Reply To: HD MTX completion

  • Jennifer Nordin

    November 14, 2019 at 7:54 am

    We’ve had these timing issues forever, with the same amount of effort. Do you use alaris pumps? We did an experiment with saline on the pump and found variables with the same rate over time. Alaris says the only way to ensure perfect timing is to make sure the pump is always at a certain level with the patient, and ensure the patient never moves? We all know how easy that is in peds. We haven’t had extreme issues lately, but titrate regularly.


    Jenny Nordin, RN, BSN, CPHON

    Children’s Mercy Hospital

    Co-Education Coordinator Hem/ Onc/ BMT/ GI

    P: 816-802-1267 F: 816-302-9988


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    ——Original Message——

    We used to weigh our bags of HD MTX + bicarb fluids (we called them big berthas) and we had a relatively small number of issues when weighing.  We also had an order that we could increase or decrease rate by 20% in order to get it to complete in time.  We had to do some adjusting at times, but not much.  When our pharmacists found out we were weighing the bags, they made us stop and we have had nothing but trouble since getting it to finish in 23.5 hours. For 2 years we have been titrating the 24 MTX bags to get them to complete–many titrations–too many. Had to make a change. 

    Now, our new process for administering HD MTX for the 24 hour infusion is that the 30 min loading dose is sent in a syringe if < 50 mls which is great, no issues.  Then the 23.5 portion is sent in primary tubing, circle primed with drug in the pharmacy, to be bifused with the sodium bicarb fluids.  We set the pump for 30mls less to account for the tubing so that we can insert the flush into the side port of the set, add the 30mls flush VTBI and it should be done in the prescribed amount of time…only it never is. Pharmacy says they are sending the exact amount of volume and calculate the rate for that total volume for 24 hours. The bicarb runs fine, but we always have to increase the rate of the MTX to get it to finish.  

    We also do this for 4 hour HD MTX. Same process.  The bicarb will finish in 4 hours, the MTX has volume left in bag.  

    Has anyone else had this experience?  We can’t figure out what is wrong.  

    Any help/ideas would be appreciated.

    Kelly Horn, MSN, RN, CPON
    Nursing Professional Development
    McLane Children’s Baylor Scott & White Health
    Temple, TX 76502