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 3. 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 etc. How do you do it so that your pressors don't get occluded (or that things don't get occluded in general?). 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/unstable. When is it ok to do that? It made me wary, because he was still paralyzed. Thoughts?
First off you are doing better than a ton of new nurses by asking questions and researching information.
I oriented lots of new grads and answered allot of questions since I was charge a fair amount of time. I tried to tell people to use their resources the hospital allows has pharmacist on duty who are there to help you if you call and ask. Never mix meds based on use i.e. pressers they can be ran in the same line because of chemical properties. A good example is diprivin which tons of nurse think has to have a dedicated port just for it. In reality you can run many drugs together such as
DIPRIVIN COMPATIBILITY
compatible with the following solutions in the IV line: D5W, D5½S, D5LR, LR
This is something that I've personally experienced on several occassions. Our pharmacy provides us with a stopcock designed specifically for administering propofol. We ALWAYS run this wonderful drug the through a designated line. By allowing it to run with other drips there is the distinct possibility, I have seen it happen, that it will cause a leak at the stopcocks of other drugs.
We conclude that the cracks in three-way stopcocks are enhanced by the increased expansion force by the lubricating action of propofol fat emulsion.
Specializes in Critical Care, Cardiothoracics, VADs.
I agree that a chart/table listing all the drugs on both X and Y axis and with green/red dots as to what is compatible with what should be in every critical care unit. We had a great one in my last unit - if I still worked there, I would send it to you! Maybe you can take that on as a project and come up with one if your unit doesnt have one already? We had it laminated and stuck to the desk in each room!
Thanks you guys! I actually figured it out... a couple nights ago my pt. coded for 7 hours and died. It was sad and very busy. But I did learn how to organize my lines (among many other things!!!!). Every time there was a break in what was going on, I labeled the pumps, lines, put similar things together, saw where I could push. It's not as hard as I thought. Though I did have 2 central lines, which made it easier. I used my institutional drug book to look up compatibilities. I saw that I could run mag sulfate with mannitol. Yes! I guess it's one of those things where you need the knowledge base + good teachers + experience. Like most everything in this profession
I always label my tubing at the injection ports and label my pumps as well. Micromedex is usually available in every ICU and it has a compatablitly section which is wonderfull. I run my mag and K+ together. I will run my TPN with insulin, as this keeps other lines open for me. I routinely run my propofol with other drips that it is documented compatable with. I had not seen or heard the above research about the cracks. Also, as tubing is changed Q12 hours on propofol infusions, that would include the stopcock. Does that factor into the leaks? One thing to take note of as well, is that even if a drug is compatible in a certain concentration, it may not be compatable at higher concentrations. One exammple is Lasix and Dopamine. We frequently highly concentrate dopamine and lasix in our renal patients, and it WILL precipitate.
Also, as tubing is changed Q12 hours on propofol infusions, that would include the stopcock. Does that factor into the leaks?
I don't know if they've research the frequency of changing the stopcocks. I do know that we have received patients from the OR with stopcocks already leaking.
I have been spending the last several months of my senior practicum in a CT & SICU. There is a question that keeps bugging me about multiple drips and I just don't seem to understand the answers I get from people. My biggest fear is bolusing a pressor or opioid or something that could have dangerous results--I am also concerned about it taking too long for a person to actually get whatever medication is going at a slow rate if I have it plugged in behind something else.
If you are running different drips (that are compatible) but they are running at different rates, what is the best way to do this?
I have heard people say they administering "Drug X" at 2 ml/hr and pushing it in with ? amount of NS. Wouldn't this bolus the drug if the NS is running faster? I would be afraid to do that.
Or if a person has fluids going at 100 ml/hr and yet has several other drugs going at much slower rates, what is the best way to do this?
One example, I put the fluids in one central line port, plugged propofol into that line, then plugged something else into the propofol. Wouldn't the drug plugged into the propofol, say going at 5 ml/hr take forever to actually get into the patient?
And I've heard people say that epi has to be run all by itself, is this true?
Thank you in advance for your replies. This issue has me all confused.
I've never heard the Mg before K thing either. Can someone explain? Why would this aggravate a hypo-k situation? Thanks in advance
few thoughts arise from this:
1) potassium channels are inhibited by magnesium. hypomagnesemia results in increased efflux of intracellular K. the cell loses potassium which then is excreted by the kidneys, resulting in hypokalemia
2) magnesium is needed for the adequate function of the Na+/K+-ATPase pumps in the cells of the heart. a lack of it depolaries and results in tachyarrhythmias. since magnesium inhibits release of potassium, a lack of magnesium increases loss of potassium. Intracellular levels of potassium decrease and the cells depolarize, hence arrhythmias
3) roughly 42% of patients with hypokalemia also have hypomagnesemia, not responding to potassium supplementation
Does your unit have access to micromedex? it is an online tool for drug therapy, and it has a great section in which you can enter all the meds your patient receives IV,and then prints out a nice chart telling you precisely what is compatible with what. I use it all the time, as i am also a new ICU nurse, and often have patients on multiple pressors, abx, sedation, electrolytes, etc. It really helps me to be able to know what i can run where and when, and how much i can put in one line. Just an idea!!
MIcromedex is a life saver. Always use it if you're unsure. Sometimes I will use my CVP port to infuse meds if I have nothing else.
Organizing your lines is very important. I always label the ends of the tubing with the name of the med. And the pump will get a label too. If the med needs to be run alone, I'll use red tape or a different color marker to help me remember (and others remember). It just takes some experience to remember what is compatible, but you'll get it in no time. And yes, it's a pain when you are busy and don't have time to be neat/organized and look up everything! But that takes time/experience too.
I'm not buying the infusing propofol alone. I use propofol on a daily basis and have never had an issue.
berry
169 Posts
First off you are doing better than a ton of new nurses by asking questions and researching information.
I oriented lots of new grads and answered allot of questions since I was charge a fair amount of time. I tried to tell people to use their resources the hospital allows has pharmacist on duty who are there to help you if you call and ask. Never mix meds based on use i.e. pressers they can be ran in the same line because of chemical properties. A good example is diprivin which tons of nurse think has to have a dedicated port just for it. In reality you can run many drugs together such as
DIPRIVIN COMPATIBILITY
compatible with the following solutions in the IV line: D5W, D5½S, D5LR, LR
compatible via Y-site with aminophylline, calcium gluconate, cyclosporine, dobutamine, dopamine, epinephrine, fentanyl, heparin, hydrocortisone, insulin regular, ketamine, labetalol, lidocaine, magnesium sulphate, midazolam, milrinone, morphine, nitroglycerin, nitroprusside, norepinephrine, potassium chloride, sodium bicarbonate, sufentanil
source for people who want it
http://www.vhpharmsci.com/PDTM/Monographs/propofol.htm
A good idea for mg and kcl have them mixed into one bag since the both run over a long period of time