Simple IV Questions

As long as the PNSS is at KVO rate, the insulin drip will infuse accordingly. Just make sure that the insulin piggyback is secure as in some situations, the infusion rate varies because of position. Or check the hourly input and hourly decrease in the IV bag of insulin to make sure you are really infusing at 8ml/hr.

As long as the PNSS is at KVO rate, the insulin drip will infuse accordingly. Just make sure that the insulin piggyback is secure as in some situations, the infusion rate varies because of position. Or check the hourly input and hourly decrease in the IV bag of insulin to make sure you are really infusing at 8ml/hr.

And if the NS needs to be WIDE open, as in, 1 liter/hr or so?

I dont think I could eyeball 8mls from a bag

Insulin deserves it's own primary line, I wouldn't ever piggyback it into another IV line for any reason.

yup...I agree with Getoverit...Insulin=dedicated line...NEVER EVER piggyback insulin this is not a safe practice.

If the patient is sick enough to require IV insulin gtt...then another IV should be started

You have only one IV access. (For whatever reason).

You have two IV medications to give. They are compatible.

Lets say one is Insulin at 8ml/hr, the other NS wide open.

1--If you put the insulin gtt on a pump at 8ml/hr and the NS via gravity, can you piggy back the insulin into the NS tubing, or is there a risk that the insulin could back up into the saline? Either during the tandem infusion, or when the NS is finished?

Hypothetically, if I had absolutely no choice, I would Y-site the NSS into the insulin, below the pump into the port closest to the patient. It would be even better if you had a Y-extension set. Because the insulin is on a pump, the rate of infusion is controlled. The insulin will infuse at the rate programmed into the pump; it is independent of the rate of infusion of the NSS. However, you should check your facility's protocols. As others have mentioned, your facility may require insulin to be infused through a dedicated line.

Or 2-- what if you had two IV solutions- neither need pumps. Say one is NS, the other an ABX that can be given over roughly 20-40 mins. If you dont want to stop your fluids, can they both be hung via gravity and infusing in tandem?

Yes.

3-- when you hang a medication that infuses slowly, are there any tricks to get it through the connection tubing without bolusing it? (or a safe way to bolus it) The connection tubing between the cannula and IV tubing has been flushed with a saline flish, so saline is sitting in the connection tubing. Im thinking in the case of Nitro at 3ml/hr, where it would literally take an hour to flush out the saline.

You need to know the volume capacity of the extension set you're using. Depending upon the brand and type, it could be as little as .4mL.

4-If a drip such as insulin or nitro is finished and you need to flush the line for a new medication, do you aspirate from the connection tubing to prevent bolusing? Or in a similar scenerio, if you needed to give a push medication while a patient is recieving a drip such as insulin or nitro (in other words, a carefully titrated drip).

Again, what is the capacity of the type of extension set you're using?

And if the NS needs to be WIDE open, as in, 1 liter/hr or so?

I dont think I could eyeball 8mls from a bag

Infusing 1liter/hr? That's like fast drip. 1,000mcgtts/min via microset or 333gtts/min via macroset @20 df? Really? Seriously? Hmmm? Theoretically, the insulin would STILL be infusing accordingly if it is theoretically on piggyback with PNSS line. It will never go back up the line. And still, double check the IV rates and actual ml infused.

On our institution, insulin drip is always on a separate access line. Lol only 1 IV access line to a human being with lots of veins in the body.

Infusing 1liter/hr? That's like fast drip. 1,000mcgtts/min via microset or 333gtts/min via macroset @20 df? Really? Seriously? Hmmm? Theoretically, the insulin would STILL be infusing accordingly if it is theoretically on piggyback with PNSS line. It will never go back up the line. And still, double check the IV rates and actual ml infused.

On our institution, insulin drip is always on a separate access line. Lol only 1 IV access line to a human being with lots of veins in the body.

Yes. Seriously.

In the ED we dump Liters in as fast as we can. And of course, we can always ask for an EJ or a PICC but if a patient comes in DKA/Hypotensive we need to do what we can with what we have until further access is established.

Thanks!! Never thought of that. Im going to look into the volume of our extension set. Great advice.

yup...I agree with Getoverit...Insulin=dedicated line...NEVER EVER piggyback insulin this is not a safe practice.

If the patient is sick enough to require IV insulin gtt...then another IV should be started

Agreed. Im not so much questioning what insulin can be piggy backed with, but the pump piggybacked into a gravity drip.

No piggybacking of insulin for me - insulin must be on a primary pump only. How it is then connected/infused into patient will vary.

I am always reluctant to infuse anything via dedicated line that flows at a rate of less than 30 unless I add a saline line behind it. Think about it -- 8ml/hr in a IV site without a saline line behind it to help flush it in to the patient is not wise. 8ml/hr will not keep your site patent - the insulin needs to reach circulation and any drip that I give that is very low volume (high concentrated) and perhaps only infuses 1 ml every 7:30 minutes - needs a "vehicle" to get it pushed into the patient.

One option would just use 2 primary pumps - 2 primary sets. 1 for NSS @ 999/hr, 1 for Insulin @ 8 units (ml) hour. (Insulin drips are traditionally 1 unit in 1 ml in every world that I ever worked). Connect the saline line to the patient and the insulin primary set to port closest to the patient on the NSS primary set (or use a Y site at the extension to connect) there will be little-to-no chance of funky back up's - machine bo-bo's or anything. Best option - given unlimited resources. This will solve the issue I noted - there will be enough saline to "flush" the insulin into the patient.

Another way and I may get thumped and I do not recommend as a rule - if I was remaining with patient for this all important hour (like flying them) - I'd just add the 8 units of insulin to the full bag of saline and when the 1st liter is in - well, the first 8 units are too. Note the volume and that is your concentration - say 1000ml , add 8 units = 1 unit per 125ml infused - label the bag. Careful with priming - but, whatever volume the pump gives you can still be very precise with the insulin dose received. But, that has to presume that anything else you would have to give this patient would be compatible with the very dilute insulin/NSS liter. I'm sure this is not a best practice - just a real life example of improvisation. The first option is the better option - this one is for limited resources/space.

Actually, the patient's IV access could be Y sited (or MacGyvered) you could put the NSS to one port w/o to gravity (if flowing well, or on a pressure bag if not) on a primary set - put the insulin on a primary set and connect to the remaining Y port. No primary set that I am aware of allows "backflushing" and with the Insulin on a pump - it will alarm if occluded. This is an option if you have some limited resources.

Make sure you work to get a second access ASAP after the patient is better hydrated from the DKA state that you are treating them for starts working and plumps up those peripheral veins. I have been spoiled by all the tools in my flightsuit for getting access

Practice SAFE!

:angel:

I work on a diabetic floor and we use one site for re-hydration fluids and insulin but on separate pumps. The re-hydration fluids run directly to the site and insulin gets run on a micro drip pump running into the port closest to the patient. Insulin infuses at to low of a rate to run it in a dedicated line and you would never infuse insulin without hydration fluids anyway, so the setup works well. We always try to have a second site to infuse abx or any iv push meds.

Agreed. Im not so much questioning what insulin can be piggy backed with, but the pump piggybacked into a gravity drip.

I hear you regarding "sometimes you don't have much choice" and sometimes the veins just ain't there (you know the ones... the long-time IV drug users, the LOLs with the spider veins that barely take a 24, the 99 YO whose veins blow just by looking at 'em cross-eyed, the morbidly obese person whose ACs are buried beneath 3-4 cm of fat).

If you really have no choice - and the doc concurs on same - be absolutely certain that your gravity line has a *functioning* check valve to prevent back flow (to check, connect a flush to a distal port and then kink tubing distally to that... if you can flush then your check valve isn't working). Keep a watchful eye on the drip chamber to note the steady, even dripping, the lack of bubbles going into the bag, and that the level in the drip chamber is not increasing...

and then work on getting another line ASAP by means of ultrasound, PICC, subclavian, EJ, etc.