proper IVP administration

I your scenario, would pause the calcium, flush with saline, give the med, flush then restart it.

Flushing the calcium is not as big a deal as flushing the insulin, your only giving 1 cc/min, so the time you spend pausing, flushing, giving med, flushing, restarting would equal the time of that 3-5 cc you flushed in.

Real world, you need to see which med would do no (or the "least") harm if you flushed if all 3 have something going. You could also stop the fluid in one line, draw out a waste syringe and then flush/med/flush so no extra meds are going in, then restart the drip (but you then have a few minutes of none of that med going). Just pick the one that you can do without for a few minutes.

I know many don't want to mess with the CVP and have to reset it, but it is not that huge a deal, just takes a little time.

One way of adding a port in this scenario is to add one to the CVP. You should be able to add a 3 way stop-cock or some sort of additional port to the CVP line. If not, giving the med and flushing with 10mls is no problem through there. Just go off to your CVP and the waveform would go flat and either say zero or some meaningless number. That's way one.

Way two would be to give the med through your KVO line (not the insulin line). Since you have the insulin tied into the KVO, the KVO is pushing much faster so the insulin is actually only really the 1u/ml concentration in the insulin line, but not the KVO line. In other words, if you turned the KVO up to 100/hr or 999/hr, your patient is still not going to get any more insulin that they are now. Therefore, pushing a compatible drug through the KVO port is no problem.

Does that make sense?

If possible I try to keep a KVO/med line by itself. Patients are typically getting intermittent antibiotics or seizure meds or replacement elytes or something that isn't compatible. While not always possible, having that line open helps.

Calcium and insulin are compatible medications, so you can y them into the same line and free up your med line.

Last week I had someone who had seven drips running with most incompatible. Ended up with five accesses to run seven drips and a KVO. It can get rather complicated at times.

I now understand the stopcock part of the CVP better and utilized that method recently. Also, I've had a scenario where the KVO was attached to the insulin (y-sited?) even though the lines were each on a pump. It makes sense for the most part but I am confused about attaching multiple lines together like that. If the pump regulates the flow it shouldn't be a problem, however with the insulin being connected to the KVO I was still confused. I know that with pressors or scenarios where all the lines are connected, it must be ok or else the patient would be getting boluses constantly and it would be an unsafe situation. I understand that the pumps control the rate like you're saying, but I am still confused about where to connect the lines so that the pumps control the rate and not "You" controlling it by where you connected the lines.

Did that make sense? I know it's simple but I'm still struggling with it. This is going into a different area (how to connect multiple IV lines together) but, I had a scenario where we had to start a pressor and the patient had a peripheral with 999 of NS going. The pressor was connected to the port behind the NS and started. Would this be ok or would that be bolusing the pressor? It shouldn't since both medications are controlled by the IV pumps? And yes I know the patient should have had a central line but it hadn't been inserted yet.

I don't know why this concept is so tricky for me haha. But thank you for your help!!

Thank you for your comment, it helped!

Check to see what is compatible. Also, start a peripheral line if possible - you can have a KVO push line there.

I had a scenario where we had to start a pressor and the patient had a peripheral with 999 of NS going. The pressor was connected to the port behind the NS and started. Would this be ok or would that be bolusing the pressor?

Lets pick a completely arbitrary number and say that the pump is pushing out 1 drop of pressor from the end of the tubing each second. You hook that tubing up to the fluid bolus tubing at a Y-site. There is still 1 drop of pressor coming out of the tubing each second. There may be lots of NSS flowing between each drop, but the patient is still receiving 1 drop of pressor each second.

Different scenario. Picture the pressor tubing hooked directly to the patient, and you connect a NSS bolus to the Y-site on the pressor. When you run that NSS, yes, it will bolus the patient with whatever pressor is downstream of the Y-site. If you use the Y-site closest to the patient, this should only amount to a few mLs, which shouldn't be an issue. If the BP goes a little higher than you'd like, put the pressor on hold for a minute or so. Or, if you hook the NSS to a Y-site farther away from the patient, they may get a 10 or 15 mL bolus instead, which would be more problematic.

Also, I wanted to clarify that the patient won't be getting "bolused constantly." The only bolus (in the second scenario, above) will occur when you first connect the NSS @ 999 mL to the Y-site on the pressor. Once the NSS reaches the patient (maybe 20 seconds later), all the pressor "bolus" will have been given and the patient will again receive the dose determined by the pump.

Hope this makes sense. It would be a lot easier to explain in person with visual aids!

The problem with bolusing the line where the pressor is is not limited to the initial extra medication they are going to receive (and I have seen bad things happen when people do this), it's also a problem when the bolus is complete and now the rate of infusion of the pressor is significantly slowed and they bottom out their BP.