Intralipid (20%) infusion administration

umcRN, BSN, RN · Nov 27, 2012

incompatible with everything in my unit apparently. Except for lasix, and TPN if that's the only thing you have going. We do not run it with any other drips, inotropes, sedation etc.

In the NICU however we would run with sedation except for versed. Different units, different practices, I don't know, but where I am now it's a no no with everything and that comes from our pharmacists

My unit is also 100% cardiac (except for the picu ecmos we get) and if we don't have central access for it it goes in a PIV.

googabin02 · Nov 27, 2012

Hi PICU nurses,
I have a question regarding practice in your unit about intralipid infusions (20% fat emulsion). Do you run them independently of the PN (if PN is also on board)? Do you run them via central access if possible? Most importantly, do you infuse them with your drips (inotropes or otherwise)? Specifically, with milrinone. I am working on changing practice on my unit, and possibly coming up with a lipid initation guideline. It would be SO convenient if I could tell everyone to run them with drips, but it seems that milrinone is the only inotrope that is documented as being incompatible. Practice trumps compatibility suggestion, though, and just wanted to see what other places are doing.
We run our lipids through PIVs most of the time, but it seems like it's pretty harsh on those little veins. Our unit is 100% cardiac, so just about everyone is on milrinone
Thanks in advance for the feedback!

We do not run ANYTHING with lipids. They run only via a central line in their own lumen. TPN can be run with other drips through a mannifold in my unit but lipids must run alone!

Pediatric Critical Care Columnist · Nov 27, 2012

Our policy is to run TPN +/- lipids separately from other infusions wherever possible. Virtually all of our amino-acids-dextrose solutions are central concentrations so MUST run via central line. If possible we run the lipids peripherally, often with Lasix. If access is an issue we will run compatible antibiotics and other intermittent meds with the TPN but preferred practice is not to unless no other option exists, due to infection risk. Our inotropes are mixed at the bedside using the Rule of Sixes modified for a volume of 50 mL and run on syringe pumps. Our volumetric pumps use a pulse delivery system and with highly concentrated inotropes ahead of them, there are huge swings in BP so we avoid running anything into the same lumen with them through a volumetric pump. So as a general rule we don't run TPN with inotropes except in the most desperate access situation.

harryalexx · Nov 28, 2012

Thanks for the responses. googabin02: I'm surprised that they run alone all the time. We routinely run lipids with Laxis or fentanyl +/- a few other drips. We also run TPN with the manifold/drips.

janfrn: Usually, the PN is such a concentration that we also run it centrally out of necessity. And yes, lipids with Lasix or fentanyl (and sometimes hydromorphone, although compatibility charts say otherwise). A few comments on your infusion situation, though. I can't believe you're still mixing your own gtts! I haven't mixed a drip in my home unit for so long. We have compounded drips in our Pyxis, and pharmacy makes all the rest. As for the volumetric pumps, we had the same problem, but recently upgraded to a "steady-state" infusion pump. It has a rolling device that delivers a steady amount. No big swings, and so far I'm super impressed. Even with MIVF carrying drips @ 3mL/hr, I don't see issues. So we almost always run our amino-acid-dextrose solutions with our drips. Although newer staff still have trouble figuring out what I mean when I say "double pump" to avoid a hypotensive crash. Oy.

So I m getting that you two at least don't run lipids with drips. Helpful, thanks!

Pediatric Critical Care Columnist · Nov 28, 2012

A few comments on your infusion situation, though. I can't believe you're still mixing your own gtts! I haven't mixed a drip in my home unit for so long. We have compounded drips in our Pyxis, and pharmacy makes all the rest.

The only compounded drips we get from pharmacy are the very expensive ones like tacrolimus, ATGAM, mycophenolate, dopamine (we don't use it very often either)... and heparin (due to a HUGE number of errors in the recent past). Everything else we mix ourselves. We don't even have an in-house pharmacist after 2230 hours.

As for the volumetric pumps, we had the same problem, but recently upgraded to a "steady-state" infusion pump. It has a rolling device that delivers a steady amount. No big swings, and so far I'm super impressed. Even with MIVF carrying drips @ 3mL/hr, I don't see issues.

That would be lovely! But our health system "just" (about 4 1/2 years ago) upgraded to the ones we have now and will never admit that they're not absolutely perfect for all users. Then they upgraded our syringe pumps to ones that take 5 minutes to program and they're universally despised.

Although newer staff still have trouble figuring out what I mean when I say "double pump" to avoid a hypotensive crash. Oy.

Been THERE!! Not me personally, but someone I was helping (very, very new nurse) had a kiddo on fairly high dose 'tropes. The nurse before her hadn't thought/bothered to put an extra port in-line so when her norepi ran out during evening rounds, she made one of the quickest and slickest syringe changes I've seen in a long time, but that didn't stop the big sag. Kid actually went pulseless and needed some CPR. New nurse was quite shaken by that.

imaginations · Nov 28, 2012

A few comments on your infusion situation, though. I can't believe you're still mixing your own gtts! I haven't mixed a drip in my home unit for so long. We have compounded drips in our Pyxis, and pharmacy makes all the rest. As for the volumetric pumps, we had the same problem, but recently upgraded to a "steady-state" infusion pump. It has a rolling device that delivers a steady amount.

I'm a very (very) new PICU nurse in Australia but we mix all our own infusions. We don't have any pre-made infusions (aside from TPN, Lipids and cytotoxics that come from sterile pharmacy.) The idea of pre-mixed syringes would be very novel in our unit. We mix syringes most of our infusions based on a dose for weight formula to create a standard dilution in 50mL syringe. Each patient has a weight based drug chart for resus/emergency drugs and an A4 page of our most common infusions printed as soon as we have a weight on the patient.

We also don't use volumetric pumps for anything but TPN and maintenance fluid. We use syringe Alaris syringe drivers with pressure gauges for all our infusions.

iluvivt, BSN, RN · Nov 28, 2012

The terminology needs to be a bit more exact when you area talking about this....when you say, "run with " are you talking about mixing in the same lumen of a VAD or a separate lumen?

1. Anything greater than 10 % Dextrose in a nutrition solution must be given in a central vein. It is the percent of dextrose that determines whether or not it must be given centrally.

2 You can piggyback lipids into TPN or PPN distal to the filter if it is a 2.2 micron filter. Any Lipids will eventually clog or occlude this size filter..... it will run for a bit until the filter get saturated and then your pump will start alarming.

3 In the event you have a 3 in 1 solution ( TPN and lipds in one large bag) you must use a 1.2 micron filter. The Lipids can pass through that size.

4. If you cannot have a dedicated line for TPN and/or Lipids then you must have a dedicated lumen. So if you have a triple lumen VAD dedicate one lumen to the nutrition and use the other(s) for anything else. You should not piggyback anything else or give any push meds through that TPN dedicated lumen and avoid using that lumen for blood draws.

5 Lipids can be given peripherally if need be because they have a close enough osmolarity to blood. ( Blood is about 280)

6 All of this important because if is done other ways the risk for infection is much greater. The Lipids are of particular concern because they can have rapid bacterial growth if contaminated...they have the nutrition cells like. You have to be cautions as well with any fat based drugs and that is why the tubing of those drugs are changed more frequently some even every 12 hrs. Also the risk for incompatibility is high especially when there are electrolytes such as calcium in the TPN.

So the standard of care here...Run the TPN and lipids either together as stated with no other drips or Lipids can be given in a peripheral vein with no other drips or meds added to it.

NicuGal, MSN, RN · Dec 5, 2012

We run most things with our lipids and TPN. We have a compatibility chart our peds pharmacy made up for us. Vasopressors are a no no for sure. We run ours thru a med line on a trifercated end connector and that line is changed every day. It depends on your hospital pharmacy.

Rookie12 · Dec 6, 2012

We pretty much always run TPN and Lipids together and it's pretty much always central (can go peripherally with the proper dextrose concentration) I've seen drips run with TPN/IL when access is an issue though its not ideal. When compatibility and access is an issue we may have to put the lipids and/or TPN on hold to give meds/antibiotics. If running drips, the biggest pain is having to change out all the lines for the drips Q24hrs if its with the TPN/IL! We also mix a lot of our drips ourselves...pharmacy will make them but they usually take too long and we get impatient...when you need an epi drip you need it 5 min ago not in an hour!!

iluvivt, BSN, RN · Dec 28, 2012

If the Dextrose concentration is less then 10 % it is then PPN and if it higher than 10% it is TPN.

eatmysoxRN, ASN, RN · Dec 28, 2012

I always put ppn and lipids on different modules and hook the lipids to the lowest port on the ppn line. Change all lines every 24 hours. I always program my pump to exactly 24 hours later too... I've seen too many lipid bags hanging for too long.