Forum topic

What is the osmolarity of sterile water versus 0.9% sodum chloride.  This is very hypo-osmolar and with multiple flushes what does this do to the patient?  Sterile water is generally used as an admixture to hyperosmolar drugs to bring down the osmolarity of the drug (especially in children). What is the rationale for using sterile water as a flush?  I would review the safety with a pharmacist for use as a catheter flush versus 0.9% normal saline which is isotonic.

Kathy Kokotis RN BS MBA

Bard Access Systems

Simply put this behavior is completely unacceptable and the nurses engaging in it need immediate education!
Flushing intravascular devices with sterile water causes RBC destruction. In a very real sense this equates to intentionally harming a patient. All nurses should be familiar with the concepts of fluid tonicity.
Anita, as a licensed health care professional you have a ethical, and possibly even a legal responsibility, to bring this irresponsible behavior to the attention of the appropriate leaders at your facility.

This is a dangerous practice for many reasons. I also agree that it needs immediate attention to educate this staff about the risks. The reasons are:

1. sterile water is exrtremely hypotonic. When injected it will cause an osmotic fluid shift resulting in excessive water being pulled into the endothelial cells of the vein wall near the injection and all other cells in the bloodstream. This fluid shift causes these cells to swell, burst, and die. Disruption of the endothelial cells exposes the basement membrane in the vein wall allowing blood to come into contact with it. This immediately begins the clotting process. So your rates of phlebitis and superficial thrombophlebitis are probably much greater than they should be for short peripheral catheters. For all central venous catheters, this risk may be minimal due to the rapid blood flow at the catheter tip, but it can still damage blood cells. Plain sterile water should never be administered IV for any reason, ever!

2. Are they drawing this up from a multiple dose vial made available from the pharmacy through floor stock? If so, I would work with pharmacy to take a serious look at having these multiple dose vials made available to the staff on all units. Why is this so readily available, for what other purposes, are they legitimate, how can you change this situation to make it safer for patients?

3. Multiple dose vials are never recommended any longer for any catheter flushing procedure due to the the high risk of infection transmission between patients. This has been extremely well documented to occur when these vials are used incorrectly with a contaminated syringe being reconnected to the vial for drawing up additional amounts of fluid needed. CDC, ISMP, Joint Commission, and INS all now state that use of multiple dose vials should be eliminated in favor of only single dose systems which include single dose vials or prefilled syringes. If one is forced to use a multiple dose vial on the nursing unit, it must be dedicated to a single patient only.

Have you investigated why they had changed this practice away from the available prefilled syringes over to having to draw up their own solution? This does not make any sense. Prefilled syringes for catheter flushing are much more cost effective than using valuable nursing time to fill syringes. I would be very curious to know their rationale for why this change occurred. After learning their motivation, you can target your educational response to address that specific issue along with the other issues. But this does require immediate attention. Nurses can be very creative in order to get the job done. While we do not want to discourage this creativity when it is needed, they also must know that policies and procedures are established through appropriate processes and can only be changed by going through those appropriate processes. Policies should always be considered nonnegotiable and nonmodifiable. Nurses, patients, physicians, no one can unilaterally alter a policy without going back to the appropriate committees. This would be a huge red flag during any Joint Commission inspection.

Hope this information helps to get them to change back to the safer prefilled syringes. Also please let us know why they changed to the sterile water in the first place. Thanks, Lynn