We are seeing different practices among the nurses regarding a continuous infusion through a cvad. I see info on this subject from 2009 and would just like to make sure the same info still stands today....
1. With a continuous infusion through a cvad, is it ever necessary to open the system to assess patency or to manually flush?
2. Incompatible medications: should a nurse open the system to manually flush between meds - or just through the pump?
3. Sometimes nurses infuse at a TKO rate to avoid the patency assessment and the flushing. If a continuous infusion is not necessary is it best to leave it as an intermittent?
Thanks very much
Andie
By "opening the system", do you mean disconnecting the IV administration set from the catheter hub or some other connection point, then attaching a syringe to the catheter hub and flushing? If so, this should NEVER be done, ever!! That technique is asking for a CRBSI. The system should never be opened until you are ready to change the IV set. Use an injection port closest to the catheter hub, attach the syringe, aspirate and flush. With incompatible meds, stop the fluid flow, attach the saline syringe to an injection port, flush, aspirate for blood return, inject the med, then flush with saline again and regulate the rate. There is no such thing as a TKO rate, meaning a rate that will majically keep the vein or catheter open and patent. Research has not established what that rate would be. Also INS standards says that any TKO or KVO rate is not a complete and legal order. The rate should be prescribed for the patient when they need the fluids. I think that a locked VAD is better for the patient as it allows easier movement and ambulation, meaning faster progress toward discharge. Any TKO or KVO rate will not eliminate the need for assessment of patency by a manual flush and aspiration for a blood return prior to giving a medication. All decisions about management of the IV sets and/or catheter hub should always be guided by what allows the least manipulation of the system and leaving the system closed until it must be opened to change the fluid container on the spike end and/or change the set at 96 hours for continuous fluids. Let us know if you meant something else by opening the system. 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
Thanks very much. Yes that is what I meant by opening the system. And thank you for that great explanation.
There does seem to be confusion on this topic. I think nurses often feel that if there is a continuous infusion that patency assessment and flushing are not required - or if they do flush it is through the pump.
Just so that I am clear - it sounds like the correct practice when there is a continuous infusion - no matter what rate is to assess patency and manually flush through the injection port closest to the CVAD hub?
Thanks very much for your help on this!
Any time you are flushing any IV system for any reason, it is never correct to open the system. I would also add that the degree of vigilance depends upon the type of fluids and medications being infused. If there are electrolytes in the fluids, esp high concentrations of K+ or calcium or bicarbonate, these are vesicants so a periodic check is a good idea. Problems with the infusion alarms, any and all patient complaints of discomfort should also drive a thorough site assessment which would include flushing and aspriation for a blood return. There are no standards for the frequency of assessment continuous infusions. There is a position statement on the INS website for assesing short peripheral catheters based on the type of infusion, patient age, and environment. The Standards of Practice states that site assessment is required prior to administering each medication. This statement does not limit this assessment to a specific type of catheter or medications - so all VADs, each and every dose of medication requires a blood return and no resistance to flushing. But there should not be a need to open the line for any reason.
If the continuous infusion is plain fluids without additives, patient has no complaints, pump is not alarming, and no other problems, there is no recommendation for frequency of checking patency through any type of catheter.
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
So Im confused, Say you have a pt on dobutamine, or milrinone q24 hours. These meds are vesicants ??? I wouldnt want to flush my dobutamine port every bag change and maybe check for blood return. How about changeing my positive end connector every seven days or after blood transfusions? changing the positive end connecetor after blood draw if I can visably see blood and cant flush it clean.??????? Doesnt this open the lumen? when we use to ask the patient to valsalva?????
And again
Must I have a written order for inserting an IV in a patient if their are no fluids, no meds, no prn hypoglycemia, no prn steriod order or not????????
Cheryl Ferraro RN, CRNI
Flushing and aspirating for patency when you change the IV administration set and needleless connector is a practice done by many and it may be a good thing to do. The issue is lack of evidence about doing this with continuous infusions. You must always consider what is infusing and what affect that flush will have on the patient's bp, etc. Regarding changing the needleless connector - First I do not think that these connectors should be inside the infusion system for any continuous infusion. These connectors were designed to allow for intermittent access to the VAD without opening the lumen. The only possible exception would be a home patient getting cyclic PN as some would call this continuous. I am talking about hospitalized patients receiving truly continuous infusions. There has never been an evidence-based need for these devices in this type of infusion, They are an infection risk, and I strongly believe they promote bad practie by allowing the line to be opened more frequently. There is no evidence that the connector must be changed after a blood draw or blood transfusion. There is only evidence to change the connector BEFORE drawing a blood culture from the VAD to avoid the chance of a false positive from the contaminated connector. If you are using a line infusing a vasopressor for drawing a blood sample, then you are already interrupting the infusion, so the flush should not make any additional difference. If you use a connector inside a continuous infusion system, that would always be changed at the same time as the entire infusion set. So you are opening the line once every 96 hours and no more. And you would use all of the methods to prevent air from entering the VAD when you do open the catheter hub. You can never change the IV set and leave the connector without being changed.
Regarding your question about an LIP order, this should be addressed in your facility policy. Only that avenue can be used to address this question. So send it through the approrpriate committees and write a policy about it. 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
Well I did leave out this PICC line Im talking about is a tl and I know some brands have a built in valve. I dont believe this one does. And of course before the line with the heartmed would be flushed time would have passed as to not give a bolus.
Thanks
Cheryl Ferraro RN, CRNI