Question Re Heparin

Blee O'Myacin, BSN, RN · Jul 14, 2007

I have been looking online and in my drug books and cant find an answer to this question...
On Thursday in clinical I had a pt with a DVT that was receiving a Heparin protocol. She was also receiving Gentamycin IV Q12 h. She only had a double lumen PICC. The nurse I was working with said that the Heparin should be stopped to give the Gent b/c you cannot run both through the PICC and the woman had no other IV access. I was under the impression you NEVER stop Heparin unless you have an order from the physician. My instructor called the pharmacy and they said the drugs should be compatible. The nurse, however, said that they were not and that we should stop the Heparin for an hour.
I know that I am just a student, and I didnt want to step on her toes, but I was in a tough spot because the nurse and my instructor were disagreeing. I could not find anywhere that the Gent and heparin were incompatible, but I do see what she was saying about running both through one PICC line.
Anyway, she stopped the Heparin and piggybacked the Gent with NS, then restarted the Heparin.
What should I have done in this case?

You should not have stopped the heparin and ran the gent through the other lumen, piggybacked with NS. A double lumen PICC has separate lumens, all the way to the top and is designed so that two incompatible meds can run through at the same time. This way if a patient has a drip or TPN, it doesn't have to be stopped for meds. Always check facility policy though, since you were there for clinical. What did your instructor say about it in post conference? It would have been a good "teachable moment" for PICC lines, IMO. You say that your instructor disagreed with the nurse. Ultimately, it is the nurse's patient, even if she is wrong. That's a tough spot there, and I wouldn't want to stop a heparin drip on anyone. Worst case scenario, you start a peripheral IV to run the IV antibiotics and just leave it as a saline lock when you aren't running the meds.

Blee

Danish, MSN, APRN, NP · Jul 14, 2007

You should not have stopped the heparin and ran the gent through the other lumen, piggybacked with NS. A double lumen PICC has separate lumens, all the way to the top and is designed so that two incompatible meds can run through at the same time. This way if a patient has a drip or TPN, it doesn't have to be stopped for meds. Always check facility policy though, since you were there for clinical. What did your instructor say about it in post conference? It would have been a good "teachable moment" for PICC lines, IMO. You say that your instructor disagreed with the nurse. Ultimately, it is the nurse's patient, even if she is wrong. That's a tough spot there, and I wouldn't want to stop a heparin drip on anyone. Worst case scenario, you start a peripheral IV to run the IV antibiotics and just leave it as a saline lock when you aren't running the meds.
Blee

That is what were were getting ready to do. My instructor explained the situation to the other students and said that she disagreed with the nurse, but that it was her patient and her license, so she wasnt going to argue with her.

My delimma was that I could find no rational to her action. We do not have access to the computer and the facility has their policies and procedures on the computer. I have a problem with this too. For instance, I went to flush a PEG the other day and asked 2 nurses how many cc's should I flush it with. Most facilities we have been at for clinicals were 30-50cc, but I know that we have to go by hospital policy. I was told 50cc's by one nurse and 150cc's by another. I had a 3rd nurse look it up and it was 50cc's.

EmmaG, RN · Jul 14, 2007

I have been looking online and in my drug books and cant find an answer to this question...
On Thursday in clinical I had a pt with a DVT that was receiving a Heparin protocol. She was also receiving Gentamycin IV Q12 h. She only had a double lumen PICC. The nurse I was working with said that the Heparin should be stopped to give the Gent b/c you cannot run both through the PICC and the woman had no other IV access. I was under the impression you NEVER stop Heparin unless you have an order from the physician. My instructor called the pharmacy and they said the drugs should be compatible. The nurse, however, said that they were not and that we should stop the Heparin for an hour.
I know that I am just a student, and I didnt want to step on her toes, but I was in a tough spot because the nurse and my instructor were disagreeing. I could not find anywhere that the Gent and heparin were incompatible, but I do see what she was saying about running both through one PICC line.
Anyway, she stopped the Heparin and piggybacked the Gent with NS, then restarted the Heparin.
What should I have done in this case?

Actually, the PICC was a double lumen, so they could run together. I've had cases where certain drips, heparin, TPN, etc., had to be held while administering other meds if there weren't enough lines and no other means of access, but ONLY with the physician's ok; the doc would often adjust the rate to accommodate for the time it was held.

But as a student, you don't have much say. Your instructor could go to the NM and discretely explain the issue. Sounds like a good opportunity for some staff education.

Danish, MSN, APRN, NP · Jul 14, 2007

Thanks for the replys. I feel a lot better knowing I wasnt a complete idiot :)

Actually, I felt like she was a really good nurse, who was most likely mistaken in this case. I was very impressed with her otherwise and I believe my instructor felt the same. I think that's the only reason she didnt go over head.

EmmaG, RN · Jul 14, 2007

Thanks for the replys. I feel a lot better knowing I wasnt a complete idiot :)
Actually, I felt like she was a really good nurse, who was most likely mistaken in this case. I was very impressed with her otherwise and I believe my instructor felt the same. I think that's the only reason she didnt go over head.

That doesn't mean she wasn't an excellent nurse. While I don't agree with her (apparently) stopping it without an order, I would much rather have a nurse who errs on the side of caution, than one who blunders ahead and harms the patient.

AprilRNhere · Jul 14, 2007

I had that come up in clinicals also and we just started a peripheral line. The hospital I was at was extremely student friendly though. I think for them it was an easy call....because they weren't sure..and it gave me the chance to start an IV.

Sorry you were put in that position.

Blee O'Myacin, BSN, RN · Jul 14, 2007

That is what were were getting ready to do. My instructor explained the situation to the other students and said that she disagreed with the nurse, but that it was her patient and her license, so she wasnt going to argue with her.
My delimma was that I could find no rational to her action. We do not have access to the computer and the facility has their policies and procedures on the computer. I have a problem with this too. For instance, I went to flush a PEG the other day and asked 2 nurses how many cc's should I flush it with. Most facilities we have been at for clinicals were 30-50cc, but I know that we have to go by hospital policy. I was told 50cc's by one nurse and 150cc's by another. I had a 3rd nurse look it up and it was 50cc's.

Not having access to the facility P&P is a huge liability for the facility. Say a student does something "by the book" that is in conflict with policy and the patient gets harmed. The patient's attorney sues the facility and they say "well, the student should know our policy" and the student says "how? I have no access to it by the hospital's rule that no student have access to a computer." Something doesn't add up and I'd be asking my Dean of Students why there are no P&Ps available to students (you need to learn how to access them as nurses), and if the facility isn't cooperating, you need to find another one that will.

That bothers me more than the nurse stopping the heparin drip.

Blee

jojotoo, RN · Jul 15, 2007

Another option - ask the PMD to switch to Lovenox for treatment of the DVT.

katienj · Jul 15, 2007

Another option - ask the PMD to switch to Lovenox for treatment of the DVT.

Lovenox is not a treatment for a DVT, but used prophylactically to prevent formation of a thrombis.

jojotoo, RN · Jul 15, 2007

Lovenox is not a treatment for a DVT, but used prophylactically to prevent formation of a thrombis.

Actually had the Lovenox people in house last week and they are very strongly encouraging use of Lovenox for treatment of DVT.

After all, Lovenox is a type of heparin - just a low molecular weight heparin. And like regular heparin, it inhibits the formation of thrombin.

oldiebutgoodie, RN · Jul 15, 2007

Lovenox is not a treatment for a DVT, but used prophylactically to prevent formation of a thrombis.

From what I understand, heparin is also used to prevent the extension of the thrombus.

According to this article from Emedicine's web site, either heparin or a LMW (Low molecular weight) heparin can be used as treatment for the DVT.

http://www.emedicine.com/emerg/topic122.htm

"Heparin prevents extension of the thrombus and has been shown to significantly reduce but not eliminate the incidence of fatal and nonfatal pulmonary emboli, as well as recurrent thrombosis. The primary reason for this is that heparin has no effect on preexisting nonadherent thrombus. Heparin does not affect the size of existing thrombus and has no intrinsic thrombolytic activity. "

Heparin or Lovenox prevent it getting worse, does not lyse the thrombus.

Oldiebutgoodie