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Difficulty: Very hardPharmacological and Parenteral Therapies

A critically ill adult client in the intensive care unit has a triple-lumen central venous catheter. The client is receiving continuous intravenous infusions of total parenteral nutrition (TPN) via the distal lumen, propofol via the medial lumen, and norepinephrine via the proximal lumen. The client's mean arterial pressure acutely drops to 45 mm Hg45\text{ mm Hg}. The healthcare provider prescribes a stat 500 mL500\text{ mL} bolus of 0.9%0.9\% sodium chloride and the initiation of a continuous vasopressin infusion. Which of the following is the most appropriate nursing action?

  1. A
    Administer the sodium chloride bolus through the proximal lumen to expedite fluid resuscitation, and Y-site the vasopressin into the medial lumen.
  2. B
    Pause the TPN infusion temporarily, administer the sodium chloride bolus through the distal lumen, and Y-site the vasopressin with the norepinephrine.
  3. Y-site the vasopressin infusion into the proximal lumen with the norepinephrine, and establish a new peripheral intravenous catheter for the sodium chloride bolus.Answer
  4. D
    Connect the sodium chloride bolus and vasopressin to the medial lumen to infuse concurrently with the propofol.

Answer

The most appropriate action is to Y-site the vasopressin infusion into the proximal lumen with the norepinephrine, and establish a new peripheral intravenous catheter for the sodium chloride bolus.
The correct action is to establish a new peripheral IV for the fluid bolus and Y-site the vasopressin with the norepinephrine. Vasopressin and norepinephrine are compatible and commonly infused together. A rapid fluid bolus must never be administered through a lumen that is infusing continuous vasoactive or sedative medications (such as norepinephrine or propofol) because the bolus will rapidly flush the medication remaining in the catheter's dead space into the client, potentially causing a fatal overdose. Additionally, the TPN line must remain dedicated.

Step-by-Step Solution

1
Evaluate the safety of using the proximal lumen (norepinephrine) for a fluid bolus.
Ruled out because flushing a vasoactive line will deliver a dangerous bolus of the pressor.
Norepinephrine is highly concentrated; rapid flushing of the dead space can cause a severe hypertensive crisis.
2
Evaluate the safety of using the medial lumen (propofol) for a fluid bolus.
Ruled out because flushing a sedative line will deliver a dangerous bolus of the sedative.
Propofol causes respiratory depression and hypotension; rapid flushing can lead to apnea and cardiovascular collapse.
3
Evaluate the safety of using the distal lumen (TPN) for a fluid bolus.
Ruled out because TPN lines must remain dedicated.
Using the TPN line increases infection risk, introduces incompatibilities, and pausing TPN abruptly can cause severe rebound hypoglycemia.
4
Determine the appropriate access for the vasopressin and the sodium chloride bolus.
Y-site vasopressin with norepinephrine, and place a new peripheral IV for the fluid bolus.
Vasopressin and norepinephrine are compatible. A new peripheral line is required to safely administer a rapid fluid bolus without flushing active medications from dead space.

Key Concept

Safe administration of parenteral fluids and vasoactive medications via central venous catheters, specifically avoiding the rapid flushing of dead space containing continuous critical infusions.
Estimated Time:2m 0s
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Topics

Pharmacological and Parenteral Therapies

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