Several questions about piggybacks, Y siting, rates, and IV med admin

[Dangaard]

*This got 5000% longer than I thought it would be. Here's a tl;Dr version =_=

tl;Dr version (all scenarios use alaris pumps)

-How do you set up two compatible meds to run at the same time into the same peripheral IV without losing meds in your tubing forever? Is it worth doing instead of hanging one med after another?

-Similar question as above, except running a med and a bolus at the same time. Also though, does the speed of the bolus affect the speed of the med being administered (my understanding is it doesn't?)? Are there times where you have to be cautious about the differing pump speeds?

-Any thoughts on adding a med straight into a (labelled) 500/1000cc bolus?

-What to do about meds from a secondary that get stuck in the line after the primary takes over? Don't bother since it's so small?

-Problems with backflow from your secondary ending up in your primary. I saw this happen severely with a coloured secondary med once. What happened? Any solution? Does that happen all the time and you just can't tell because everything's clear/colourless?

tl;Dr version ends. Feel free to skip over the rest of this entire post which I think is mostly just details and rambling.

Lets say I have two IV meds to give along with a 1L NS bolus. Both meds are in 50ml NS minibags and are compatible with each other. I want to run both these meds at the same time using the same peripheral IV using 2 Alaris pumps.

Trying to set it up in my mind, I have one primary bag of 1L NS for the bolus hanging under a secondary (Drug A) which is y-sited above Pump A, which then attaches to the patient. That's not a problem. Then for Drug B, I have it attached and primed through a primary infusion set hooked up to Pump B, which is then Y-sited with the primary from Pump A below the pump.

With that, I have the problem that once the end of Drug B hits Pump B, it will complain of air in the line and will no longer infuse, meaning I've got maybe close to 10cc of diluted drug out of a 50cc bag not getting to my patient (let's assume there's no extra in the bag to compensate). Is there a solution for this? Is the solution to piggyback Drug B off of a another 50cc NS and get pump B to infuse 10-15cc NS at the same rate that Drug B is supposed to be infused at to flush the line?

Give the time and trouble used to set up an extra primary and secondary then, is it just more efficient to hang the next bag of meds when the first is done using pump A?

Alternatively, what if you need to run meds at the same time as a bolus? Bolus goes through pump A, and then med goes through pump B? Do you run the med as a primary, or as a secondary so you can flush your med after? Also, when is there concern over the infusion rates when you y-site below the pump? Say you're bolusing at 999cc/hr through line A, and running meds at 100cc/hr in line B, which is y-sited to line A below the pumps. Am I correct in saying that line B is depositing meds into line A at 100cc/hr, so therefore even though line A is running at 999cc/hr, the patient is still only getting the meds at 100cc/hr? Is there a time when different rates of y-sited lines becomes a problem?

On another note, a nurse once suggested to me to utilize 500ml and 1L boluses to administer a NS compatible med over that time by adding it straight to the bolus. Labelled of course. Any thoughts on this?

Couple more questions! In general with secondaries and minibags, since the pump can't know which bag to pull from and simply goes off of whatever fluid is at a higher elevation, isn't there typically some meds from the secondary bag still stuck in the secondary line once the primary takes over considering part of the secondary line will always be beneath the primary bag of fluid? I presume in most cases this amount is negligible?

Also how do you know your secondary isn't just backflowing into your primary bag? Most secondaries are the same colour as the primaries, but I distinctly recall seeing somebody hang a secondary bag with yellow tinged antibiotics (pretty sure it was ABX), then looking later and seeing plumes of it wisping up into the primary bag. The lines are the same lines that I've always used and seen, so I presume there are no backflow valves. I'm not sure if that happened while pump was actively running, or if it just happened that somebody removed the lines from the pump with the secondary unclamped, thereby allowing backflow into the primary. Do you actually have to clamp your primary line above the first y-site to prevent any backflow every time you run a secondary?

As an aside, I stopped to watch that particular situation as the pump ran, and I was surprised to see the only thing filling the drip chamber was the clear colourless primary solution. The primary had actually flown a little bit up the secondary tubing, and as the secondary fluid flowed down its own tubing, once it hit the bifurcation with the primary tubing, it flowed upwards towards and into the primary bag, and primary solution kept flowing down. Maybe density and solubility was at play here? I'm not sure.

Sorry for the massive wall of text full of questions? I mean, I can set up simple piggybacks just fine, but nobody has ever shown me how to properly y-site two pumps together, and then I find that nobody can particularly explain how any of it works, other than it just does and don't worry about it. Fluid dynamics isn't really my strongpoint so I'm having some difficulty self learning it =/

[Karou]

Are you working at a hospital? Are you still in orientation?

With as many questions as you have about administering IV fluids and multiple medications, I suggest you ask someone to give you a lesson on the pumps that your facility uses.

[Dangaard]

Hmmm, I'm worried that my tl;Dr version may have simplified my questions a bit much. Thank you for the responses though!

No this is not homework. I'm doing my final LPN practicum in an ED, and I do know how to use the pumps. Unfortunately we only get taught the very barebone basics. Setting up a standard primary fluid with piggyback meds, I can do no problem. Setting up a second channel and y-siting it in, we don't get taught, and most of my questions like these that I've asked have been met by blank stares or shrugs or misunderstandings so I'm not sure if I'm miscommunicating my questions or if something else is going on.

The question about y-siting is more specific to setting up "channel B". I've seen posts here that refer to setting up this channel as a primary, then connecting it downstream to channel A. However, once the med gets to the pump, it won't continue because of the air above the med. Basically I'm just asking if the solution is to just hang a flush and set up channel B as a piggyback. I've never seen meds being run like this though, and in my area, when I asked about it, I was told to just run the next med when the first was done instead. I'll try asking somebody else tonight when I work to get a hands on answer.

Regarding the bolus, I was looking for confirmation or denial that say, if you had a 100cc/hr med through channel B hooked up to a 999cc/hr bolus in channel A, the patient will still get the channel B med at 100c/hr even though the channel that's bringing the med into your patient is running a 999cc/hr (1099cc now? not sure.)

For adding meds to a bolus, we run our boluses through the pump at 999cc/hr (I know, there's a difference between this kind of bolus and a wide open bolus where you run by gravity and squeeze the bag). So say you have an order for 500cc NS bolus and 10mg metoclopramide. Our pumps run 10mg metoclopramide in 50cc NS over 30 minutes. If you added the metoclopramide into your 500cc bolus, it would finish in 30 minutes, which is the same amount of medication in the same time as if you minibagged it. I asked this question specifically because an RN mentioned it to me as a possibility and I was looking for second opinions.

I'm not clear on how backpriming prevents meds from getting stuck in the secondary tubing once the primary infusion begins. Part of the secondary tubing will always be below the bag of primary fluid on account of where the upper Y-site is. My understanding is that once the fluid level from the secondary reaches the top level of the primary bag, the primary will take over, leaving whatever secondary meds left in the tubing to sit and very slowly drop as the primary level drops. OK, let me rephrase, yes, I know backpriming can remove those meds from the secondary set so you can run a different med through that line later, but how do you get that med IN to the patient, instead of into the garbage?

I think the best way to explain my question about the backflowing is in the long winded post. I saw it happen to a relatively experienced RN on a med/surg unit, so it's not like it happened to me and I never got help for it or asked until now. I've also read about the same concern on this board. There perhaps is indeed a backflow prevention valve in our primary sets, and the one I observed just happened to fail maybe?

https://allnurses.com/help-piggyback-run-t441497/

[sandiamts]

Dangaard, go to ED charge nurse for help. This is dangerous not understanding how to infuse the drips. You don't want to infuse a K rider rapidly and stop a patients heart! Or infuse heparin at the wrong rate. This is frightening.

So vital you understand the equipment.

[SierraBravo]

sandiamts said:

Dangaard, go to ED charge nurse for help. This is dangerous not understanding how to infuse the drips. You don't want to infuse a K rider rapidly and stop a patients heart! Or infuse heparin at the wrong rate. This is frightening.

So vital you understand the equipment.

THIS!!!

[SteffaDee, BSN, RN]

Of course, the following can be facility specific. So make sure to look up your policy.

Your primary should be NS or the ordered fluid and your secondary is the medication. The secondary should be above the level of your primary (at my facility we use little hooks for this). With this set-up only one channel is required. And always make sure the medication is compatible with the fluid it is infusing though. Refer to Photo here: Intravenous infusion | definition of intravenous infusion by Medical dictionary

Gravity is what allows the entire amount of medication to flow from the secondary bag, to the patient. Keep in mind the medication is "heavier" than the saline it flows through. That is why the drips are necessary; to regulate this effect.

Keep in mind different IV medications are required to be infused over different times; refer to the IV manual. Therefore never administer medications as secondary lines to boluses (I make exception for some narcotics as you want them infused quickly anyway if were going to give via IV push).

If one medication is to be given over 30 minutes and one over an hour, you'll have to give them back to back, as you are correct in assuming that they infuse at different rates within the cording. I would select the 30 minutes one first. Naturally, you can also use two different IV sites as well.

If you saw back drawing, I can only assume its because the primary and secondary were at the same level, therefore causing gravity to interfere with the downward flow of the medication.

When I read your post, I mainly keep thinking: If the medications are compatible, why not put them together in the same secondary minibag? Instead of x2 50 mL minibags in a Y set-up, use a 100 mL minibag and put the compatible medications within using a single line.

Again, make sure you review best practices and facility policies and procedures.

[morgana_j]

It's interesting how people responded to your questions.Your questions are things I think a lot about lately (I'm in nursing school). Not everyone realllly ponders this stuff though, obviously. Nor were they able to explain themselves very well.I just don't think they really understood what you were asking. I don't have the energy to respond right now as I just spent so much time reading all these ridiculous responses.Maybe later.But, I appreciate your critical thinking, definitely.Best to you.

[godofkahn123]

These are great questions by OP.

So what is the final answer to the question: Trying to set it up in my mind, I have one primary bag of 1L NS for the bolus hanging under a secondary (Drug A) which is y-sited above Pump A, which then attaches to the patient. That's not a problem. Then for Drug B, I have it attached and primed through a primary infusion set hooked up to Pump B, which is then Y-sited with the primary from Pump A below the pump.

Should Drug B be set up as a primary or secondary to be Y-sited with Pump A??

Also, is there a maximum combined rate for infusions that are Y-Sited should not exceed since we are running Drug A and Drug B concurrently?