standard concentrations, does your facility use them ?

AliRae · Dec 24, 2007

We went to them right before I left, and it was a nightmare. I guess there are always kinks to be worked out, but come on!

One of my last days I was in charge and I helped admit a baby post arrest at home. He came up on dopa, and we needed to titrate the drip up. The "smart" pumps that we used with our standard concentrations wouldn't let us. So we ended up busting out calculators, breaking out an old pump and going ml/hr. He definitely had some fairly labile BPs during that time!

Pediatric Critical Care Columnist · Dec 24, 2007

We're still using the rule of 6's. Well, actually the rule of 3's since we mix everything in syringes. We have found that we often can't run anything on a volumetric pump in-line with our pressors and we NEVER run any vasoactive med from a bag; it's the pulsatile delivery of the pump that causes our peaks and valleys. For every volumetric pump at one of our bedsides we might have ten syringe pumps. The drawback here is that for big kids, the maximum concentration guidelines mean we're changing the syringes frequently.

(Hey Ali, how's it going? When do you ship out again?)

AliRae · Dec 24, 2007

The drawback here is that for big kids, the maximum concentration guidelines mean we're changing the syringes frequently.

What are those guidelines? Is it a standardized thing or something your facility has?

(Hey Ali, how's it going? When do you ship out again?)

Just bought my ticket! February 7th. I have a one way ticket to Africa, and I'm not planning on coming back before February of '09. Yahoo!

Pediatric Critical Care Columnist · Dec 24, 2007

The guidelines have been put together by our clinical pharmacist from a variety of sources: Micromedex, the manufacturer's recommendations, the Compendium of Pharmaceuticals and Specialties (Canadian thing) and others. We have computerized "recipe" sheets for our emergency drugs, critical care infusions and antibiotics that are basically Excel spreadsheets. You plug in the child's age and weight and the computer generates your recipe sheets with individualized doses and maximum concentrations. Most of us do the math ourselves anyway, but they're handy in codes and when there's a question about how high we can go with doses and concentrations and other little niggly issues. I can print some up and send 'em to you if you like!

The drugs that cause us the greatest consternation are the big gun pressors like epi and levo, vasodilators like nitroprusside and the antiarrythmics like amiodarone and esmolol. Some of our patients are BIG, as you know, and the pumps might be running at 10 ml and hour or more... syringe changes q6 and getting them changed quickly so the kid doesn't notice you're doing it... There aren't usually enough pumps available to allow double-pumping except in extreme cases.

OMG Ali, you're going soon. I knew that, but having a date makes it more real! Stay safe over there.

climberrn · Dec 25, 2007

We're still using the rule of 6's. Well, actually the rule of 3's since we mix everything in syringes. We have found that we often can't run anything on a volumetric pump in-line with our pressors and we NEVER run any vasoactive med from a bag; it's the pulsatile delivery of the pump that causes our peaks and valleys.

So the syringe pumps don't have that same delivery system? It makes sense but I never thought of it that way. Do you have a policy about it? I'd love to look at it...it's starting to be a big problem.

Pediatric Critical Care Columnist · Dec 25, 2007

Syringe pumps use a plunger driver to deliver the infusion at a steady, continuous rate. We use the Alaris Asena (http://www.dovermed.co.il/Images/Products/small/582.jpg) which has the capability of using syringes from 5 mL to 60 mL. We use them for intermittent infusions of antibiotics and other meds that have to be given over a set period of time, as well as for our pressors and most of our sedation drugs too. They're very convenient for that use. The display gives us a visible run-time based on the size of the syringe in use and the position of the plunger. They're accurate to within a couple of minutes and give you a 'five percent remaining' warning, so you will always know when you'll need to mix a new syringe. I'm not sure if we actually have a policy or just an unwritten rule, but I can check. I do know that there are often as many as 20 syringe pumps at a single bedside for our cardiovascular surgical kids. If you click on the image it will enlarge and you'll see that there are 8 syringe pumps visible; I think there are two more out of sight under the edge of the table. (Can you pick out the baby?) We label each pump with an orange sticker that tells us what drug is infusing and what the concentration is i.e. EPINEPHRINE 1 mL per hour = 0.1 mcg/kg/min. When you walk up to one of our bedsides you can see at a glance what's running and what the current dose is. It's very handy!

climberrn · Dec 30, 2007

We use syringe pumps but we also have bags of drugs mixed. Our concentrations are either 4 mcg/cc or 64 mcg/cc. The former can end up with giving way too much volume, the latter has been resulting in the aforementioned swings in BP. I'm wondering if we need to put all pressors on syringes. Then the problem becomes that if that isn't loaded into the syringe as an option, we're off "guardrails" and the hospital freaks.

AliRae · Dec 30, 2007

Our concentrations are either 4 mcg/cc or 64 mcg/cc.

Our hospital has 5 or 6 standard concentrations, A-E (or F) ranging from least to most concentrated. NICU babes end up with A and B usually, and our kiddos usually range from C-E (or F). It's nice to have a lot of different options and I think that would help some of the swings you're having. Our pumps are programmed with the letters and such.

climberrn · Jan 1, 2008

Our hospital has 5 or 6 standard concentrations, A-E (or F) ranging from least to most concentrated. NICU babes end up with A and B usually, and our kiddos usually range from C-E (or F). It's nice to have a lot of different options and I think that would help some of the swings you're having. Our pumps are programmed with the letters and such.

Our problem (as denoted by pharmacy) is that since we aren't a children's hospital, they have to load drugs for all age groups and there is a limited amt of data that can be loaded. Additionally, they've chosen to load drugs like ampicillin/ cefotaxime, lasix etc. etc. Thus leaving less room for drugs like oh, say, epi or neo. (are you hearing the sarcasm? :devil: ) I may have to become a one woman crusade.

AliRae · Jan 1, 2008

Our problem (as denoted by pharmacy) is that since we aren't a children's hospital, they have to load drugs for all age groups and there is a limited amt of data that can be loaded. Additionally, they've chosen to load drugs like ampicillin/ cefotaxime, lasix etc. etc. Thus leaving less room for drugs like oh, say, epi or neo. (are you hearing the sarcasm? ) I may have to become a one woman crusade.

Crusade away! However, just be sure that when they program the dang pumps the limits are appropriate. Like I said before, there's nothing worse that being in the middle of a wicked situation and finding out that the pump doesn't think you should be giving that much epi and stops you cold. :uhoh3:

We definitely don't have abx loaded into the pumps. It's just meds that are given by drips. All other meds (abx/steroids etc) we bypass the drug library and go to a straight ml/hr option.

Pediatric Critical Care Columnist · Jan 2, 2008

Okay, I printed up an extra copy of the drug sheets I did up for my admission yesterday. If you want a copy, send me a PM with your personal email address and I'll email you a scanned image of them.