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Discussion

TPN and ABX

Hey all~

Today I saw a pt with TPN running and Lipids who had a bag of NS piggybacked and connected at the Y-site on the NS bag was the antibiotic. The pump it was on had room for 3 lines. My question is: if the TPN was occupying one of the lines on the pump, the lipid was occupying the other line on the pump--if the NS was set at the rate of the ABX with the ABX at the y-site, would the ABX just run through the NS at the prescribed rate bc it is hanging higher than the bag of NS (that it, the entire bag of NS wouldn't infuse, the prescribed ABX would only run through it) I guess I just can't visualize how this would work. Sorry this is confusing, but any insight would be appreciated. What's your hospital's procedure for this type of situation or what would you do? I'd be afraid to stop the TPN in the middle of infusing to run the ABX by itself (mainlined).

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Why wasn't the abx put on the secondary port of the NS with secondary tubing? I assume the pt had a triple lumen central line, correct? And a triple pump? Therefore the abx should have been run on the secondary port of the NS.

hmm my minds eye is cloudy....lol....it seems that the ABT is running into the NS line, and if it is hung above the NS, yes, it will infuse at whatever rate the NS is set for......my question is WHERE is the NS connected to the patient?

TPN should be run through separate line, not to be mixed with anything else.

  • Expert

If the patient had TPN infusing, then they should have a central line in the first place. And usually with three ports to that line. Nothing other than the Intrallipids should be in the same port. Never any antibiotics with the TPN. You can find Intralipids mixed directly into the TPN, or as a separate bottle. So you would still have at least one port left over. TPN has more than 10% glucose and therefore requires a central line.

When hanging IV piggybacks, you usually will use a carrier, such as normal saline ro keeo the line open, and can infuse your piggybacks thru that. You usually use a shorter tubing for the IVPB, and the main IV is hung lower so that the IVBP will infuse first. Teh pumps have programs that can be set for the piggyback, the main fluid actually stops running while the piggyback is infusing and then automatically converts back to the previous rate.

--if the NS was set at the rate of the ABX with the ABX at the y-site, would the ABX just run through the NS at the prescribed rate bc it is hanging higher than the bag of NS
Even with a pump set for "Primary" (NS) and "Secondary" (piggyback ABX) - it still depends on which bag is hung higher. Physics and gravity take precendence over machinery - remember, your pump still depends on gravity ;)

I'd be afraid to stop the TPN in the middle of infusing to run the ABX by itself (mainlined).
The TPN shouldn't be infusing with anything else - problem doesn't exist in the first place! If there was only a single lumen PICC, TPN gets the PICC. I'd start a regular peripheral IV to run the ABX.

cheers,

  • Author

One last question, if you have time (I promise). If it is going into a triple lumen catheter (3 small, seperate tubes), why couldn't the lipids go through one port, TPN through another, and the ABX without the NS through the third? I was under the assumption that the NS was hung to "clear the line" so the TPN and ABX wouldn't miss, but now that I think of it, if it's a TLC, they wouldn't mix anyway would they? Maybe I'm overthinking, ahhh!

that would work, however, freq one port of a tlc is reserved for blood draws..... and, as was mentioned earlier, it is common to hang a "main line" of NS and piggy back intermittent meds into it, above the pump....that way you are not connecting and disconnecting as freq....and can run different meds through that line intermittently/serially

During orientation one of our pharmacists came and spoke to us regarding med admin. He stated that if there is a triple lumen PICC or central line, you can run TPN and lipids through one (or two) ports and antibiotics through the third. They are considered separate lines.

  • Author

so if one lumen has TPN going through it, one has lipids running through it, then the other can have a bag of NS with piggybacked meds as precribed running through it? That would be ok even though as you said one lumen/port is usually reserved for blood draws (that is, it is ok the NS is occupying that lumen bc it's only keeping the line clear and could always be taken down when ABX arent infusing in order to get blood from that port?) Also, can lipids be connected at the y-site to the TPN or do they need to go through a seperate port? Thanks so much!!

Just to add to the confusion. :devil: I work in a PICU. We frequently hang TPN + Lipids and will infuse certain antibiotics, pressors, fentanyl, versed, vecuronium, nimbex etc to the line with TPN. We have a very large compatablities book that we reference for this type of thing. A small child with a TLC, multiple meds including post transplant meds don't leave alot of choices. A common scenerio for us may be a TLC with TPN, Lipids, Dopamine, Versed, Vec, Fentanyl in one port, CVP with antibiotics in second port and a post transplant med such as PGE in the third. Also the child with a single lumen Broviac with TPN and antibiotics leave us little choice. All depends on where you work and who you are working with.

so if one lumen has TPN going through it, one has lipids running through it, then the other can have a bag of NS with piggybacked meds as precribed running through it? That would be ok even though as you said one lumen/port is usually reserved for blood draws (that is, it is ok the NS is occupying that lumen bc it's only keeping the line clear and could always be taken down when ABX arent infusing in order to get blood from that port?) Also, can lipids be connected at the y-site to the TPN or do they need to go through a seperate port? Thanks so much!!

The answer to the first question is yes.

The second answer is, it depends. At some facilities the lipids are already mixed with the TPN in one bag..........problem solved.

If you have a SEPARATE bag for lipids, string up a new line and separate pump. Y-site into the TPN line AFTER THE TPN FILTER. If you Y it up before the filter, the lipids will clog the filter.

Clear as mud, eh?

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