I am a new NICU nurse in a Level IIB nursery... I am very curious as to what other units do in regards to IV medications. We retrograde nearly all of our medications, but from what I hear this is relatively rare and syringe pumps are more popular. I am wondering what your unit does and why.
My real question though is about gentamicin.
- How often do your docs/NPs order it... I see quite alot who order every 12 hours, but also have seen 18 and 24 (and even less often if renal function is poor).
-What would be the rationale of starting at say every 24 hours vs. every 18 hours when first ordering (no renal function tests done yet).
-What is the dose usually ordered... I've seen everything from 2.6 mg/kg/day up to 6 mg/kg/day on my search on the internet. Any fairly standard dose?
- It seems pretty standard to give it over 1/2 hour, but how much do you dilute it too (our very handy IV administration manual at work, which is used on all units, adults/kids/neonates, states dilute to a concentration of 1-10 mg/mL...)
That whole retrograding sounds very dangerous, especially on such fragile patients! What if the nurse accidentally forgets to clamp the port.....the med will end up being pushed in! And having to recalculate your fluid rate while the med goes in? Sounds like to many places for errors to occur and not very safe! I wonder if it is even considered an acceptable standard of care in the neonatal world anymore? Syringe pumps are so much easier, why wouldn't a unit use them?? Very interesting! And your unit should definitely be using a neonatal type drug reference, as we all know things are very very different for our babies!
I really don't like retrograding either, for exactly the reasons that you pointed out; I live in fear of giving a whole dose of medication push. We are having a syringe pump movement on the floor at present (I think it wasn't done before because we just didn't have enough syringe pumps for every baby/no money in the budget/alot of older experienced nurses who were more comfortable retrograding because 'thats the way we've always done it. If a drip like dopamine is being infused that will definitely go over a syringe pump). So hopefully soon we will be a syringe pump only unit!!
The university hospital I worked at quit retrograding meds in the early 80s. They had a talk for the nurses from a pharmacist explaining why it isn't a good, reliable or safe delivery method for neonates. I'm very surprised it's still being used in any NICUs.
wow...I haven't seen that since the early 80's on any floor where I work! Your unit or pharmacy should have a med guideline for NICU...if they don't, someone dropped the ball. Our similac rep gives us 2 new neofax each time they come out. There is also a pediatric pharmacy book we use. We have a large "Bible" in our unit too that the docs reference too...if anything is written outside of those guidelines it must be cosigned by an attending. What do you do if something is incompatible with what is hanging? Retrograding is very unsafe and this is why most hospitals have gotten away from it. We run all meds, including IL on our smart pumps. Just because that is how it has always been done, doesn't mean it is right. I would also be worried in a legal sense that you do not have any guidelines for your meds. That is very worriesome.
Does your hospital have a practice council or does your NICU do roundtable discussions...this is something that needs to be brought up.
I think sometimes it takes new blood to see things that really need to be addressed... just to clarify I come from a municipal hospital 10 bed (supposed to be 10 anyways, sometimes upwards to 15-18) Level IIB NICU. So we do short term ventilation, CPAP, TPN and alot of feeding and growing... anyone under 32 weeks gestation gets shipped away to a bigger center. We have no neonatologist, just pediatricians who do daily rounds with varying levels of experience in neonatology (eg. depending who is on call depends on the probability if a kid gets UAC/UVC, some have very little experience in this area). We have a wonderful staff of senior nurses who have seen alot in the 20+ years they have worked and many of them have worked Level III as well, so often times they can "guide" the pediatricians who need assistance. These very experienced/knowledgable nurses however, can be reluctant to change...
I agree 100% on the dangers of retrograding meds (have only worked since December and I try to set up a medline if at all possible and there is an available syringe pump, pharmacies solution is to share syringe pumps but that seems to be a huge infection control issue in my mind). To answer your question about incompatible meds usually we have a double/triple ended connector where one port will be running say TPN and the other port will have a maintenance line of say D10W. When the incompatible med needs to be run the TPN is stopped for that duration of time and the med is run through the maintenance line of D10W. Of course this requires stopping and starting the TPN which is not always best scenario. If the infusion cannot be stopped like dopamine its usually being given through a UVC, I believe, and then a peripheral IV will be started for other meds (I don't take care of kids this sick yet so I'm not 100% sure). Overall our kids aren't nearly as complex as the microprems in a Level 3 so it seems to work, however flawed the system is.
In regards to pharmacy... ours is chronically understaffed pharmacy (no pharmacist on nights, porters pick up meds from the night pharmacy), pleads ignorance to NICU meds (if you find an error let us know and we will change it in our manual), and no fault to them just are not terribly helpful. I agree that we really, really need change in this area and I am ordering a Neofax for the unit. I was very excited to see a book like this existed as the official hospital manual is not at all geared towards neonates. Our clinical educator is attempting to tackle changing our unit over the unit to using "smart pumps", where there is a library inside the med pump that figures out dosage etc. based on weight, and meds like dopamine will be mixed to a common concentration (I believe I saw another person post on this just recently) however, she is one person and pharmacy, the experts in the field of meds, are not giving alot of support, so it is taking forever!
As to the statement "just because something has always been done that way does not make it right" I am on your side and hopefully soon there will be a change!! The unit I am on is known for being "resistant to change" but hopefully with new hires and new blood we can provide the impetus for change.
I just got hired yesterday to work casual/per diem in a Level IIB NICU in a large city center and I am extremely curious and excited to see how that unit will compare to the one I work on!!
Kudos to you summerlove2. I know how hard it can be try and bring about change in a unit that is so resistant to change, and especially when you are the newbie! Believe me, I've been there! But it's obvious that you care so much about your patients and want to bring about important change. Keep up the good work, and don't let others who do things "because that's the way they've always been done" discourage you. Nursing is constantly changing, and part of being a good nurse is keeping up with the evidence and best practice standards. Good luck with your new job!
may I ask once you have mixed your Gent do use additional Gent to prime the tubing for the pump or do you make enough for the dose and follow up with a NS flush ? We are just beginning to be handed down this task. We are a Level II nursery and our pharmacy use to provide the gent in a syringe in the exact dose. we would infuse on the pump and flush it with Ns over the pump. we are now being suppied by a childrens hospital with a 62 bed nicu and they tell us to mix the dose ,overfill the syringe with the proper concentration to prime the tubing and run it over the pump, so when the pump is finished the tubing has additional gent in it..when doing this you cant flush or you give extra gent via the tubing and flushing after would seem to instill the last .5 too quickly, well maybe there are many times flushing isnt necessary? How do you do your administration on the pump. Our pumps are great! they infuse by weight dose drug etc tremendous safe guards...its just the rest of the set up i'm wondering about seems like it's a dangerous way to possibly give extra dosage.
We have measured and tested our particular brand of IV tubing, triflow, t-connector, microclaves, etc (everything from where the syringe touches the tubing to where it hits the baby's bloodstream) and found that our "priming volume" is 0.7ml. So here's our procedure:
1. If we have a med that is less than 0.7ml, we fill the syringe up to that volume.
2. Clamp off the other ports of the biflow/ triflow (for example, if you have TPN-IL-Rx, the TPN and IL are clamped and just the Rx is open so when you prime it doesn't sneak up the other ports).
3. You push in the 0.7ml of med. The med is now sitting in the tubing but has not touched the baby.
4. You attach your flush syringe and set it at the rate you need. If the med needs to go in over an hour, you program in 0.7ml over 1 hour.
5. Unclamp the other ports and press start on your pump. By the time your pump rings off, all the med has gone into the baby at a consistent rate and your tubing is now cleared with flush.
If the med volume is greater that 0.7ml (let's say 2.5 ml that needs to go in over 30 minutes):
1. Clamp the other ports and push in 0.7ml of med, leaving 1.8ml left in the syringe still attached.
2. Unclamp and program your pump: 2.5ml needs to go in over 30 minutes, so that's 5ml/ hr.
3. The pump will read empty when your first 1.8ml of med has gone in (running at 5ml/ hr that's about 22 minutes).
4. Put a flush on: 0.7ml of flush solution at the same rate (5ml/hr; volume limit of 0.7ml) so that everything has gone in at the same consistent rate (the flush will take about 8 minutes).
Sorry if that's all confusing; easier to explain in person! My biggest pet peeve is when people don't run the flush at the same rate as the med. With the above scenario that would mean 28% of the med would be running at a different rate, which depending on what it is could be bad news.
I'mANurse!
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That whole retrograding sounds very dangerous, especially on such fragile patients! What if the nurse accidentally forgets to clamp the port.....the med will end up being pushed in! And having to recalculate your fluid rate while the med goes in? Sounds like to many places for errors to occur and not very safe! I wonder if it is even considered an acceptable standard of care in the neonatal world anymore? Syringe pumps are so much easier, why wouldn't a unit use them?? Very interesting! And your unit should definitely be using a neonatal type drug reference, as we all know things are very very different for our babies!