No pump, no drip rates - OR

[anathema]

During my clinical rotation at the OR in the small town I live in, the preop and operating room nurses did not use a pump for the IV, and "eyeballed" the drip rates (their words). Our school has a Facility Evaluation Form that we fill out for each clinical rotation, and we rate the facility and leave comments about what we did, or did not like about the facility. In my evaluation I put that "I was not impressed" with the fact that no pumps were used, and no drip rate calculations were performed. I got called aside by one of clinical instructors after I submitted my paperwork, and was told that it was facility policy not to calculate drip rates in the OR. I work at the LTCC attached to this facility, and I will be looking the policy up the next time I work, but has anyone else heard of this? is this standard nursing practice? I know in the LTCC they use pumps, and in the ACU and ICU they use pumps, so why not the OR? and if no pumps, why not drip rates? This goes against everything we learned about medication administration!

[Brandidrn]

We never use pumps in the ER where I work and over the years I have gotten good at eye balling it and nothing has ever happened now if we had to wait to run things on pumps that u can never find it would be disastrous. Plz don't freak out and try to bust nurses who have worked for years on the nursing theory u have learned in school it never goes well so until u work in real world nursing I would bite my tongue

[Julius Seizure]

I am not sure how the nurses give fluid when anesthesia is not involved in the case because I am not there.

I am a nurse anesthesia student and I can tell you that there are fluid calculations constantly being done in my head. Deficit calculations from being NPO, blood loss, evaporative/insensible loss, blood pressure regulation, comorbidities, etc.

There is no drip rate order because I decide how much fluid my patient needs. I know if I'm ahead or behind and if the patient needs more or less. It has to do more with the administration over time than it does a specific drip rate.

Well this impresses me!!

[smileyfacefee]

That's right. Sometimes during surgery the patient's blood pressure may drop and the nurse anesthetist may have to increase fluids to get it back up. It is really adjusting the rates based on what's going on with the patient at that time. Patients vitals can change very quickly during surgery.

[HouTx, BSN, MSN, EdD]

Great thread - very informative. Nobody is calling names or using epithets. Full disclosure: I am a COB.... it was hard for me to 'trust' pumps and give up taping those bags "just in case".

I think the underlying issue here reflects scope of practice issues. Nurses management of IVF is very diligent - just as all other medication administration orders. However, in the OR, physicians are in direct control of fluid management rather than having to manage the process via transmitted orders. So, although the nurse's role is very important, the anesthesiologist and surgeon are directly in control - anything that would interfere with their ability to rapidly intervene as needed to manage patient fluid status is contraindicated. This includes pumps.

Most pump cartridges also have some sort of "fail safe" mechanism that prevents a runaway IV. During surgery, the patient is always "unstable" and clinicians have to be ready to respond immediately. Can you imagine the chaos that would ensue if a patient suddenly needed very rapid IVF infusion and this was prevented by the tubing??? Unimaginable.

[ScrappytheCoco]

There is tubing you can use to set a simple drip up at a certain rate...you just turn the dial to the number you want. I will eyeball fluids and not worry about it. You don't always need a pump.

[Double-Helix, BSN, RN]

I'm right there with the OP on this one. Some things are okay to run off the pump - boluses, maybe some abx, etc.

However, what if the abx that needs to be given is Levaquin instead of Rocephin? If that's getting run too fast, the patient's at risk for Torsades because of the QT prolongation. How about a Zosyn that's ordered to run over four hours because of kidney function issues? Bolus that one in and the patient's kidneys are going to be worse off than they were before.

How about something running in really small doses like Vasopressin? Even with microdrip tubing at 60 drops per ml, you'd only need 270 drops in a whole hour to get the dose right. You might not even see one drop fall in the ten seconds you watch, if you're only watching for 10 seconds. It's going to be more like one drop every 13 seconds.

Sorry, I don't think it's safe either, and if that makes me a stick in the mud so be it.

Your post seems to lack a basic differentiation between titrating fluid via gravity and running it wide open. Just because something isn't on a pump doesn't mean it can only be run at one rate. If you need to give Levaquin over 60-90 minutes you use the roller clamp to slow the fluid down to an appropriate time frame.

Pressors are not going to be managed by the OR nurse during surgery, but by the anesthesia team, so those don't apply here.

Obviously there are some drugs that need to be run on a pump or very tightly titrated. Those aren't the fluids/medications we're talking about here. OR nurses are most likely to be giving maintenance fluid, bolus fluid, standard intraoperative antibiotics and blood products.

It may not seem safe to you or the OP because you lack familiarity with it. But Cook26 is right that fluid management is about more than running something at the same rate for a specific time. Correcting deficits often means bolusing fluid more quickly initially in a case and then slowing to a maintenance rate. It means increasing or decreasing rates according to vital signs, blood loss, and other variables.

Anyone who has been in the nursing industry for a time knows how the Joint Commission loves to micro-manage medication administration in the interest of "patient safety." The fact that OR nurses aren't mandated by JC to run fluids and medications on a pump should tell you something.

[Vanilla101]

Before pumps, Dial-a-Flows were the BOMB! The first generation of pumps only measured rates in ml/hr. Weight based drugs had to be calculated by hand, fortunately pocket calculators had been invented by then. The current pumps that have the formulary programmed in & calculate weight based rates are wonderful, but not foolproof. Overriding the pump, hanging the wrong drug on the pump, inaccurate programming or failing to scan can have disasterous outcomes. Overall, it's all about attention to detail.

[lavenderskies, BSN]

I appreciate your input. It sounds as if you do count drip rates though, even if it's over a 10 second time period. I don't have an issue with that. The nurse told me that she doesn't do drip calculations. Maybe she really meant that she counts them over a 10 second period, but that wasn't the impression I came away with. She was not looking at a watch or a clock while she was eyeballing it, and while it is possible, I doubt she was counting both seconds and drip rate in her head. I understand the real world isn't the same as what we are taught in school, but my original statement still stands, I'm not impressed. :/

Maybe you're not impressed because you don't have the experience yet to eyeball a rate and know that it is at approx 125ml/hr or 200ml/hr or 500ml/bolus etc because when you've done it a few hundred and then thousand times.....you'll easily be able to eyeball it and hopefully impress an unexperienced student with your skills

Sheesh.....I just read another thread about a student unhappy with their staff nurse preceptor and another about the poor attitude of floor nurses towards students and then this. Students wonder why some staff don't want to have students shadow.....who wants someone with little to no experience criticising their skills that took years to hone? Just sayin.