Did I do this right? I am a new grad. I worked hard at figuring this out. Any feedback appreciated. thanks.

[SICU Queen]

Well, first of all, 4.1 ml/hr is such a tiny amount that, when you come back 12 hours later, the bags may not look like much has gone in. I've found some antibiotics with as much as 20 ml over what the amount says on the bag - you have to account for the fluid from the antibiotic that was added to the base fluid. If your pump is set right then it should be infusing. Another thought may be that for some reason the other shift had to stop them for a while? Especially if she's got other antibiotics. I don't know what else it could be.

Of more concern to me, however, is why on earth didn't they change the line out? I've NEVER done continuous antibiotic infusion for a suspected line sepsis.

As far as what you've figured out, it all sounds good.

[CritterLover, BSN, RN]

most piggybacks mixed by pharmacy have some overfill (more volume than is written on the bag). so your 100 cc bag probably had 110ccs or so in it. that would account for their being "slightly more" volume than you expected still in the bags of vanc.

your rate calculation (based on a 100cc bag) is correct, though you could have rounded up to 4.2cc/hr (not a big deal).

the problem that i see is that most facility policies prohibit infusing tpn with any other drug, other than lipids. are you sure infusing the vanc and tpn through the same port didn't violate your hospital policy?

vanc is actually compatable with quite a bit, though not with zosyn; and i've run it through tpn in a home-health setting before (ok'd both by md and pharmacist, and didn't violate any policies we had), so i'm not sure that you had any compatability problems (it would have depended on the exact make-up of the tpn).

infusing other medications through tpn is usually a pretty big deal in most facilities. the physicians may have been aware that the tpn and vanc were running together and were ok with it. however, it is very important to remember that physician orders cannot trump hospital policy, unless the policy lets a physician order trump it.

(what i mean by this, is that if a hospital has a certain policy, say "pts on dopamine drip must be on telemetry," the doctor can't write an order that it is ok for the patient to be on dopamine and not on telemetry -- say your hospital is out of telemetry beds --unless the policy allows for it: "pts on dopamine drip must be on telemetry unless otherwise ordered by the physician.")

am i making sense?

so if your facility has a policy that nothing except lipids can run through a port with tpn (my facility has this policy), then there could be a problem.

[CritterLover, BSN, RN]

well, first of all, 4.1 ml/hr is such a tiny amount that, when you come back 12 hours later, the bags may not look like much has gone in. i've found some antibiotics with as much as 20 ml over what the amount says on the bag - you have to account for the fluid from the antibiotic that was added to the base fluid. if your pump is set right then it should be infusing. another thought may be that for some reason the other shift had to stop them for a while? especially if she's got other antibiotics. i don't know what else it could be.

of more concern to me, however, is why on earth didn't they change the line out? i've never done continuous antibiotic infusion for a suspected line sepsis.

as far as what you've figured out, it all sounds good.

i've seen them do the abx infusions before on implanted lines (permacaths, ports, and hickmans), so it doesn't surprise me. well, actually what i tend to see is "vanc locks," kind of like heplocks, where they pack the catheter with vanc and let it dwell. i've done this with home care patients with infected ports. they wouldn't be able to do that in this instance, though, since they were infusing meds through it. the continuous vanc infusions would be the next best step.

(other than all that is involved with changing out an implanted line -- or or ir and the like -- if they put a new one in each time every patient got line sepsis, some would eventually build up too much scar tissue, or get stenosis in the veins near the insertion points, that the patients would eventually run out of access points. the vanc locks are usually a good first-line treatment for an infected tunneled line.)

probably would have been a good idea, though, to put in some other central access in the mean time for the tpn, while the vanc was infusing. especially since it isn't a very good idea to have all that sugar running through an infected line, helping the bacteria to grow and multiply.....

[Daytonite, BSN, RN]

of more concern to me, however, is why on earth didn't they change the line out? i've never done continuous antibiotic infusion for a suspected line sepsis.

a hickman line is a tunneled catheter that is placed surgically and required a trip to the or. thus, they'll want to try a number of different ways to save the catheter before resorting to another invasive procedure--especially with a suspected sepsis.

[hollyberry678]

Thanks to both of you for your replies.

As I said, I am new...I wondered why they didn't change the line myself, but with my newness figured changing a subclavian hickman was a big deal...maybe they are hoping the low grade temps will resolve. I know they got this recommendation from Infectious Disease docs...

Yes, I should have rounded up-- it come to 4.16 or 4.17 ml/hr. dont know why I didnt, trying to be conservative, I guess, but I should go by the nursing math/rounding up I learned...

The pharmacist was aware of this...I would hope they are aware of TPN policies... you are right about checking policies. We dont really HAVE a unit policy book. There is supposed to be hospital policies on our computer/hospital internal website, but it is very hard to find things...I really need to ask our clinical nurse specialist to show me how to access things, as the times I have tried, nothing showed up for that particular item (tpa port infusion, for example). But this is realy important to be able to reference! thanks!

Yes, for the Zosyn, the one line had to be stopped for that to infuse...

[melski68]

is there any reason you could not place a periph line for the miv, and antibiotics (cept the vanco and potassium) put the tpn.lipids through one port. vanco K+ in the other port. and everything else periph.

better yet, is she not a candidate for a picc line?

[GrumpyRN63, ADN, RN]

I've never had a pt on cont Vanc, what's happening w/ the TPN, is it running WITH the Vanc??? I've never piggybacked anything into TPN line, always dedicated line, If so, seems rather counterproductive to me, 1) High sugar = great medium for bacterial growth 2) If the TPN is running ATC at say 40 or 60/hr or even worse if cycled at 120/hr say 10-12 hrs that Vanc is just getting flushed away. I can't imagine Vanc and TPN being compatible

I think the best scenario , if they want to try and save the Hickman, is ONLY run the Vanc thru each pigtail in divided doses ATC and give the pt a double PICC in the interim for TPN/IVF/Meds (JMHO)--Keep us updated on the final outcome, I'm curious --thanks

[kcalohagirl]

Never had a patient on continuous vanc.

What I have been told previously by pharm, however, is that vanc, once it is mixed, has a limited life. In other words, that bag of vanc that pharmacy sends you is only good for 2 hours at room temp before it degrades. (at least that is what I was told)

That is why vanc is not pre-mixed in the pyxis machine, but comes in the little bottle that you add to the bag of fluids. . . . .

I would query the effectiveness of continuous vanc under thos parameters.

Does anyone else know if vanc becomes ineffective after a certain amount of time at room temp, or has pharmacy been feeding us a line???

I have also been taught never to run anything with TPN.

[CritterLover, BSN, RN]

never had a patient on continuous vanc.

what i have been told previously by pharm, however, is that vanc, once it is mixed, has a limited life. in other words, that bag of vanc that pharmacy sends you is only good for 2 hours at room temp before it degrades. (at least that is what i was told)

that is why vanc is not pre-mixed in the pyxis machine, but comes in the little bottle that you add to the bag of fluids. . . . .

i would query the effectiveness of continuous vanc under thos parameters.

does anyone else know if vanc becomes ineffective after a certain amount of time at room temp, or has pharmacy been feeding us a line???

i have also been taught never to run anything with tpn.

the iv drug book i have states that "reconstituted solutions may be refrigerated for 14 days. when diluted, solutions are stable for 24 hours at room temperature."

[color=#483d8b]so yeah, maybe your pharmacy is feeding you a line.... or maybe there is something particular about the brand of vanc they use. (though i'm not sure what that could be).

[color=#483d8b]i do know that i have occasionally had outpatients on vanc infusions per cadd pumps, and those bags are at room temp for 24 hours, even though they arn't continuous drips.

[color=#483d8b]i also know that i have never had to reconstitute vanc myself, and i've had to reconstitute many abx for outpatients that are mixed by pharmacy for inpatients. our outpatient pharmacy always mixed our vanc for us.

[color=#483d8b]my drug book also talks about continuous vanc infusions: "use only when intermittent infusion is not feasible. add ordered dose to compatible solution and give by iv drip over 24 hours."

[color=#483d8b] so, while not common, vanc drips are accepted practice.