Need some solid answers

tracy9559 · Jul 29, 2006

that's a lot of questions......generally you should try to put similar drugs together. sedatives together, pressors together, tpn has to be on it's own, insulin with magnesium and potassium. sorry i'm in england and forget exactly what is compatible in the states.

but what did stand out was your comment about turning off the morphine/ versed while the pt is paralyzed........big no-no!!! go up on your pressors, titrate down on the sedation but i was taught a pt should never be paralyzed without proper sedation.

i'm sure others can add to that.

good luck!

dfk, RN, CRNA · Jul 30, 2006

Hi all,
I am in my sixth month (1 month off orientation) as an RN in a burn ICU. Lately I've had patients that were on a lot of drips, or needed to be started on a lot of drips... and I'm not sure how to be organized about it. The pt's on my unit usually have one or two central lines, and we have connectors that go on the central line ports that can make 1 port into 3this works fine as long as compatible. I'm wondering, what is your system when you have to hook someone up to fluids, versed, morphine, a paralytic, 3 different pressors, TPN, insulin, FFP etca good method about pressors is to run it into a kvo line, one that will not be used for rapid infusion as bolusing pressors is not a favorable outcome, unless of course they are coding with no pressure. How do you do it so that your pressors don't get occluded (or that things don't get occluded in general?)kvo lines all around. I've asked the nurses I work with, but we haven't had the time to go over it.
Also, I was in a situation where we turned off my pt's versed & morphine because his pressure was so low/unstableversed does not affect pressure much at all. When is it ok to do thatnot a good practice to stop all.. agree with previous post.. bolus fluids, albumin, modified trendelenberg, (lower transducer - just kidding)? It made me wary, because he was still paralyzedwhat was he paralyzed with? versed for sedation and morphine for pain. Thoughts?
Thanks so much for your guidance!

after compatibility and flow issues, it boils down to experience and what u become comfortable with.. many orders say titrate to whatever, be it pressure of, ramsey of, etc... a good goal re: pressors, eliminate the ones with the most caustic outcomes and the ones that shouldn't be used for longer than stated period of time.. although needed, i've seen levo rot a pt's tongue.. nipride never checked for thiocyanate levels, etc... research and read as well.. and never give up asking questions..

begalli · Aug 1, 2006

Here's how I'd set it up for a patient with multiple drips, maintenance fluid, frequent piggyback meds, and an order to transduce the cvp.

My lines:

a great 18 guage peripheral in a large a/c,

a triple lumen in the right subclavian and

an introducer/cordis in the right IJ.

My IV drips/meds:

D5 1/2 NS w/ 20 meq KCL at kvo

versed

fentanyl

insulin

epi

nipride

lasix

(hmmm, sounds more like a swan than a triple lumen eh?)

tpn

q 6 hour calcium/potassium/magnesium checks and replacements

vanco q 12 hours

many other scheduled meds and prns

Transduce the cvp through the brown port of the triple lumen.

TPN will always go to the blue port of the triple lumen all by itself. To remember this I was taught to think of TPN as food and the blue port as blueberries!

Connect all the drips (except lasix) via stopcocks through the white port of the triple lumen with the drug running at the most constant rate at the end of the row of stopcocks. Many nurses place a 3-5ml/hr "chaser" of normal saline at the back of the stopcocks, but I personally choose not to do that.

Hang the D5 1/2 NS w/ 20 of K+ all by itself on the introducer/cordis and run all scheduled and prn meds, including electrolyte replacement and IV abx as piggybacks through this line. The timing of the meds is important and something that you will have to adjust so things are given on time....but it can be done. I like to keep this giant line open and available in case we have to give large volumes fast. Also, if an additional peripheral line is not available and if blood products need to be given on a one time or very seldom basis, I would give it through the large introducer after d/c'ing the maintenance and flushing the line thoroughly. Once the blood or whatever is done, I'd hook the D5 etc, etc, up again.

Hook the lasix up to the peripheral line (it needs to be alone).

I would probably prefer to have one more peripheral for this patient and just keep it saline locked flushing it periodically to keep patency. As a matter of fact, if this patient were receiving blood products then I would absolutely have another peripheral and use it for the blood, ffp, etc instead of using the introducer. That way there is no possible interruption to the meds flowing piggyback through the introducer.

I would recommend to always keep IV drips such as those I listed above together. If you need to add a drip, just use a stopcock and add it to the row as long as the meds are compatible. Just be sure to label everything at the pump and at the patient (portion of tubing attached to the stopcock).

I also like to use a flat armboard and wrap it with a piece of chux, plastic side down. I secure the row of stopcocks to the top of the armboard with plastic tape and then secure the armboard itself either to the sheet or pillow case or the patient gown with a kelly clamp. Using the chux under the stopcocks will show if anything is leaking.

Generally it's easier to learn what drugs absolutely need seperate lines or can't be added to a row of stopcocks than it is to learn what drugs are compatible. Most IV drips can run together. If you EVER have a doubt either ask or look it up.

I hope that helped. I remember being new in the ICU and having really sick patients that just kept getting more and more drips added to whatever they already had. It was so confusing and when I think back to when the more experienced nurses helped me straighten it out after the patient stabilized, I just laugh. It was such a mess but I got the job done!!

It'll take time, but you'll get it! Keep asking for someone to show you.

If a patient is on a paralytic they MUST have sedation and pain meds running. I would take great issue with anyone who told me to shut either of those meds off on a paralyzed patient. I hope you have someone to help you with this if any doctor requests an order to do so and you cannot convince him/her otherwise. As a nurse, and if no doctor is telling you to stop the meds, just don't do it. Titrate other meds to attain your desired parameters.

begalli · Aug 1, 2006

Oh! Burn ICU, maybe not a lot of peripheral IVs.

I think you can still my my idea though.

Gosh, gotta give it to you for going into Burn right out of school. It's tough.

gradcare, LPN · Aug 1, 2006

VivaRN,

Just remember to keep you inotropes on a single lumen where they cannot be bolused (assuming that they are compatable) if they are not compatable then you have to use two dedicated 'trope lines. I have seen bolused noradrenaline and it is not fun.

Also remember to mark your lines and pumps this makes it easier to put your hand on an injection point for bolus drugs in the event of problems. It also reduces the ability of people to bolus your pressors instead of your sedation....ouch. Marking the pumps also makes it easier for the medico's to determine howmuch of what they are on. I don't know what the relationship between RN's and DR's is like in your unit but in ours it is generally very good with a lot if mutual respect.

Does your institution have an injectable drug hand book? If so it sould be a big help in deciding what infusion runs with what but generally try to keep like with like. It is also good to keep a large bore line for your colloids / blood products if you can. A good way to get lines occluded is to turn them off and not use them again for a shift or so. To prevent this what you can do is after turning of say your tropes or (pressors) and tollerating them off for 2 hrs or so perhaps aspirating the lumen (take about 5-10 mls of blood and then flushing the lumen with n/saline and then using the lumen for something else. If the pressors need to go back on you can simply change back to what they were like originally. But check you unit policy first.

As to paralysed not sedated......not nice !! Remember it is possible that the resulting increase in BP is due to your patient freaking out over being aware but unable to move or being in pain.

Cheers

VivaRN · Aug 2, 2006

Thanks, all of your comments are so helpful. I like seeing the thought process in how you organize your lines. Helps it make sense. It's nice to know what the general principles are, as people seem to "do it their way" within those parameters (making it hard for them to explain it to me). I actually went to my manager and got a copy of my institution's pocket drug book - I didn't know we had one! Learning this is making me a better nurse when it comes to handling critical situations. I'm curious, how did you experienced nurses learn this skill? And what drugs do you generally watch out for as far as compatibility (ie, bicarb)? Thanks again!

dfk, RN, CRNA · Aug 2, 2006

Thanks, all of your comments are so helpful. I like seeing the thought process in how you organize your lines. Helps it make sense. It's nice to know what the general principles are, as people seem to "do it their way" within those parameters (making it hard for them to explain it to me). I actually went to my manager and got a copy of my institution's pocket drug book - I didn't know we had one! Learning this is making me a better nurse when it comes to handling critical situations. I'm curious, how did you experienced nurses learn this skill? And what drugs do you generally watch out for as far as compatibility (ie, bicarb)? Thanks again!

learning is just that.. always learning ! you will find your own way as well.. you even see how your co-workers do it when covering for them, change of shift, taking care of a beeping (not bleeping, although sometimes) pump...

as for drug compatibilities, there should be a chart that has compatibilities that you can check.. always can call pharmacy and ask if two or three are compatible (may take a little longer for an answer).. perhaps your unit has computer-ready info.. iv drug books should have a table in the back of the book (or somewhere similar)... perhaps a unit iv drug book, etc...

as for bicarb, traditionally run alone..

mag and k can be run together (remember mag before k, unless mag is low therapeutic, otherwise you will compound your hypo-k) -

again, this all comes with time and researching... two things that should always be between you and pt safety!

cookielady,rn · Aug 2, 2006

after compatibility and flow issues, it boils down to experience and what u become comfortable with.. many orders say titrate to whatever, be it pressure of, ramsey of, etc... a good goal re: pressors, eliminate the ones with the most caustic outcomes and the ones that shouldn't be used for longer than stated period of time.. although needed, i've seen levo rot a pt's tongue.. nipride never checked for thiocyanate levels, etc... research and read as well.. and never give up asking questions..

See, things like checking thiocyanate with nipride is something I've never heard and I hate not knowing important things like that

VivaRN · Aug 3, 2006

Exactly! Preferably, I would like to know certain things like that BEFORE the situation arises... but usually it's more in the moment, as I go to do something and the experienced nurse says, "hang on". Mag before K+? I didn't know that either! God bless the experienced nurses who save my patients from me

dfk, RN, CRNA · Aug 3, 2006

Exactly! Preferably, I would like to know certain things like that BEFORE the situation arises... but usually it's more in the moment, as I go to do something and the experienced nurse says, "hang on". Mag before K+? I didn't know that either! God bless the experienced nurses who save my patients from me

it's unusual that a level like that arises to something serious, but i don't thing docs think of it. perhaps it's because no one is usually on nipride longer that a few days.. it is at the discretion of the RN to add a level when sending labs, no? you may be the hero in the end...! there are some things that once you learn you will never forget.. simple or not.

JenSICU_CCRN · Aug 3, 2006

I don't know if your pharmacy will do this or not, but this is another suggestion that we utilize. Our pharmacy is great, and we have sick, sick, sick pts a lot of the time in our SICU since we are trauma, neurosurgery, and a bariatric center (you all know what happens with a leak-youch)...anyway, our pharmacists will make a grid of all the drips, prn's, and scheduled ABX and replacement as to what is compatible or not...even though you think all pressors can go togehter...They CAN'T. Levo and neo aren't the greatest together because one has to be placed in D5 and the other in NS....I can't remember which, but the pharmacy always helps me out with this also.

Jen