Let’s say you have a patient that comes up from the ED on norepinephrine at 20 mcg/kg/min running through a peripheral line. They’ve been at 20 for the past 90 minutes with a stable map >65. No A-line yet. The ED team started a central line, but didn’t switch the line and you receive the patient with the norepinephrine running peripherally.
How do you go about switching it to the central line without causing your patient to have a MASSIVE drop in their pressure?
Asking for a friend. This did not happen to me. 😉
New bag to central, titrate up on that and down on the piv. Ideally with an a-line.
👆🏻👆🏻👆🏻what they said. And technically you should be changing to new bags/lines anyway with a new central line placement.
OMG as an ED nurse it NEVER occurred to me to hang a new bag. D’oh!
General policy, at least in the ICUs I've worked in, is that you never move a set of IV tubing from a peripheral to a central line, as the peripheral has less stringent infection control practices compared to the treatment of a central line. If a central line is put in place, you must spike an entirely new set of tubing with fresh bags for any drips you want to continue running.
Do you give a little “bolus” to prime the line? Or do you gradually titrate up on the central line until you see a rise in MAP and then gradually titrate down on the peripheral?
I wouldn’t. I made the mistake of that once when I heard about it when I was a newer icu nurse and my patients BP spiked up to like 250…idk how that could be safely done TBH and it was a big mistake that I tried lol. better to go gradually. Let’s use your example with Levo at 20. I would keep the PIV Levo at 20, start the central line Levo at like 10. Wait for an increase in BP, cut PIV Levo to 10, wait for things to level out, bump up central line to 20, wait for increase, then turn PIV Levo off. And try and aspirate what you can from the PIV once the BP is stable before you flush the line. A lot of this stuff isn’t policy driven, I know it’s crazy but it’s truly just experience and vibes with some stuff lol. Titrating pressors feels like an art form to me or like a fun game. I miss it. Im in PACU now and occasionally I get a train wreck ICU waiting for a ln ICU bed to be ready, but mostly it’s having someone on like 50 of Neo and titrating down and then off once they wake up a little more 😂
You have to remember it only takes about 1-2 ml to prime a standard IJ. Don’t get all crazy with your priming!
Hah. At least that was levo and not adrenaline. Saw a nurse try and "prime" the central line with it once, HR went through the roof.
You can probably prime the tlc with the levophed if you know the lumen priming. You'd have to know the actual "model" of the tlc or look it up on a package. If it's like 0.59, just use a 3ml to draw up like 0.58 (same concept as packing a catheter with heparin or using tpa) and then switch it. At the same time if you are using the 16mg/250mL levo, which if @20mcg/min means its getting 0.31mL/min and using a catheter with lets say 0.59 would take somewhere just under 2 mins to reach patient and half life is 2.4mins... you can really just switch it without really worrying about it to be honest. Or set up 2 lines running at the same rate (20mcg/min) and just cut the peripheral off at like a one minute and 50 seconds IF you wanna be that particular
I’m an ED nurse…..I do NOT want to be that particular. 😂 I just don’t want my patient to die.
Priming volume on most CVCs is so small. Most triple PICCs are <0.5mL per lumen, which is saying a lot for how long they are even with an 18ga lumen. Unless you're priming a cordis it doesn't take a lot. Honestly I've seen some large bore saline locks that have more priming volume, can't recall the brand. We had some for a while that had like 3mL of priming volume which was crazy, some of our ED nurses couldn't comprehend that if you start propofol on 5mcg it'll take an hour to reach the patient.
No, because if any gets to them, it'll jack up their pressure to Cheech/Chong and it ain't worth it
I know because sometimes we'll stop the levo, and coworkers will leave it attached for a while onto an IV that doesn't draw, so you won't be able to draw from it, and have to do the world's slowest fucking flush, preferably out of a 3 cc syringe and with an aline, so u can make sure you're not overdoing it.
I don’t bolus or prime. I do the latter. Just start a new bag into the cvc at the lowest dose, then cycle the cuff q2-3 and once you have a little buffer on the MAP titrate up on the cvc bag and down on the piv bag. Itd be better with an aline but I wouldn’t delay the switch over for one unless you suspect the cuff is inaccurate.
📝
I’m ER switching to ICU next month so I’m like double 📝
In alignment with most of what everyone else is saying but a little more specific and quick. For the busy ER RN:
1- hang a new levo line and hook it up to the central line. 2-Draw back on the central line until you get blood so you can estimate how much volume is in the line. This way you don’t need to look up manufacturer specs if you don’t know. 3- draw some levo off the line in a syringe and prime the line with .1-.2 less mls than you think it needs. This avoids an unnecessary bolus to the patient. 4- start the levo centrally at the peripheral rate 5- ideally with an a line but at least every 3-5 min if only NIBP, once you see the bp come up, cut off the levo peripherally. (If doing it with NIBP I’ll usually just wait a few seconds and then cut the peripheral infusion in half and then off when I see the bp respond)
Note: as long as it is transient, a little hypertension or hypotension shouldn’t be too harmful to the patient. Depending on the patient one or the other may be less harmful so lean toward that.
Lean hypotension for- Hemorrhagic stroke, aortic aneurism Lean hypertension for- sepsis, hypovolemic shock
Fuck dude the draw back to estimate prime is god tier thinking. Definitely putting that in my toolbox
OOOOHHHH that drawing back on the central line is totally something I could do. LOVE this!
This pull back method is how we measure our prime volume for our Epoprostenol patients in CVICU. Excellent technique.
I’ve learned so much lmao
The best way is to get levo hanging on a second pump/channel. Hook it up to your central line start it and wait a good 30 seconds and then shut off the peripheral Levo. If you've got an A. Line, instead of waiting 30 seconds wait until your BP starts to rise then shut off the peripheral Levo
Unless they are a hemorrhagic stroke or a triple A a little bit of transient hypertension is unlikely to be harmful. In those cases I'll just turn on the central level then immediately turn off the peripheral.
All these others titrating up and down on each other... This should be the top comment. Don't make it harder than it needs to be.
Agree with the titrating . Starting the Levo to the central line and titrating down on the peripheral.
Also I really love how ED and ICU nurses came together in this.
As others have said, start a new drip, which is preferred for central line hygiene, OR slow flush the PIV at the approx rate of the infusion.
Or just send it.
Just set up a mini manifold and start a carrier at like 40mL/hr. If they start to drop a little just flush the peripheral you were using. People telling you to start another line are crazy time wasters.
New bag to central line and discontinue the peripheral bag when the central line one is running.
Right but it’s more nuanced than that. One way to read this, you would leave the pt with no pressors for the time it takes the new Levo to clear out the saline from the lumen of the cvc. Some patients definitely can’t handle that, I’ve certainly had guys that drop precipitously if your pump alarms for infusion complete for a few seconds
Start new bag and new line. Wait till about 2-3ml of new pressor has infused, then turn off peripheral pressor. Cycle your BP frequently and maybe you have to titrate aggressively for the transition period.
When I was in med-surg we would just y-site the drip to a carrier at 50-100ml and shut off the peri. They will be alright.
This is what we would do in anesthesia land
Two options start new bag thru central and titrate them together to get the PIV off. Or you hook up central and “prime the line” with levo if you’re a cowboy.
Once the line is confirmed, hook up a second line. Some places I work allow for norepi boluses, so I would give one to flush the saline out of the line and get the infusion going, titrating down the peripheral line and up the central. It goes pretty quickly TBH. Depending on the patient and their diagnosis/reason for needing support I’d allow a bit of hypo or hyper tension as well for a moment or two as things settle.
I make a new bag with new IV tubing and let the first one run dry…<less than 30 min and the. Titriate the new iv on the central line. Most times unless my patient is crashing
I will run two bags simultaneously (one into the PIV, one into the central).
My personal practice is to run the central at the same rate as the peripheral. Once I see the BP start to rise - showing the central is now kicking in - then I will shut off the peripheral.
You can also simultaneously up/down titrate the two bags until the peripheral is off
Tangent. I saw 20 and was like whaaaaat???!! We do weight-based dosing.
I meant 20 mcg/kg/min
There’s no way that’s what you meant 😅 20 is mcg/min dosing. The “max” for weight based dosing is usually 1 mcg/kg/min anywhere I have worked.
Seriously how did I have to scroll down to the very last comment for anyone to mention that 20mcg/kg/min is not a real levo dose. That is 20x the max levo dose.
A CVICU nurse is probably your best source for advice
I’ve seen a few ways to do this
One I don’t recommend - give a “little push” of the pressor to cover them during the time the central access takes to infuse. Have seen massive spikes in BP relating to that, idk if that is truly high risk for stroke but I assume it’s not good.
Going with situation you described, there’s no a line so you can’t make super reliable micro adjustments and monitor beat by beat.
My pref if you have a minute -
Hang a new bag of Levo (technically it’s best practice to use all new tubing and lines for a new central line). Run the PIV levo AND the cvc levo at the same time. Cycle BP frequently. If you’re paying attention, they definitely won’t have a crazy spike in BP (to 240s or something) and you’ll definitely avoid hypotension. If you want, you can run the CVC levo slow at first so you see less impact of both running at once. Once the saline is cleared out of the cvc lumen and you can tell from BP that both are infusing, bump the cvc rate up to the intended rate and shut off PIV.
If you prime a new line and switch them out really quickly (same concentration no reprogramming) then they can usually deal with it just fine but if it matters have the CVL one hooked up ready to go, stop the PIV one, wait a couple seconds and start the CVL one.
Recommend keeping both running at the same time if they are on more than a whiff of Levo. Momentary hypotension shouldn’t be a major problem but some people definitely are pressor dependent and tank without it. Consider that a drip running at 20ml/hr will take 3 min to infuse 1ml — and it has to clear the saline in the lumen before the first drop reaches the patient
Prime a new bag, get a second pump and use it with the new bag. Then attach the new line to the central line so right when you detach the old line you can immediately restart the levo through the central line. Alternatively you could also do it with just one pump but have phenyl ready in case you take too long to restart the levo.
New bag and prime a new line to attach to the central line. Possibly program another pump to immediate switch. If it’s going to tank them that quickly in switchover you probably need to get vaso on board too
Just a floor nurse here. Will their BP really take a massive hit in the <10 seconds to switch the line from the PIV to the CVC? Why not get a new bag of meds, make a new line set for the cvc-since you have to have new tubing anyway-press stop on the PIV then press start on the cvc?
The issue is that the levophed is running at a very slow ml/hour rate, so it would take several minutes for it to reach the patient when newly hooking it up to a central line bc the central line tubing is primed with NS, not levophed.
idk, the work arounds I’m reading here sound way too complicated. Couldn’t you just prime the line with levo instead of saline? Probably wouldn’t work if you needed multiple drips at once, but if we are talking just a levo drip is there a reason why this wouldn’t work?
You can, you just have to make sure not to push any levo in past priming the line, cause that could then cause a sharp raise in BP. One person in the comments mentioned to pull back on the central line til it’s all blood return so you know how much to prime it with levo than doing a little less than that, which I think is a great idea. My point was just that it’s just more complicated than just stopping one and starting one at the same time and takes some planning/thinking to successfully do it without creating a sharp decline or incline in BP
Y’all are wild. Bless u
To give you an example….my “friend” had a patient stable on levo, they switched from peripheral to central line (maybe 3 second delay) and the pressure went from ~100/70 to 55/35 in under 3 minutes because until that central line is primed with the levo the patient is getting NO PRESSURE SUPPORT.
Some patients, yes. 20 mcg/ min of Levo is a decent enough dose to potentially cause a significant drop in BP if there is a pause in the infusion.
I would prime a new bag and connect it to the central line. get that programmed and running then d/c the peripheral.
Just uptitrate the levo to get thru the line a little faster and once you see the MAP go up drop the dose to what it was before. Y'all over complicate this shit too much with starting two bags of levo at once
I would just have a new bag ready to go and programmed at 20 mcg/min. Connect it to the central like on admission and trash the peripheral IV.
I personally hate PIV pressors. My unit has a policy that we have to check for patency and blood return hourly if they have peripheral pressors. If not, we need a new line ASAP
If it’s running high what we typically do once they get a central line is get it max concentrated and then hook it up to the central line leaving the one on the peripheral going and titrate to get the started con off. It’s kinda a pain in the ass but you are not going to be running through hella bags. Had a patient one time on CRRT and they refused a central line and was going through a bag of levo like every 45 minutes
Get all new tubing (gtt and an NS driver). I personally start the new gtts on a new pump (you can do it on extra channels on the old pump, but then you have to override the be alarms and that’s annoying). If you don’t have a driver on the PIV, I will usually cut the rate in half and start it at the same on the CVC. One their pressure is stable there, I turn off the NE in the PIV and titrate up on the CVC and then either draw back like 5 ml blood and flush the PIV or change out the extension and flush (slowly, even though it’s only a tiny bit).
If they do have a driver in the PIV NE, I titrate that off while titrating up on the NE in the CVC, instead of in big jumps. Because then the NS is clearing the line and I don’t have to worry about the whole changing the extension tubing or accidentally pushing a bolus thing.
I try to err on the side of a little hypotension, rather than hypertension.