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Difficulty: Very hardPharmacological and Parenteral Therapies

An adult client in the intensive care unit is being treated for severe sepsis and metabolic acidosis. The client has a triple-lumen central venous catheter (CVC) in the right internal jugular vein. The current continuous intravenous (IV) infusions are as follows:

• Proximal port: 0.45%0.45\% sodium chloride with 150 mEq150\text{ mEq} of sodium bicarbonate infusing at 150 mL/hr150\text{ mL/hr}.
• Medial port: Epinephrine infusing at 0.05 mcg/kg/min0.05\text{ mcg/kg/min} for blood pressure support.
• Distal port: Total parenteral nutrition (TPN) infusing at 75 mL/hr75\text{ mL/hr}.

The client's morning laboratory results indicate an ionized calcium level of 0.85 mmol/L0.85\text{ mmol/L} (normal: 1.05-1.30 mmol/L1.05\text{-}1.30\text{ mmol/L}). The healthcare provider prescribes 1 g1\text{ g} of intravenous calcium gluconate to be administered over 15 minutes. Which action by the nurse is the most appropriate?

  1. Establish a new peripheral intravenous catheter to administer the calcium gluconate.Answer
  2. B
    Connect the calcium gluconate to the Y-site of the proximal port while the sodium bicarbonate is infusing.
  3. C
    Pause the epinephrine infusion on the medial port, infuse the calcium gluconate over 15 minutes, and resume the epinephrine.
  4. D
    Administer the calcium gluconate through the Y-site of the distal port along with the total parenteral nutrition (TPN).

Answer

The correct action is to establish a new peripheral intravenous catheter to administer the calcium gluconate.
The correct action is to establish a new peripheral intravenous (IV) catheter. The central line is currently fully utilized with incompatible or life-sustaining continuous infusions. Sodium bicarbonate precipitates with calcium, epinephrine cannot be paused without causing hemodynamic instability, and TPN requires a dedicated line. Calcium gluconate is safe to administer via a peripheral line, unlike calcium chloride which strictly requires central access.

Step-by-Step Solution

1
Analyze the proximal port utilizing sodium bicarbonate.
Determined that calcium and sodium bicarbonate are highly incompatible.
Mixing them forms an insoluble calcium carbonate precipitate (chalk) that can cause a fatal pulmonary embolism.
2
Analyze the medial port utilizing epinephrine.
Determined that the epinephrine infusion cannot be interrupted.
Epinephrine is a life-sustaining vasoactive medication; pausing it for 15 minutes would lead to acute cardiovascular collapse.
3
Analyze the distal port utilizing TPN.
Determined that the TPN line cannot be used.
TPN requires a strictly dedicated line due to the high risk of infection and potential for precipitation with the calcium (due to phosphates in TPN).
4
Evaluate alternative administration routes.
Conclude that starting a new peripheral IV is the safest and only viable action.
Unlike calcium chloride, which is a severe vesicant requiring a central line, calcium gluconate is safe to administer via a peripheral intravenous catheter.

Key Concept

Safe administration of parenteral therapies requires strict adherence to drug compatibility, maintenance of dedicated lines for TPN, and continuous infusion of life-sustaining vasoactive medications.
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Topics

Pharmacological and Parenteral Therapies

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