Pump problems and pressors?

[kitsune01, BSN, RN]

I'm a nursing student doing my senior practicum in the NICU. Yesterday there was a weird incident with the baby my preceptor and I were caring for and I was wondering if anyone had seen anything like this happen.

The baby was on dopamine at 10mcg/kg/min, and pharmacy had mixed it so at 10 the rate was 1ml/hr in a 25cc syringe. The dopamine was going into the second lumen of his UVC by itself, the other lumen was running tpn and lipids. The rate had last been changed about an hour before. Right before shift change the syringe pump alarmed, saying the pressure in the line was increasing. My preceptor checked the line and didn't find any problems, and the alarm resolved by itself in under a minute. BP at the time was fine. A minute or two later his BP spiked suddenly, with the map going from mid 30s to high 70s in about 20 seconds (I was looking at the monitor when it happened, so I know how quick it was) . My preceptor paused the dopamine briefly and we switched out the pump as fast as we could. Fortunately we had another syringe of dopamine from pharmacy so we were able to get that set up on the other pump really quickly. His pressure went down to acceptable levels pretty fast after that, his heart rate never went below 90, and his sats didn't really drop, but it was scary as hell. Called the NNP who came right over, checked on him, and helped out by filling out the incident report.

The weird thing was something similar happened to him two days before, where his BP acted like he'd gotten a bolus. I don't know whether the pump alarm went off beforehand that time or not. Now everyone is trying to figure out what could have happened and wondering if they can trust the pumps. It probably wasn't the same pump, because the first one was swapped out and sent to biomed. No one had touched him or the lines either time, the UVC was in good position and hadn't had any problems with it otherwise. The previous day the dopamine was in a 12cc syringe and there were no problems. I've seen pumps set off the "pressure increasing in line" alarm before with no obvious cause, but only with large syringes, so I was wondering if it could be an issue with large syringes and relatively low rates not keeping a constant pressure in the line. Also wondering if that high a concentration is safe if the accuracy of the pumps are in question.

Anyone seen anything like this? The pumps were medfusion 3500, by the way.

[texas2007, BSN, RN]

Does your facility normally run Dopamine by itself? The only thing I can think of is that perhaps the line was starting to clot off (thus the pressure increasing alarm.) and then the clot cleared and the kid got a mini bolus due to the syringe having to push harder. When we have rates less than 2 ml/hr (the standard KVO), we will usually get an order to run them with carrier fluids with heparin to prevent the line from clotting.

[littleneoRN]

This doesn't answer your question, but it is essential to highly concentrate drugs like dopamine. Even if we're not intentionally fluid restricting, our little ones don't have much room for extra fluid. Maybe they're just getting 2.5 ml/hour of TPN, for example. You can't also be running a drug that puts in a couple of mls per hour or more of fluid on top of that, and then have UAC fluids, etc. etc. So we need highly concentrated drugs and pumps that can reliably infuse very fine volumes.