question about IV pump

[newohiorn, BSN, RN, EMT-P]

I'm pretty sure I know the answer to this but since I really irritated my preceptor by arguing with her about this yesterday I want to be sure. I just transferred to a critical care unit so I'm in orientation but I've been a nurse for about a year and a half so I think I have a decent understanding of IV pumps.

My patient had 0.9 NS running as a maintenance IV on a pump. There was a piggyback of 3% normal saline (500 ml bag) that was to have run for 3 hours at a low rate prior to the start of my shift. When my preceptor and I went to check the patient the pump screen showed that the primary was running at 50 ml/hr but the piggyback rollerclamp was still open (with at least 300 ml left in the bag) and the piggyback bag was still raised higher than the primary bag. I pointed it out because I believe the pump was still pumping in the piggyback fluid (now at the primary rate) because the pump is going to pull from the higher bag if all stopcocks are open regardless of whether or not the screen says primary or piggyback as the pump doesn't know which bag is primary or piggyback. The preceptor disagreed with me stating the pump would pull from the primary because that's what the screen showed and she tried to demonstrate that but the piggyback bag appeared to be the one dripping before she got mad and ripped it down. I wasn't trying to be right to be right--I needed her to see that the patient may have still been getting the 3% for longer than ordered in case it would cause him a problem. Am I correct?

[Christie RN2006]

You are correct. The pump pulls by gravity, it doesn't know which bag it is pulling from, the pump isn't quite that smart! The only thing that would matter about which program (primary or secondary) the pump is reading is that it would give you inaccurate inputs in the pump.

Was the patient supposed to get the whole bag of 3% saline or just a specific amount? If they were only to get a specific amount, that is actually a med error. When we have to give partials of bags such as the 3% NaCl, Osmitrol, ect. we put the amount into a buritrol (sp?) so that way we know exactly how much the patient got.

[newohiorn, BSN, RN, EMT-P]

Thank you for the response. The patient was not supposed to get all 500 ml of the 3%, which was precisely my concern. Because I'm new to critical care I don't yet have a good understanding of what 3% does to someone so I wanted to be sure my preceptor understood he had gotten more than he should have in case we needed to do something about it. Unfortunately, I think she interpreted it as me arguing with her about how the pump works when I was really more concerned about what might have been done to the patient. As it turns out his labs came back fine so it didn't harm him but who knows how long that 3% would have infused.

[Christie RN2006]

Thank you for the response. The patient was not supposed to get all 500 ml of the 3%, which was precisely my concern. Because I'm new to critical care I don't yet have a good understanding of what 3% does to someone so I wanted to be sure my preceptor understood he had gotten more than he should have in case we needed to do something about it. Unfortunately, I think she interpreted it as me arguing with her about how the pump works when I was really more concerned about what might have been done to the patient. As it turns out his labs came back fine so it didn't harm him but who knows how long that 3% would have infused.

http://www.fda.gov/medwatch/SAFETY/2005/Jun_PI/Sodium_Chloride_PI.pdf

That site contains just about anything you need to know about 3% nacl infusions. At my hospital, we only give it if the patient has a central line. It can be used for fluid resuscitation and for diuresis. The extra nacl in the venous system pulls fluids in. We give it very rarely. One problem it can cause is the patients sodium level to go way too high. It can also cause venous thrombosis and phlebitis, especially if given in a peripheral vein (this is why we use central lines)

[ukstudent]

What type of pump do you use? Some pumps do not use gravity for piggybacks but are pump programmed, the palm pump is like that. Can be programmed for both running at the same time (primary plus piggyback) or just piggyback.

[newohiorn, BSN, RN, EMT-P]

We use Baxter Colleague pumps.

[morte, LPN, LVN]

What type of pump do you use? Some pumps do not use gravity for piggybacks but are pump programmed, the palm pump is like that. Can be programmed for both running at the same time (primary plus piggyback) or just piggyback.

how does this work?

one way around the issue in the OP, would be to set a dose limit on the PRIMARY fluid...say 10 ml.....that would alert you to the fact the dose was finished.....or run the 3% without the mainline, and set a dose limit....

[meandragonbrett]

IT's going to depend on your pump. The pumps we use do not pump primary/secondary via gravity it knows which one is which.

[morte, LPN, LVN]

IT's going to depend on your pump. The pumps we use do not pump primary/secondary via gravity it knows which one is which.

can you tell me the brand of pump, and how it "knows", because i have yet to see one....but i dont do a lot of hospital work anymore....

[Soonstudent]

I see 3% NaCl used mostly in closed head injury pt's to reduce cerebral edema. I didn't see that mentioned in the link.

[RNcDreams]

You were right to be concerned! It can be tough to try and "think" like your pump in order to troubleshoot.

We use Alaris pumps, and they, like stated above, are gravity based.

On our pumps, you can set up you primary fluid and tubing with a rate of KVO or whatever, and then connect your secondary to the highest port on the primary tubing, and hang it higher.

Then, you can go into the pump's main screen, choose secondary, put in your volume and rate. Then all the clamps are opened, and you can see a small picture on the screen that shows the smaller, higher-up bag "highlighted" (it's darker in the little picture than the primary, big bag).

I've made it habit to always stand and wait and make sure the piggyback bag is dripping.

Also, these pumps will run the word "secondary" along the screen, and make a very loud Beep when the secondary infusion is done and the pump is reverting over to the primary fluid/rate.

I haven't had any issues so far!

Hope that helps!

[anonymurse]

There was a piggyback of 3% normal saline (500 ml bag) that was to have run for 3 hours at a low rate prior to the start of my shift.

Yeah that's flat-out dangerous. I'd never use a piggyback line if less than the whole bag was supposed to run in, because the only way to ensure it'll shut down after the correct volume has been given is to set the VTBI accordingly. Too much of a chance someone else might make some bad assumptions. Like maybe someone only saw the NS bag and knew how fast NS was supposed to run for this pt and punched the rate up. Whatever, it's a med error waiting to happen.