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Old 05-22-2007, 04:10 PM #1
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Default Alan's IVIG bag had a hole in it!!!!!1

Right now, the visiting nurse is in my kitchen jerry rigging a new bag to hang on the IV pole.

When she came in, I gaver her the bag of Gamma and when she tried to connect everything, she said 'UH OH, IT'S LEAKING". And she has never had this happen before. I gave her some strong tape, she tried taping and sealing it but when she turned it over, it leaked again.

So she went out to her car, got a bag of Saline Solution. She is standing over my kitchen sink draining the saline bag, then she will infuse the bag with the Gamma from the leaky bag and HOPEFULLY, ALAN CAN GET HIS 9th infusion. He had 5 in the hospital, two at home last month, and today is the second of two days. So it's his 9th infusion.

They are laughing in the kitchen. I gave her a clean bowl for any excess and she is moving the solution from the original bag of Gamma into the (now empty) bag of saline solution.

Let's hope this works.

oh my!!!!

Melody
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Old 05-22-2007, 04:24 PM #2
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Default Melody!

IVIG needs to be mixed and poured into bags under completely sanitary conditions - was it the bag of IIVG that was leaking and shes putting into another bag????????? Dont want to alarm - but the last thing you want is any risk of contaminiation!
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Old 05-22-2007, 04:29 PM #3
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Exclamation Do not use if

sterility is compromised!

The infusion supplier should replace it. How did it start to leak? Around the tubing, what?

I agree with kmeb....do not use!
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Old 05-22-2007, 05:10 PM #4
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Default Important!

HAVE THE NURSE CALL THE PHARMACY NOW!
Do not pass go - just do it!
YOU DIAL SAY IT"S AN EMERGENCY AND MUST SPEAK TO A PHARMACIST!
It's obvious the nurse really doesn't know the protocol. The pharmacist WILL!
We all know you need ALAN, and thus we need you!
Please don't delay? PLEASE! - j
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Old 05-22-2007, 05:57 PM #5
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Shocked Oh, dear, gee whiz, Melody!

Melody:

Please let us all know how this emergency turned out. I am sure we all are alarmed about the infusion not being sterile. Worry, worry. Biting nails.

Shirley H.
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Old 05-22-2007, 06:47 PM #6
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Default

Okay, everybody calm down. Alan has about another hour to go in the infusion.

This nurse was marvelous. And she was sanitary in every single step she took.
She took a bag of saline out of her car (it was sterile). She then used all new sterile tubing.

She took out a brand new sterile (big) hypodermic thing).

She emptied out the saline bag and she took the gamma out of the leaky thing and she put all the solution into the (now empty) Saline Bag.

So in essence, she transferred from one sterile environment to another.

The funny thing was when we tried the tape (the leak was on the bottom of the bag (as it hangs from IV Pole), and when the leak wouldn't stop, she immediately turned it upside down so it stopped leaking (we didn't want to lose any of the Gamma).

So I said "why not use my glue gun and seal the leak and then we use the tape). She laughed and said "No, don't worry, while this has never happened before, I have a bag of Saline in my car, I'll just empty it and transfer the Gamm into it." And that's exactly what she did.

Then she cleaned up my kitchen counter and you would never know there were bags hanging from the cabinet and dripping into the sink.

So what happened afterward????

I fed her Teriyaki Chicken, my patatas, some brocolli and my muffins.

She was in heaven. She's inside right now talking with Alan. They are having a ball.

So this CRISIS turned out not to be a crisis.

Take care and thanks to all of you for being so nice.

Melody
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Old 05-22-2007, 06:59 PM #7
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Default Ivig

Please call the pharmacy and the doc - the pouring etc has to be done in a completely sterile envinronment - not a kitchen.... there are very strict regulations regarding this... in fact - a bag of IVIG should never be used at all if it has any hole or leak of any kind - but refused.... its Alans health we are worried about....

Last edited by BEGLET; 05-22-2007 at 09:17 PM. Reason: still cant type
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Old 05-22-2007, 09:18 PM #8
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Default IVIG, IV bag leaks

Melody

I am an RN...what she is doing is totally WRONG!!!! He can get septic from that..it is likely contaminated. I want you to call the nursing agency immediately and your physician as well.

I can't belive some RN would be that stupid. I am sorry to be so blunt but that is like using a dirty needle, even worse.

I am so mad!!!
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Old 05-22-2007, 09:28 PM #9
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Default

Mel

That bag was contaminated the second that it got a hole in it...that moment. Whatever caused the hole penetrated into the sterile fluid in that bag....it could be anything, and no antibodies in IVIG won't kill it....

She simply transferred contaminated IVIG, into a sterile bag, using sterile equipment...but that is no help...the contaminant is already in the fluid.

Alan will likely be OK, but this is horrible practice!! On the other hand, he could have staph or strep or e.coli or God knows what, in that bag...whatever was in the frig, or pharmacy, or vehicle, that the IV bag was sitting in before the leak was discovered....whatever was on her hands when she handled the bag. If you have the IV bag that leaked keep it. It could be what you need to track down a germ if Alan does get an infection. Septicemia is very dangerous.

This is utterly unacceptable. No nurse in her right mind would do this, no matter how nice she is, she risked a patient's life. I am even more peaved.

I did home care nursing for years, and this just blows my mind!!

IVIG is very expensive, however it is not worth saving costs over a patien'ts life...ever! I can not tell you how angry I am!!!
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Old 05-22-2007, 09:56 PM #10
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Default

Mel

I am still seething. Sterile procedure is one of the FIRST things nurses are taught. It is repeated over and over again thru out your education....then when you are hired, they go over it again...every nursing agency has a procedure and policy written regarding this...this is so elementary, it makes me wonder if your nurse is really a nurse. You are usually required by your employer to demonstrate sterile technique every year in a skills test.

This could not only cost her, and should cost her her nursing license, or at least her job. Her judgment is so poor, she needs to start all over...step 1 of training.

This could cost your home care provider their license or certification, certainly if the state or joint accreditation heard about this they would immediately discipline or fine the agency. It is THAT serious of a screw up.

Feel free to PM me for more info. For all of you....do not let any one ever stick a thing into you that is not sterile....no double picks with a needle....no leaking IV bags or tubes....Even a leaking tube requries dumping the bag, as stuff can travel upstream. Think of how many germs live on the head of a pin...

You should call the nursing agency's oncall number and you tell them what happened now...it needs to be written up....and you need a new nurse. I am sorry you are emotionally bonded with this person, and that is tough, but this action is so incredibly professionally obscene I won't sleep all night!!

Mel, you and Alan are the nicest people. This kind of stuff should not happen to you....It should not happen to any one. This is malpractice.
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