So confused about IVPB

[AbigailJo]

Hi all, I have recently started working on a Med-Surg floor. Most of our patients have many IVPB, but the problem is we are never given the rates to run them. Or worst yet, the rate listed is wrong. As some who is new, it's very scary to me to think I could possibly run something too fast. This morning, the doctor ordered one sodium chloride, 3 magnesium, and 3 potassium. The only one that had a rate was the sodium and it was 50ml/hr when another nurse told me it should be 25ml. I ran everything very slow out of fear of running the sodium and potassium too fast. The result was, I had only hung 2 of the bags before dayshift got there and I could tell she was annoyed that I didn't finish them. She pointed out I could have gotten another pump and ran more than one at once... but wouldn't this mix meds?

How is am I suppose to know the rates? What are some IVPB you need to run slowly? How do I know what I could run at the sametime without causing an adverse reaction?

I'm so worried about causing a problem for my patient, and I also want to be a thoughtful coworker. Thank you for your help.

[brownbook]

The three IVPB orders you gave as examples are not written in a way that makes any sense. They are not orders for any IVPB's I have ever heard of.

Your post is so confusing in so many ways. I don't know where to begin.

[Kallie3006, ADN]

I don't get it. Is the sodium chloride supposed to be normal saline and used as a maintenance fluid? 3 magnesium? 3 grams of mag? Usually its 2 grams. 3 of potassium? 3 what? 3 bags? Potassium IV is usually 20 or 40 meq. Are these running in a PIV or a central line? Does a pharmacist not verify the orders? Why are the doctors writing incomplete orders with not having a rate or infusion time? Did you call to verify the rate with the DR.? NS, Mag and Potassium are all compatible with each other but those questions need to be directed to your pharmacist for clarification. Was the patient in tele? What was the lab values for potassium and mag? Is there a reason IV was ordered instead of PO?

I'm as confused as the title of your post.

[AbigailJo]

The patient had normal saline running at 75 ml/hr on a peripheral line. She was NPO and yes I had lab values. No tele. None of our IVPB orders come with rates. I was told by my nursing manager that this is is how it's done throughout the entire hospital. When I asked the charge nurse if I should call the doctor to ask him the rate, she laughed and said how would he know he never hangs IV meds. This is why I came here, to get help.

The order was for:

1 bag Sodium Phosphate 3 mmol/mL in a 50ml bag

3 bags Potassium Chloride 20 mEq / 100 ml

3 bags Magnesim Sulfate 2G / 50 ml

I was told by the charge nurse to hang the sodium phosphate at 25ml/hr.

[Accolay]

If your hospital doesn't have medication orders that come with IV rates, then I'd say it's behind the times- this is how accidents happen. If you're getting rates that are incorrect, that's an Event Report where I come from. Write it up and get it fixed. Kudos on you for attempting to find the correct answer though.

Do you have access to Micromedex, Lexicomp or similar at your work? The answers usually lie within. You can also look up compatibility of IV medications with those- very handy of you're not doing so already. Use your resources, know your commodities. The charge nurse is probably right that the MD doesn't know infusion rates, but a Pharmacist should. Call them if you have the option in the wee hours to chat when you have a medication question. I hate waking people up, but that's why they get paid the big bucks.

I can't remember the IV rate off the top of my head for KPhos, but 3mmol is at the lower end of dosing and our hospital rate for that through a PIV is something like over two hours methinks, so 25mL/hr sounds about right. I may follow up with this next time I have a chance to check.

20mEq potassium is administered only via central line according to policy where I work, and that would be over one hour. 10mEq potassium would also run over an hour through a PIV. Sometimes potassium administered via PIV can still cause a pt discomfort. Try diluting it with another NS line or the maintenance line or run at a slower rate. Or dilute with your maintenance fluid using a buretrol if you have them on your floor.

Mag can run through a PIV, each 2g over one hour.

Hopefully you had more than one IV on that patient. Those 'Lytes can take f-o-r-e-v-e-r sometimes to finish up even if you know exactly how to administer.

[meanmaryjean, DNP, RN]

Where the heck is your pharmacist? If you don't have a clear directive- ASK THEM- they are the experts and it's their job.

[JKL33]

These people sound nuts.

The question is, is there really no further policy- or pharmacy-related clarification of administration rates or do they just not know about them?

For example, many facility-specific policies delineate how much potassium may be administered how quickly through which type of line on which unit(s).

In addition, surely you must have access to either an up-to-date print or electronic drug reference. Surely. These will tell you things like "...not to exceed [amt of med/time]" (amount of drug per unit of time). Even this information is better than "that's what [non-pharmacist so-and-so] said to do."

Bottom line as already mentioned but bears repeating - - you must contact your pharmacist for these kinds of questions. They can also answer any compatibility questions you may have so that you can know with confidence how best to administer these medications in a timely manner.

Your best bet is to never give any medication based on unconfirmed recommendations/what so-and-so does.

This sounds like a situation where you will have to take the initiative to practice safely. Every time.

[AbigailJo]

Thank you all for your replies. I didn't realize this was such an uncommon practice. I am new to IV medications and the people around me act like this is proper practice. I will contact the pharmacist tonight and write down her recommendations. In addition, I do have access to Lexicom. I'll use this going forward to compare with the orders I receive.

[brownbook]

I'm not one to strictly adhere to "policy". But it seems like a doctor order to give any of the IV examples Abigailjo cited without prescribing the rate, the nurse just ?? assuming or guessing ??, is practicing medicine without a license?

Actually not the rate so much as, "give 20 meq of potassium in 500 ml of LR over 4 hours".

As JKL33 said, these people sound nuts.

[Triddin]

Our orders almost never have rates included... we are expected to refer to the facility's electronic parenteral drug manual and get the rates from it.

[Kallie3006, ADN]

You was attempting clarify medications you was not sure of and was unable to get a viable response from your charge, good for you for questioning this. I apologize if my previous post did not come across as seeking clarification for the question presented. Keep in mind that some reference sites that give info on IV infusions are going off the manufacturer's guidelines which is not always safe or best practice for the patient population in question.

See if your facility has policies and procedures in place for electrolyte replacement. The ones I have seen will give a lab value range and how much to replace with. IE: K 3.3 give 20 meq PO and repeat in 2 hours recheck in 4 hours after 2nd dose administered. 20 meq IV infuse at 25cc/hr for 2 hours ect.

I was always taught to y site IV potassium to NS because the K burns like hockey sticks and is very caustic to the veins. Most places want IV potassium to be infused via central line because of this.

Always monitor your patient to see how well they are tolerating and be extra cautious with excess fluids to your CHF pts

[MunoRN, RN]

In every place I've worked I've never seen an MD order a rate, they only order the dose, except for maintenance fluids or fluid resuscitation, in which case the rate and or volume to be given is essentially the dose. I don't think the majority of them would have any idea how fast various medications should be infused. That's what your pharmacists and drug reference sources are for. I've also never seen an MD order that was along the lines of "3 bags magnesium 2mg /50ml", that order should read "6 grams".