Standard Concentrations

Pediatric Critical Care Columnist · Jun 11, 2011

We currently use the Rule of Sixes but are supposed to be moving to standard concentrations. We also recently got a bunch of new "smart" syringe pumps that we're expected to use as designed, but they're set up for the standard concentrations that haven't been rolled out yet. AND... there are two different libraries, one for PICU and one for NICU - never the twain shall meet. You don't know which pump you have until you turn it on. Today we had several issues with this, due to the NICU standards being so different from our current ones. We ended up overriding the "smart" features and running them all in mLs/hr. There have been a number of serious errors in programming too. Like a full syringe of midazolam infusing over an hour. Apparently no one understands the principle of making one change at a time...

umcRN, BSN, RN · Jun 11, 2011

we use standard concentrations which were in use long before we got the "smart pumps" which we have now, so far no major issues that I have heard of. The smart pumps have a separate profile for each unit but we select it upon turning the machine on, nicu, critical care, acute care, blood, feeding etc are all programmed into our pumps. We have occasionally in the NICU needed to use the critical care profile for our larger babies and those on heavy narcs being followed by the hospital pain team but physicians have to put an order in for that and we have to have an order for any guardrail overrides

Pediatric Critical Care Columnist · Jun 11, 2011

We actually have two different models of Smart Pump. The Alaris has multiple profiles we can choose from and that's all great. But when they bought new syringe pumps they didn't go with the obvious choice, they bought Medfusion 3500s instead. They have a single profile. The libraries were set up without consultation with the end user so we have several drugs that we have to bypass the guardrails for. And they take a long time to get up and running. When my patient's systolic BP is 39 and I need an epi infusion going NOW... well, it's just NOT going to happen. Maybe in 5 minutes...

neopedsflight · Jun 12, 2011

We currently use the BBraun smart pumps, after trialling the Alaris smart pumps. We wnet withthe B Braun because thats what the OR wanted to use, and they mix all of their own drugs as they would like them, thus when they come out of the OR we mix up new concentrations and have our infusions going at different rates, the potential for error and alterations in patient status while changing the syringe is huge. The other issue we are currently dealing with is that pharmacy would like to mix all of our infusions which while maybe sounds good in theory waiting 30min to an hour for an epi infusion doesnt sound ideal to me. Thanks for all of your responses, thay are very helpful, TRacy

Pediatric Critical Care Columnist · Jun 12, 2011

We currently use the BBraun smart pumps, after trialling the Alaris smart pumps. We wnet withthe B Braun because thats what the OR wanted to use, and they mix all of their own drugs as they would like them, thus when they come out of the OR we mix up new concentrations and have our infusions going at different rates, the potential for error and alterations in patient status while changing the syringe is huge. The other issue we are currently dealing with is that pharmacy would like to mix all of our infusions which while maybe sounds good in theory waiting 30min to an hour for an epi infusion doesnt sound ideal to me. Thanks for all of your responses, thay are very helpful, TRacy

Yeah, that's kinda where we went too. (Same thing with our monitors... we trialed 'em, rejected them and are now stuck with 'em.) We often switch out infusions mixed by anaesthesia too, which really t's off one of them in particular. And I agree, waiting 30+ minutes for that epi is not gonna work! What we've been told about the standard concentrations is that pharmacy will mix up a supply of bags... and we'll fill our syringes from the bags. The bags will be in our Pyxis. Where I used to work, we had a satellite pharmacy right on the unit, with a pharmacist on site 24/7. They mixed everything and would have it ready and at the bedside in less time than it takes us where I am now to get the drug from the Pyxis, do the math, draw it up and have it double checked, mix the infusion and get it going. It was GREAT!

umcRN, BSN, RN · Jun 13, 2011

We can pull ready made dopa/epi from our pyxis. We can mix first dose abx from the pyxis and we have all our sedation drugs we could need from the pyxis

After those first doses pharmacy will make and send everything for the patient

imaginations · Jun 13, 2011

Could someone point me toward where I could learn about the concepts of 'rule of sixes' and standard concentrations? (I'm a nursing student and have only experienced adult icu. I would like to learn about PICU concepts!)

Pediatric Critical Care Columnist · Jun 13, 2011

The Rule of Sixes is pretty simple. It's a shortcut calulation for infusions that are run as mcg/kg/min such as epi, norepi, dopamine and so on. You multiply the patient's weight in kg by the desired concentration of a drug then multiply the result by 6 and that's how many mcg of the drug you put in a total volume of 100 mL. Then your infusion will be mixed such that 1 mL/hr will be the desired concentration and your pump will reflect the dose simply by looking at the rate.

So for an epi infusion and a patient who weighs 20 kg, for example:

Desired concentration = 0.1 mcg/kg/min

Weight = 20 kg

(0.1 x 20) x 6 = 12 mg

The "long" way is like this: 0.1 mcg x 20 kg x 100 mL of fluid x 60 minutes / 1000.

(0.1 x 20) = 2 x 100 = 200 x 60 = 12000 /1000 = 12. All you're doing is eliminating the 100 X 60 /1000 step.

If you want your patient to be getting 0.5 mcg/kg/min (which is a LOT of epi!) your pump would then run at 5 mL/hr. If you walk up to the bedside an the epi pump is running at 0.4 mL/hr then you would just know that the dose is 0.04 mcg.kg.min. Make sense?

Since we run all of our vasoactives on syringe pumps we use the Rule of Threes and mix everything in a total volume of 50 mL.

imaginations · Jun 13, 2011

Thank you very much for explaining that to me. Can you tell me why this rule 'works'?

This is different to adult ICU and adult nursing in general where doseages are standard rather than weight based. In adult ICU there is a standard concentration (albeit single/double/tripled strength variants) for typical ICU infusions like norad, midaz, morphine, vasopressin etc. It makes sense that in PICU as in pediatrics in general that drugs and infusions are weight based. Do you spend a lot of time doing your maths and checking it? I would be so unsure of myself!

Pediatric Critical Care Columnist · Jun 13, 2011

Some bright person was doing the math one day and realized that it was unnecessarily complicated. It makes it a lot easier to mix infusions in a hurry when you use the Rule of Sixes and it used to be a staple in the PICU. But it's falling out of favour with the advent of Smart Pump technology and increased scrutiny of med errors by such agencies as the Joint Commission. Here are some articles (pro and con) that might help you out:

http://www.massgeneral.org/children/specialtiesandservices/neonatology/med_admin_process_manual.aspx

http://emergencymedic.blogspot.com/2010/08/rule-of-six-in-drug-dosing-and-infusion.html

http://www.scribd.com/doc/12844849/Preventing-Pediatric-Medication-Errors

http://www.ismp.org/faq.asp#Question_18

http://www.hcpro.com/HOM-40932-1588/Subtract-rule-of-six-from-hospitals-medication-dosing-equations.html

I have issues with the claims being made in some of these. On our unit, every single medication is double-checked by another RN. We do not have a unit-dose program or even on-site pharmacy support at night. (Our transplants often come back in the middle of the night and we don't have their immunosuppressants because pharamcy refuses to send them up until the patient is actually on the unit... so the on-call person comes in from home and it can take up to 90 minutes from admission until the drugs arrive on the unit. Not acceptable!) Virtually ALL of our infusions are mixed by the nursing staff, and the vast majority of our parenteral drugs are reconstituted and drawn up by nurses. There are a handful of antibiotics (pip-tazo, vanco, cipro, amp... any of the ones that are stable for 24 hours) that are provided as unit-doses but even that is inconsistent. If we're not competent to mix infusions correctly then we aren't competent to mix and draw up all those other meds either!! The majority of our patients are cardiac and are fluid restricted. Having only two or three standard concentrations is going to make our fluid control very difficult. And then of course, there's the time it takes to program these so-called Smart Pumps. One other thing that really bothers me is that the sharp end of the stick - the bedside nurse and the intensive care physician - are never consulted about these changes. They're thrust upon us and we're told to just deal with it.

We do calculate every dose we give to our patients. We do have every dose checked for accuracy before we give it. We both sign the MAR. Yes, it's a lot of math!! But it's a routine so once you know how to do it, there's not a lot of difficulty with it. All of our COWs have the parenteral manual on them so it's easy to look up the recommended dilutions, the min and max concentrations, min administration times, routes and so on.

kessadawn, BSN, RN · Jun 13, 2011

We use standard concentrations, and pharmacy mixes nearly everything for us. Our pharm is in house 24/7, though. PICU RNs can mix gtts at the bedside for emergency needs, and some are available pre-mixed in the med room. I have never used the Rule of 6's, we have been using standard concentration for a long time in my hospital. I find that we have few med errors, but I would expect that as your unit gets more used to using standard concentrations, the rate of error will go down. All gtts are a nurse double check, regardless, so that cuts back on error, and we do use smart pumps as well.