Reply To: PCA, tacrolimus drip, TPN tubing

  • Katherine Terry

    January 24, 2023 at 11:04 pm

    Hi Katelyn! I transitioned from our BMT specific unit to the PICU where I still often take care of BMT kiddos. Both units use different setups due to the nature of level of care. On BMT the standard we used was a “daisy chain” of Y-sites with the PCA being last and closest to the patient. If there was no PCA then the lipids would be last. In the PICU we use manifolds so the set up is a little different, but lipids are still attached to a separate Y-site (not on the manifold) that is closest to the patient, while the PCA can be attached to the manifold. In the BMT set up the tacro (or CSA) drip would be next-closest, meaning it would come directly after the lipid Y-site (coming from the patient). In the PICU the tacro is simply attached to the manifold (considering compatibility with other non-BMT typical drips) or placed in a separate PIV on its own (not the other lumen of the central line so as to not contaminate). 
    I’ve had several discussions with both the PICU and BMT pharmacists that I’ve worked with about this very subject. Their council is that in regards to tacro, as long as whatever carrier it is being run with (e.g. TPN, NS, LR, etc.) is being infused at a faster rate than the tacro drip itself, the location of the tacro line port (microclave/Y-site/max-zero/etc.) does not matter because the carrier will always carry it in at the same rate regardless of location. So, even if something is bolused accidentally it will still not infuse any faster than the carrier is carrying it in. It’s a little easier to picture with a manifold because the carrier is at the top while the additional ports are on either side, so the infusions coming from the sides are being immediately mixed and carried with the carrier. The same concept is true with “daisy-chaining” and/or using several Y-site. 
    I hope this helped!

    Katherine Terry, MSN,RN
    Houston, TX
    United States
    Original Message:
    Sent: 01-23-2023 02:41 PM
    From: Katelyn Wilding
    Subject: PCA, tacrolimus drip, TPN tubing

    Hello! Through our practice council, we standardize our IV tubing set ups. I have encountered several different opinions about how best to connect PCA, tacrolimus drip, and TPN/lipids. I would love to know how this is done at other hospitals?

    Currently, we have a lipid “y” connector with reflux valve that goes to patient first. PCA tubing with reflux valve is then connected to lipid “y” connector. Last, tacrolimus is attached to port on the other end of PCA tubing. The benefit of this is prevention of accidental narcotic bolusing when there are occlusions, and prevention of lipid infiltrating the rest of the tubing system (we change lipid tubing and microclave q24hours). However, a lot of nurses are hesitant to connect tacrolimus drip so far from the patient.

    Thank you!

    Katelyn Wilding, RN
    St Petersburg, FL
    United States