They didn't teach me this in nursing school and I could have killed someone!

UM Review RN, ASN, RN · Aug 8, 2005

The information is not correct. It is perfectly OK to run any other drug through the second or third lumens of a central line. Also, an embolism is caused by air injected into the line, not a drug. Finally, an insulin gtt can be run with TPN/lipids, since it's often added to the actual TPN sometimes anyway.

I had a pharmacist tell me to stop the TPN to run the Unasyn ordered for a Pt. "just to be on the safe side" even though the Unasyn was to run into a different lumen on a PICC line.

Any thoughts?

lady_jezebel · Aug 8, 2005

I had a pharmacist tell me to stop the TPN to run the Unasyn ordered for a Pt. "just to be on the safe side" even though the Unasyn was to run into a different lumen on a PICC line.
Any thoughts?

I've never had to do this. We have access issues in the ICU, and use incompatible drugs in different lumens of the same central line. However, there probably are some drugs that shouldn't be mixed in immediate circulation -- chemo, for instance. But this probably even depends on the type of central line used.

Here's just a random paper about incompatibilities & central lines:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=29014

As for the PICC, however -- there are many types. Could it be that certain types do not allow for incompatibilities? Anyone know? Any PICC nurses here? I know that some PICC lines are mistakenly not inserted all the way into the subclavian, and are thus called "midlines" & are truly peripheral lines & must be used more cautiously.

I'm interested to hear what other people have encountered regarding this issue...

zacarias, ASN, RN · Aug 9, 2005

If a PICC line is truly in a central vein, you are OK with incompatible drugs in DIFFERENT lumens. However, if you are drawing blood from a PICC, you have to make sure that the other lumens are flushed. For instance, if you had TPN running on another lumen 1, you would have to stop it and flush lumen 1 before drawing blood from lumen 2. This is because the drawing blood can "suck" fluid from the other lumen and distort the sample (TPN really messes up lab values). Does that make sense?

UM Review RN, ASN, RN · Aug 9, 2005

I know that some PICC lines are mistakenly not inserted all the way into the subclavian, and are thus called "midlines" & are truly peripheral lines & must be used more cautiously.

This was most certainly a PICC line in this instance, and our facility does Xray for placement. Most of our PICCs are placed by Radiology, so we're able to be pretty doggoned sure.

Midlines usually come with the patient from outside places.

Maybe it was a new Pharmacist?

pricklypear · Aug 9, 2005

I had a pharmacist tell me to stop the TPN to run the Unasyn ordered for a Pt. "just to be on the safe side" even though the Unasyn was to run into a different lumen on a PICC line.
Any thoughts?

Maybe your pharmacist was related to our pharmacist? I swear, I've never heard so many "I'm not sure", "I don't know", "probably", "maybe, maybe not" from any pharmacist ever. And the mistakes that have come out of our pharmacy? Whew.

Anyway, I can't think of one single instance where compatibility would be an issue AT ALL with seperate lumens of either a picc or a midline.

Rnannie94 · Aug 13, 2005

I have seen many times nurses pushing medications thru lines with something else running.
Back in my LPN days, I asked an RN to give a push for me, the pt was nauseated. I had IVF- like NS hanging, and an Ancef abx piggybacked, and running. She didn't check anything, walked into the room, and pushed the antiemetic thru the primary line, and walked out. I followed behind her, and realized the line was completely white, with crytals in it. I unhooked the patient, and stopped it before it reached her.
Many years later, and am an RN...
Since then, I learned, always, just unhook the primary line, flush the IV, push the medication (however long), flush again, and hook back up the primary line. I have NEVER had an interaction, or had to spend time looking up to see if meds are compatible. It really takes less time, and is the safe way.
And as far as I know, nothing is to be piggybacked into TPN, BUT lipids. It's in our policy at our facility.

I'm not sure how many other antiemetics do this, but phenergan can't be given when an antibiotic is running because it will crystalize. You do have to be really careful about unhooking the line and flushing well to prevent it. Unfortunately, this was learned the hard way on my unit - luckily it didn't reach the patient - and we learned from someone else's faulty push. :rolleyes:

Rnannie94 · Aug 13, 2005

I heard of a nurse in AZ that had a pt that was npo. Doc ordered MOM and the nurse put it through the central line.
I don't know if this is true or just an urban legend type story, but i've met some nurses that I could see doing something like this. SCARY

I've heard of that also. We had a nurse attempt to give a child a dose of motrin suspension via the iv line. Luckily she was caught before actually doing it. :selfbonk:

zoxena&Alexis · Aug 13, 2005

Don't forget that most TPN'S are prepared with 70% Dextrose!!! So stopping it for any length of time without a taper could be critical to the patient

Roland · Aug 13, 2005

Don't forget that most TPN'S are prepared with 70% Dextrose!!! So stopping it for any length of time without a taper could be critical to the patient

What sort of taper is called for over what period of time? How does one integrate the information with the need to suspend the TPN line and flush in order to administer medication?

gypsyatheart · Aug 13, 2005

What things "didn't" you learn in nursing school or during orientation that could have resulted in a patient being harmed? I knew a person who said that she was never taught that certain (any?) IV medications cannot be given during a TPN feeding in the same PICC line. She had a situation where she was going to push a med using a free lumen on the same double lumen PICC line while TPN was running, and was stopped at the last second by another nurse who just happened to come into the room. I cannot remember the med, but she was told that it would have likely caused an embolism had she proceeded. This caused me to ponder what other sort of "common knowledge" that is sometimes missed in school and on orientation, but that could result in real client harm. What would your "top three" things be that fall into this category?

I have said it before and I'll say it again, once you graduate nursing school and pass boards....all that means is you are now ready to learn how to be a nurse. Nursing school teaches you all the theory you need to know, but as many others have said, there is no way nursing school could possibly cover every technicality of each area of nursing! We'd be in school forever! Actually, that is how you should look at it....once you actually start practicing, you are getting OJT...ask lots of questions, remember the basics from nursing school, resaerch and read, read, read! Never stop educating yourself! Medicine is changing so much, we are always learning. The day you start thinking you know it all, that's the day it will bite you in the b*tt! :rotfl:

Remember it's your license, take the time to protect it and your patients. :)

Roland · Aug 13, 2005

I have said it before and I'll say it again, once you graduate nursing school and pass boards....all that means is you are now ready to learn how to be a nurse. Nursing school teaches you all the theory you need to know, but as many others have said, there is no way nursing school could possibly cover every technicality of each area of nursing! We'd be in school forever! Actually, that is how you should look at it....once you actually start practicing, you are getting OJT...ask lots of questions, remember the basics from nursing school, resaerch and read, read, read! Never stop educating yourself! Medicine is changing so much, we are always learning. The day you start thinking you know it all, that's the day it will bite you in the b*tt! :rotfl:
Remember it's your license, take the time to protect it and your patients. :)

I get what you are saying. I was just looking for a nice list of "Oh Duh, I didn't know that" type nursing/technical things that I could work on putting in my head right now. You know the stuff that the veteran nurse learns after ten years after he/she had made a blunder or had to ask several times. Here's a good example I have overheard nurses (while working as a CNA) who were going to hold Beta Blockers on a client because their client's blood pressure was too low (say 90/60). Well they neglect to consider that on at least two of these occassions the pulse was extremely elevated (120 in one instance and 115/ min in the other). The guideline is to hold these medications when the blood pressure is low and the pulse rate is low. In fact, the reason that the BP was low is likely because the heart is beating so fast that end diastolic volume is too low because the heart is beating too fast for optimal filling (Starling's Law or something). My significant other has also experienced this several times on her unit and she says it is one of the most common mistakes /errors she says that she sees nurses make.

Wel, I'm looking for a list of "just that sort of thing". Errors, that are easy to make, and or things that are commonly overlooked. A sort of (if you know nothing else here are 100 things you should get through your head as a nurse). I for one have at least 18 or more months before I'm going to be acting as a real nurse with my own license. Of course I have to get a certain amount of "book information" in my head if I'm going to graduate nursing school. However, that's also time to get a significant amount of "real world info" in there too. I wanted a sort of "How to be a Nurse for Dummies" a crib sheet of critical thinking, a guideline for the mentally challenged or at least overwhelmed if you will.

caroladybelle, BSN, RN · Aug 14, 2005

Don't forget that most TPN'S are prepared with 70% Dextrose!!! So stopping it for any length of time without a taper could be critical to the patient

I don't know about Texas, but I have rarily seen greater than a Dextrose 17% TPN. And I have worked in several states. Given how difficult it is to push a single amp of Dextrose 50% through IV tubing, I would be hard pressed to see how well Dextrose 70% would run.

As far as tapering, in BMT, we half the rate for two hours, half that for two hours, and then stop the infusion with some followup accuchecks. If a TPN bag runs out early, we infuse D10W at the same rate until a new bag is obtained.