I am looking for thoughts on best practice for hanging chemotherapy. We have had numerous discussions on whether it is best to hang chemotherapy agents on primary tubing or as an IVPB on secondary tubing. There seems to be pros and cons to both. It is our practice to hang most chemo agents long-lined into our control bag (NSS or D5W based on compatability) and connected with our phaSeal adapter. The other discussion has been with some to hang the chemo agent on a secondary tubing with only the control bag being on primary tubing. I cannot find evidence for either method being Best.
Pros to Long-lining
- Ability for control fluids to infuse simultaneously with chemo especially if it is an irritant
- Immediate disconnection of chemo in case of rxn
- Minimal risk of backflow into primary solution
Cons to Long-lining
- Inability to infuse remaining 10 ml of chemo without opening system, removing chemo bag, & hanging flush
- Weight of tubings at peripheral IV site
Thoughts?
One other point that has been discussed is related to the medication order being written as Continuous Infusion vs IVPB. My understanding is that the order for IVPB identifies the intermittent rate of infusion not the type of tubing used to administer the medication, correct?
Nancy Moran, BSN, RN, CRNI, OCN
IVPB does not indicate a flow rate of any kind. It only means IV piggyback. A specific rate would have to be included in the order if the LIP wanted to specify it. Rates are determined by the drug and placed on the pharmacy label. IVPB does not even indicate the type of administration set to be used. It could be a short secondary set or you could use a regular long set piggybacked at a lower injection port. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I am no sure I understand all of your post including abbreviations - rxn?
I would prefer to have a primary continuous infusion of plain fluids to initiate the IV, both peripheral and CVAD. This allows a thorough assessment of the functionality of the catheter and vein, checking for blood return, flow characteristics etc. Are you using an infusion pump or gravity flow? Peripheral infusion of vesicant should be by gravity to assess quality of fluid flow.
All medications would be piggybacked into this primary set. The primary set would contain medication that must be infused and the primary fluid would serve that purpose. If gravity, the backcheck valve in the upper part of the set would allow the primary fluid to resume when the piggyback is finished. If pump, you would program in rates for both infusions according to the directions and capablity of that pump. The pump set would hold more residual drug than a gravity set and would also require fluid flow to deliver to patient. If the medication were the primary line, there would always be drug left above the piggyback injection port that could not be delivered without adding a new fluid bag to that set - a waste of time and resources in my opinion. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Several considerations for chemo tubing set-up . . . it seems the simpler the set-up, the less risk for error. Nurses are very familiar with secondary short tubing and the set up. We do all of our chemo short or continuous infusions this way, UNLESS it requires non-PVC tubing which we only have as a primary set. Your comments make me wonder if your IV room is priming your tubing prior to adding the chemo. We appreciate the IV room doing this for us, both for secondary sets and the non-PVC primary sets. One of the considerations I would add to your list is how easy it is to backprime AFTER the infusion to clear the connection for discontinuation, which is one of the work practice controls we use. Another consideration is your IV pump. Where I used to work, we could concurrently run a secondary and a primary line in the same cassette. Where I work now, it's all physics and the pump channel just pulls whatever is under more pressure above the channel. Something else I think about is if there is a continuous fluid infusion order, say 100 ml/hr, can it be halted while I infuse a 500 ml chemo bag in an hour. I dare say the answer is yes most of the time. If the answer is no, and if we only had one lumen to infuse through, I would get another primary tubing set up with saline or D5 and still piggyback the chemo. Then the primary tubing with chemo on its secondary line could be Y sited closest to the patient into the fluid infusion primary. I just think the drug loss in a primary IV tubing when you're infusing a 50 mL bag is too great with no good way to flush it through without greater risk of exposure to nurses. Chemo does get complex. We have had to run 4 channels on some patients because of all the pre-meds, continuous infusions, incompatibilities, etc.
If you like, please reach out to me and I can get you in contact with an Oncology practice that utilizes IVPB for Chemo delivery.
Dan Izzo
Daniel Izzo, RN
Director of Clinical Support
Integrated Medical Systems, Inc.