Trying to see what best practice is....There is a pre-mixed bag of heparin hanging as a primary solution. Per the heparin protocol a PTT is obtained every 6 hours and an IV push bolus may be indicated per the results of the PTT. (Per our policy we cannot run the pump to deliver the bolus). Do people flush with saline at the y site after administering the IV push dose? I feel you have to in order to get the med out of the y site but then there is a length of IV tubing with heparin in it that is also delivered to the patient.
I look forward to responses. Thank you.
This is a dilemma! You policy about NOT adjusting the rate of the pump is great. If you do not flush with saline, it takes some time for the injected bolus to reach the patient, depending upon the infusion rate of the pump. You would need to check the volume of your pump IV set, the distance between the last injection site and the catheter and estimate how long it would take the injected volume to reach the patient - say estimated 5 mL volume in the set at 15 mL for hour would require 20 minutes to get into vein. On the other hand, flushing with saline to have the heparin bolus reach the patient would result in a rapid bolus of the hepairn in that distance of the IV set, which would vary based on the amount of heparin in the infusing fluid. Ideal would be to have an injection site at the catheter hub but the closest you could get would be the extra injection site on a double lumen extension set. I have never seen anything recommending one way or another. I would take this to your P&T committee and let them decide. Which of these risks would be the least? Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I agree that setting the pump to deliver a bolus is not a good idea. Too much room for error. I looked at our extension tubings to get an idea of volume. Our standard small bore extension set is 8 inches long with a priming volume of 0.6 ml. Our large bore extension set whichis 7 inches long with a priming volume of 0.7ml. Our standard pump tubing is 120 inches long with an approximate priming volume of 22 ml for the entire tubing. It is approximately 7 inches from the connector to the 1st y site. This would give you an approximate volume of a 2 ml for the distance involved (calculation 22 ml /120 inches = 0.18 ml/inch. 0.18 ml/inch x 7 inches = 1.26 ml .
Total volume from y-site to IV catheter 1.26 ml + (0.6 or 0.7 ml) = slightly less than 2 ml.
This should only take about 10 - 15 minutes for the volume to reach the patient. Since most PTTs are rechecked in approximately 4 hours since last bolus (and what lab is exactly on the minute) putting your bolus closest to the IV catheter should not be an issue.
If you give the patient a 2 ml bolus of heparin you will give the patient approximately a 100 unit bolus (25,000 units heparin in 500 ml bag; 50 units/ml). But remember you are going to flush again with NS and then the patient won't get 2 ml of heparin and then the heparin will start flowing again.
It should all come out in the wash.
I would vote for clean the connector and give the bolus. The less the connector is manipulated the less risk of infection. We never disconnected the heparin tubing or reprimed after giving a bolus. The tiny if any additional heparin given is not worth the infection risk.
I hope this helps.
Mary Penn RN VA-BC 15 + years cardiology experience