Hi all. I am in search of some proof that meds outside the 5-9 pH range need to be administered centrally. I am getting some push-back from a couple of doctors who Want to order a piv or midline. Any help would be appreciated...articles,, research, etc. Thanks!
Have the physicians read the manufacturers insert. I know that INS states the 5-9 pH rule for mid lines, the insert also states this. My understanding is if you use the line for other than what is stated you are legally liable. At the institution I work at we use all Bard catheters and follow the manufacturers directions. Our physicians wanted to use midlines and extended dwell catheters in this way also. I referred them to INS and manufacturer's recommendations along with the rational behind the guidelines and they were very receptive and are presently working with pharmacy to see if diluting some of these Meds would be effective. Hopefully, a solution to satisfy the physicians and PICC/IV nurses occurs. I hope this helps a little!
I think you'll have a hard time maintaining this position. It's a pretty absolute statement. To say that all medications falling outside the 5-9 pH range require central access is not necessarily true. First of all I have never seen this statement in print anywhere. Many guidelines recommend central access for continuous infusion of vesicants, but not necessarily intermittent or one-time. Also several factors contribute to whether a medication is classified as a vesicant, pH being only one of them. In fact if you read the article in Jan/Feb INS this year by Gorski, et al, "Intermittently delivered IV medication and pH: Reevaluating the evidence," you'll see that pH may not play as large a role as it was once thought to play. In my humble opinion, vascular access device selection should remain a patient-based decision involving multiple factors including patient condition, medication regimen, duration of treatment and resource availability, among other things. Your policy should address the whole patient picture, not just the chemical profile of the drug.
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
Keith is correct. The literature review article he mentioned will result in some changes in the INS standards. I cannot tell you what those changes will be at this time. But pH is not the sole factor in deciding on the most appropriate VAD for your patient. The current standard is not an absolute statement either. It says that drugs with pH above 9 or below 5 should not be infused through peripheral veins, but this is not the same weight as a "shall" statement. 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
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there are infusates falling well within the 5-9 pH range that are known irritants.
The concept of medications with a pH between 5 and 9 being irritants is no longer supported in the literature. We have to change our thinking on this issue. The single factor of a pH below 5 or above 9 as the only one to drive any CVAD insertion is not appropriate. There is no evidence about an increased risk of vein irritation with these drugs. There are many other factors that must be considered in this clinical decision. Given these factors, high or low pH could contribute to the need for a CVAD but pH as the sole factor is not sufficient to choose a CVAD. The risk with high or low pH is related to tissue injury if there is an infiltration/extravasation and these wide variations in pH could increase the tissue injury. 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