Hi there,
2 questions:
1) What is the proper way for flushing and checking the patency of a line? Do we flush forward first before aspirating or do we aspirate first?
2) What is the proper way for "popping the seal" on a NS / Heparin syringe? Do we pull down on the plunger or do we push forward with the cap on? Some say that pulling down on the plunger is pulling down into a contaminated area. Is there evidence based practice for this?
Thanks
Donna
Hi Donna,
Checking the patency of the line is aspirating of blood as long as you see (you can check one of the forum here). Either you can see it on the external lumen of the CVC OR EXTENSION PORT. No need to bring up the blood up the syringe. Some CVC have opaque external lumen, so it is advisable to have transparent needleless connector (Eg. BD Q-syte, etc).
According to BD Posiflow Pre-filled syringe, to break the seal of the Prefilled syringe, just push the plunger without opening the cap. In short, just put a little pressure on pushing your plunger and you will hear clicking sound. Once the seal is broken, rotate the cap a little without removing the cap and expel the air. Now you are ready for access.
I hope you gain information from this. Thank you. Happy New year.
Maan, Nurse Educator
What is the national benchmark for CLABSI rate?
Hi Donna,
Checking the patency of the line is aspirating of blood as long as you see (you can check one of the forum here). Either you can see it on the external lumen of the CVC OR EXTENSION PORT. No need to bring up the blood up the syringe. Some CVC have opaque external lumen, so it is advisable to have transparent needleless connector (Eg. BD Q-syte, etc).
According to BD Posiflow Pre-filled syringe, to break the seal of the Prefilled syringe, just push the plunger without opening the cap. In short, just put a little pressure on pushing your plunger and you will hear clicking sound. Once the seal is broken, rotate the cap a little without removing the cap and expel the air. Now you are ready for access.
I hope you gain information from this. Thank you. Happy New year.
Maan, Nurse Educator
What is the national benchmark for CLABSI rate?
Dear Donna,
1.Just to share with you the correct flushing steps
S - Saline ( First check the patency of the lumen by aspirating and check for the positive backflow in the lumen or needleless connector) then flush.
A - Administer Medication.
S - Saline to flush the lumen.
2.According to manufacturer's instruction
a.Prior to using syringe break loose the syringe plunger by pushing firmly on thumb press with the cap still on,until you feel the plunger move.
b.Expel air and access solution by twisting off tipcap and pushing plunger forward.Use syringe to prime / flush vascular access device following institution policy.
There is no single method for flushing any catheter. You could push forward first to assess for resistance, then aspirate for a blood return. Or you could aspirate first, then flush. RE popping the seal on any prefilled syringe - always follow the specific instructions for each brand as they could be different. RE pulling the plunger into a "contaminated area", here is the concern about that issue. Prefilled syringes can either be filled in an aseptic or clean method or they can be terminally sterilzed. Aseptic filling is the same as what your pharmacy would do - fill syringes that are internally sterile with sterile fluid in a laminar air flow workbench, then put them in a cellophane overwrap. Terminally sterile means that the sterile syringe is filled with sterile fluid, then sterilized again after filling, then packaged in the cellophane overwrap. This overwrap is not sufficient to maintain the complete sterility of the inside and outside of the syringe. It is merely a dust cover. The fluid pathway is sterile - any place where there is fluid inside the syringe. There will always be a small segment of the inner syringe barrel that is not inside the fluid pathway. This area was sterilized initially however the dust cover overwrap will not guarantee sterility of this small segment. I would still consider it to be clean, and it is no longer considered to be still sterile, but I would not label it as "contaminated". And due to this simple cellophane overwrap, the manufacturer can not state that this segment is sterile. Based on this, many nurses prefer to push some of the saline in first, then aspirate so that you do not withdraw the syringe plunger beyond its original position inside the syringe barrel. Please note that a prefilled syringe that is completely sterile is inside a tough tyvek package that maintains the sterility of the entire syringe and can be dropped onto a sterile field. Do not be confused between this type of sterile prefilled syringe and the language used to label the regular ones as "terminally sterile". This just means that at the end of the filling process they have been through a sterilization process that meets FDA requirements and I consider a terminally sterile prefilled syringe to be a safer product that an aseptically filled syringe. In my opinion, you must know which type you are actually using. You can read more about this in an article I wrote a few years ago. Go to my website to download it:
www.hadawayassociates.com/Misuse_of_Prefilled_copy.pdf
Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you all for your wonderful replies. It's getting so confusing because different facilities seem to do different things. My goal is to achieve best practice but my main concern is patient safety first.
What I question now is "clean" vs "sterile". I have worked with the sterile packages of NS and the ones with the 'dust covers' ... love the terminology. My question is, "Is pulling back into a 'clean' area safe enough to say no bacteria exists in that area?"
The other question has to do with the INS Standards in section #45 Flushing and Locking. Under the Practice Criteria letter E it states, "The nurse should aspirate the catheter for blood return as a component of assessing catheter function prior to administration of medications and solutions." I do not see anywhere else in the INS standards where it states anything differently about flushing. This section is repeated in the TPN section as well. So, the question here is, "Is this telling me I should not attempt to flush first before aspirating?" .... NS is a solution, correct? Why doesn't the standards tell me I can flush first?
Thanks again, this forum is so very helpful,
Donna
Donna Lussier
RE your first question - you will need to direct that question to the manufacturer of your brand of prefilled syringes. You did not state if you are using one that is aseptically filled or one that is terminally sterile. So only the manufacturer should address that issue.
Standards of Practice are not written to be the same as a procedure. There is no evidence to dictate that the flush or the aspiration must be done first. That same statement about aspiration appears in the standard on flushing and locking, and parenteral medication and solution. Yes NS is a solution, however it is not one that will produce any tissue damage if it does leak out of the vein. And the relatively small amount of 1-3 mLs or so that would be flushed in before the aspiration will not produce any concern for compartment syndrome. So in my opinion, it does not really matter if you flush or aspirate first. The key is that you are meeting no resistance when you flush and that you can obtain a blood return that is the same color and consistency of whole blood. Focus on those primary components of this process instead of requiring such a prescriptive approach to the exact sequence of this total VAD assessment. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861