Forum topic

 My answers would allow practice that is compliant with INS Standards:

1. - a IF there is no incompatiblility between any med in the primary fluid and the secondary med and if piggybacking is possible above the pump cassette. 

2. a. - they should always remain connected to reduce manipulation and potential contamination, regardless of where it is connected on the primary line. 

3. the same secondary can be used for multiple meds if there is compatibility. If not compatible, connect multiple sets to the primary line and leave them connected. The entire system should be changed at the same time and there should not be connection and disconnection. 

4. there is no magic KVO rate. A physician's order for rate and fluid type is always required to make it a legal order. If giving meds on a pump, the carrier fluids may be necessary to avoid leaving a large amount of the med in the set. In my opinion, most meds do not require infusion pumps and can be manged by gravity with a simple primary set connected directly to the needleless connector on the catheter hub. Downside to this is the requirement for the nurse to return ASAP when finished to disconnect and flush to prevent backflow of blood into the catheter lumen. Another issue is the saline shortage and this is one practice that could change to save the available bags of saline. 

Lynn

 1 A

2 A: Yes, B: Yes, C: Yes, we use the same tubing, the same tubing can be used for incompatible infusions so long as the tubing is flushed between infusions, it makes no difference if it's the primary or secondary being flushed to make it ready for another medication

3 A: No, C: 96 hours

4 A: When appropriate, yes.  B: 15 ml/hr  C: No order is requried since the purpose of a TKO infusion is as device maintenance, which means it's not considered a medication infusion, the rate is determined by facility policy.

 Then your facility has chosen to limit the number of injection ports on the sets provided. Sets are made with 1, 2, 3 injection ports. Lynn

 There usually is only one injection port above the pump cassette. But there are other injection sites below the pump cassette and these could be used for piggybacking when all drugs could not be given through the one port above the cassette. This would mean that the drug would infuse by gravity rather than going through the pump - a set up that has been used extensively in the past. I think we have gone way too crazy to give everything through a pump when it is not required.

When a basic administration set is used and connected directly to the primary line below the pump or attached directly to the catheter hub without a pump, there is only a very small amount of drug left in the set. It is the pump tubing that allows the large portion of drug to remain in the set and not be delivered. This is the way we gave drugs for many, many years. I know I am dating myself, but it is time to re-evaluate our practices with the severe shortage of NS that is predicted to continue for the remainder of this year. Drugs can be given safely without a pump or carrier fluids and without wasting a large amount of the dose but it does require more nursing attention to when the drug has finished infusing. 

The only way to avoid the blood reflux that would occur when direct infusion by gravity is used would be to use one of 2 brands of needleless connectors that function by pressure - Nexus TKO and ICU Medical's Neutron. Both of those have a silicone disc with a slit valve that automatically closes when the infusion pressure is gone. When the IV set holds a column of fluid about 10 inches in the set, the infusion pressure is gone and the slit valve closes. These are the only 2 brands that function in this manner. 

Lynn

 There are just too many safety and other benefits associated with pumps to make any sort of case for going back to not use them as basically standard practice in the hospital setting.  This leaves us with one port for secondary infusions, which really isn't a problem.  I really don't see the rationale in why only a portion of the tubing can be flushed between infusions to make it ready for a medication incompatible to the previous one.  Once connected, the primary and secondary set become a continuous, branching lumen, there is no reason to believe that what works for one portion of that lumen won't work for another.

I see an annoying trend here of challenging Lynn.  While she is obviously well able to speak for herself and endlessly patient, it bothers me to see this forum warp from a great resource for practitioners to a platform for personal vendetta and arguing over minutia.  I have to wonder if the purpose is a genuine pursuit of knowledge?  

There are many applications for gravity infusion and as dollars tighten we will need to be adaptable.  Not every facility can afford a large inventory of pumps.  I've worked in a great hospital that ran antibiotics less than 100ml by gravity per policy and it worked just fine.  When more than one antibiotic was ordered that same facility used one tko primary carrier fluid and one secondary tubing backflushed between antibiotics.  This hospital had a strong nursing education department, practice was consistent across the facility.

 Thanks for your support from JIll and Kristine. I am an old warhorse with thick skin, but sometimes it does seem like posts border on being rude or at least edgy. And sometimes when messages continue, I will stop adding to the conversation. As an educator, my posts will always pose alternatives and ask questions. My point in this discussion was to highlight the severe shortage of IV fluids, especially NS, which could require us all to analyze and change the ways we are now infusing piggyback meds. This shortage is not expected to be gone any time soon. With 42 years of infusion experience, I have seen many successful methods for giving meds and some not so successful. The basic principle for engineering any infusion system is to A) minimize manipulation of all connections and injection ports to as few as possible, B) while at the same time maximizing the patient's ability to be disconnected from infusion when fluid/meds are not required to facilitate movement/ambulation and work toward discharge,  C) prevent contact between incompatible medications, and D) allow for the correct level of rate control based on the fluid/meds and patient circumstances. That is a lot to consider but I believe that all are required. Lynn

 I would hope there's a general agreement that everything we do should be subject to critical thinking, everything we do should have some sort of rationale behind it that withstands criticism, I do agree it's important to be critical of the idea rather than the person.

I'm not really clear on how other methods would save NS.  The NS shortage has been attributed to the winter flu season, so it is likely to improve in the near future and already has to some degree.  Using a primary line only would still require NS to prime and flush given the amount of fluid that typically needs to be wasted to properly prime a line with today's valved ports, it seems like that would actually require more NS than using a primary/secondary set up since you'd have to remove the NS bag used for priming at which point it can't be used for the next dose.

 The shortage if IV fluids is much much more than the flu season although that was one excuse given by one company. One plant was stopped completely and that volume had to be absorbed by the othe 2. This will continue for the rest of this year. Lynn