I work in an infusion clinic associated with our hospital.
We often see daily antibiotic patients. These patients usually have a PICC line.
We are not open on the weekends, so these patients are see as out patients on our med surge floor. I just found out today that they save the tubing and reuse it for that patient. Cleaning a port and piggybacking the end in until the next day, reconnecting that to the PICC.
They say this is ok because tubing is good for 72 hrs.
nope. dear Lord who makes up these rules?
INS standards, CDC Safe injection practices, usp 797 all apply. 24 hrs is the maximum use for these sets. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you! It was the director of the med surg unit who told me this. I have been in touch with education. We will get this changed!
Thank you Lynn,
Thank you Lynn for reinforcing the 24 hour limit on tubing that have been unhooked from the patient. We are working on that issue at our hospital. I would like to address the other practice mentioned.
All tubing ends MUST be capped with a new sterile cap during the 24 hour period each time they are used. "Piggybacking" into the "cleaned?" hub of the line is not acceptable. That area is a dead end space and can quickly become a breeding ground for bacteria. How do you know what the person before you did? I have watched staff just plug in without cleaning. If so they have just introduced the bacteria on the hub into the dead space. Now you come along and may very carefully clean the hub but you plug into an area that has bacteria in it and then unplug it later and plug it into the patient.
This is an old habit that must end. We have started to combat it by knotting tubings (along with tubings left open to air when we are called to start an IV) and placing a new set on the pump. This is not as much a nursing issue as much as it is a administration issue as in recent years we have been cut out of education and annual compentency altogether. Thankfully this is starting to change as all of a sudden our infection rates including peripheral IVs have started to climb. We are finally being asked for our input. YEAH!!!! We keep reinforcing the lack of education/ongoing education as the root cause.
Thanks to all for a great forum.
Mary Penn RN Vascular Access Team
St Charles MO
I agree Jill, as my head exploded when I realized that that same horrendous practice was occurring in my facility. When the in-patient managers all agreed that the tubing intermittent or continuous was all ok for up to 96 (yes 96) hours I was speechless. Our CNE asked me if that was an issue and of course I said that absolutely that had to change immediately. You do wonder how these practices evolve! My mistake in thinking they were still following all the rules as we did when we had a fully functioning IV Team. We are now only a PICC team and are no longer involved in the semi annual staff education or orientation of new hires. It is a constant battle to insure all standards are followed for all issues.
In my experience resistance to the 24 hour rule is common, what evidence can be cited to make a stronger argument for this practice?
The absolute lack of evidence about IV administration sets used to deliver intermittent medications is the only thing we have now. An intermittent set is connected and disconnected with each dose. When you open the package, both ends covered with the caps and the fluid pathway is sterile. There is no published evidence about the level of organisms accumulating on the male luer end of intermittently used sets. Because of this lack of evidence, the INS standards has chosen to leave the standard for intermittent sets at 24 hours, which was the original length of time all sets were used. Studies on extension of set use has either not included intermittent sets or did not state that they were included. So the total lack of evidence to support an extended use of intermittent sets. CDC Guidelines state that the length of time of intermittent set use is unknown. At least this calls attention to the differences between a set that is continuously connected and one that is used intermittently. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thanks for the info Lynn. It's certainly more challenging to encourage this practice without a evidence to point to. It seems to come down to an issue of "burden of proof" on each side. Given that there's some (weak) evidence to suggest less frequent tubing changes might actually reduce infections, one side argues that 72 hours plus should be the starting point and more frequent changes would require evidence, and the other argument is that 24 hours should be the starting point and there should be evidence to support anything longer, without more evidence it's difficult make a strong argument.
While we're on the subject, a question that comes up often is how we define intermittent. It's fairly straightforward when the plan from the beginning is to only have the line connected to the patient during intermittent infusions, but it gets confusing in other situations. For instance, what happens when a tubing is disconnected to move to another port, or to take the patient for a walk, or change clothes, etc. Does it become "intermittent" when it's disconnected and should then be changed 24 hours after it was disconnected? What if that additional tubing change causes an additional tubing connection manipulation that would not have occurred otherwise (we're trying really hard to get staff to avoid tubing connection manipulations whenever possible, yet in this situation that would seem to be contrary to that rule).
Your reasons for disconnecting a continuous infusion are not acceptable to me. I would never think of stopping any prescribed infusion to have a patient ambulate or take a shower or change clothing. I had an argument at midnight in the hospital where my father was just admitted but I would not allow her to disconnect his infusion to change the gown to a telemetry gown. I taught her how to run the fluid container and IV set through the sleeve in the same direction as the arm and that is the only way I would allow it to happen. Stopping for 15, 30, 60 minutes means the patient is not getting the prescribed therapy and this will slow down their progress toward discharge. This is one thing I have become passionate about because I think it is primarily done for nursing conveneince with any thought to the total ramifications. Stop this practice and the whole intermittent question becomes easier. A continuous infusion should only have the spike removed from the container when it is time to change that container. Also, all IV sets must be completely changed when you start a new catheter. So I am not sure what you mean by "moving to another port". Piggyback secondary sets should remain connected to the primary line and all be changed at the same time. For multiple medications use the backpriming method or attach each secondary to a separate injection site, but do not allow disconnection from the primary line. Again, another thing that makes intermittent set use more clear - when the continuous fluids are gone and the only thing left is 1, maybe 2 meds infusing over 30 to 60 minutes. Anytime these sets are manipulated, both ends are involved. I will stick with the burden of proof being that we need evidence to show that longer use is safe. I think this is what is causing a lot of CRBSI. You can have a pristinely clean needleless connector, then attach a dirty intermittent set and still introduce organisms. Once we have some data on this, I think we may find that it is unsafe to use these intermittent sets more than 1 time, but no evidence on that yet. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
As I mentioned previously we strongly encourage to leave lines always connected, this includes with intermittent infusions, which in my understanding makes them 'continuous' tubing since they are contininously connected. Our policy is also to never disconnect a secondary from a primary, it's considered permenantly attached and changed with the primary set.
We had a 'no exceptions' policy for keeping all tubing hooked up continuously, regardless of circumstances, but we had to backtrack on that. We had a patient who was being walked. This can be very difficult, particularly when going through doorways, to manage both the patient and the IV pole. We had a patient fall in a doorway and in the fall the tubing attached to the IV pole pulled the IJ cath downward, causing a large dissection of the IJ vein which required emergent vascular surgery and the patient was lucky to survive, so we've had to accept that there are some exceptions to this rule.
By "changing ports" I'm referring to situations where lines may need to be disconnected to reorganize. You might have a single med going into a lumen, and now need to another which may require adding a splitter or 'tree'. Also, sometimes a med is added that is incompatible with other meds, so which meds are going through which ports might need to be changed. Or just situations where tubing is disconnected to flush.
In terms of 'burden of proof' I think the argument is that less frequent tubing changes have already been proven safe, so what we need to prove is that intermittently infusing lines are indeed dirtier than continously running infusions even when disconnected momentarily and even when changing the tubing sooner would result in an additional tubing change that would not have occurred otherwise. I think part of where our message becomes inconsistent is when we say to never manipulate or disconnect a connection unecessarily, but then encourage them to do just that. Clarifying the difference would certainly help encourage compliance.
Maybe I put too many questions in the last post so I'll cut it down to one: Does a line originally intended to be continuously attached become "intermittent" at the time it is disconnected and is therefore to be changed 24 hours from that point?
In my opinion, the answer is a resounding Yes to your queistion. Disconnecting an IV set that is intended for continuous infusion is not best practice as it
1. increases catheter and line manipulation which can increase contamination
2. stops the prescribed infusion during the disconnection period which can slow down the patient's progress when medications are compounded in the fluid container
Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I agree that disconnecting an IV set should be avoided as it increases manipulation and the chances of contaminition, which is why our policy is to avoid disconnecting tubing regardless of whether or not infusions are continuous or intermittent, which brings up the questions that come from staff that I can't answer, maybe you can help:
If the golden rule is to avoid all additional manipulations of tubing connections and ports, why would we recommend changing tubing at 30 hours (assuming it was disconnected for some reason after 6 hours) when it otherwise would have remained connected and therefore unmanipulated?
I agree that medication orders should be followed and our policy is that a MD order is required to interrupt or otherwise alter the affect of an infusion (this varies somewhat by the medication, half life, etc) although we haven't applied this to the situations where the duration which an infusion is paused is likely to have any clinical significance, such as pausing maintenace fluids to change out tubing, but I'll pass on your suggestion.
Disconnecting the set at 30 hours means the the male luer of the set is easily contaminated while disconnected. You could easily be reconnected a contaminated set. This is a 2 sided system and both sides require careful attention - the male luer end of the IV set and the catheer hub. So the set that remains connected is not manipulated and has little to no change of contamination while the disconnection encourages contamination. Continuous sets should remain connected and changed no more frequently than 96 hours. Once there is no clinical need for continuous fluids, intermittent meds are infused using a set that is connected and disconnected therefore needs to be changed at 24 hours. I think using a slow infusion continuously to piggyback intermittent meds is continuing a complex infusion system and also slowing down the patient ability to ambulate and work toward discharge. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
We've based our policies on statements made on your blog as well as our understanding of INS standards, apparently we've misinterpreted both so maybe you could clarify.
Due to contamination and infection risk with each manipulation, we discourage unecessary disconnections including for convenience purposes. While there is not an issue with interrupting fluids to disconnect temporarily when nothing is running, the contamination risk would seem to be exactly the same, as a result there's some confusion about the purpose behind leaving tubing connected when possible and the purpose of more frequent tubing changes if the line is disconnecting at any time for any reason.
That brings up another point that maybe we misunderstood. Our policy is that if the tubing is disconnected at any time for any reason then it becomes an intermittent tubing, maybe we've used too broad of an interpretation. For instance, if a new tubing is connected, and then a minute later disconnected to add a y-splitter between the lumen port and the tubing, then it becomes intermittent and should be changed in 24 hours (even though the infusion it's carrying may be a continuous infusion and wouldn't need to be disconnected otherwise. I agree that the change at 30 hours in the example I gave earlier presents some risk which is why it's confusing to tell staff to make that tubing change at 30 staff because it was disconnected 24 hours prior to that.
How should I respond to staff who are confused as to why we don't discourage the frequent connections and disconnections that would occur between intermittent infusions, yet consider a single extra connection to be reason enough to change the set at 24 hours (even if this means breaking the closed system once again to change the set).
Now I am confused! Disconnecting when nothing is running? Then why is there any infusion set connected? Opening the connection a minute later to add a y splitter? That says very poor planning to me.
Continuous sets should be set up at the beginning of an infusion and remain connected to the catheter hub for at least 96 hours. There should not be any reason to open the line. Changing clothing is not acceptable. Inserting a new add-on piece? Why was there not adequate planning during the initial set up? The only way a continuous set should be opened is when you are replacing an empty container for a new one on the spike end. This should be done carefully to prevent contamination of the spike. For instance, don't pull the covering off of the new container while holding the exposed spike in your hand. The rebound could easily cause the spike to touch something dirty. That is the way sets were used in the published studies and the basis for allowing them to remain in use for 96 hours and CDC also says they could remain up for 7 days! So there should not be any questions about a continuous infusion now being changed to an intermittent set change frequency. So I would look at those situations when the staff nurses are opening this line and why it is being done, then work to reduce, preferably eliminate, these interruptions.
The problem is that no studies have been conducted on sets used for the delivery of only intermittent medications. INS chooses to use the original max of 24 hours due to the absence of this needed data. CDC states the change frequency for sets used intermittently is an unresolved issue. But this statement does emphasize the difference between these 2 ways to use IV sets. Sets used intermittently will have a period of non-use when the male luer end must be capped with a new sterile dead end cap each time. No other covering is acceptable.
The primary concern is always going to be the contamination of the male luer end of the set. I do have an abstract presented at SHEA in 2011 by Loyola Univ on contamination of NC and male luer end of IV sets showing that 37% of male luers cultured positive for a variety of organisms while 24% of connector surfaces were positive. This is early and unpubllished but it is all we have. This study was done in 5 ICUs and does not clearly state whether this was all continuous infusion, all intermittent infusions or a combination of both. Frankly I don't understand how these male luers were contaminated if they were remaining connected for continuous infusion. So the goal is to keep an infusion system closed when there is continuous infusion. When there is no need for continuous infusion and there is only intermittent meds, allow maximum patient movement by having the patient only connected to the set during the infusion time. This method demands careful attention to how that intermittent IV set is managed when it is not connected.
Frequent connections and disconnections? How frequent? If the patient is on multiple intermittent meds, it may be more appropriate to piggyback secondary sets to a carrier fluid of NS, then leave this NS slowly infusing. Again the goal is to reduce manipulations of the entire system. When the need is only 1 or 2 intermittent meds only, these sets are being manipulated on both ends with each dose (q 8 or q 12 etc), it must be changed at 24 hours.
So the bottom line is reduce, preferably eliminate, the number of times a continuous set is disconnected or manipulated in any way. With continuous fluids, piggyback med sets to the primary set and leave them connected for the 96 hours, changing all at the same time. Do not allow sets to be disconnected from the catheter hub as you have stated. Your example of disconnecting to add a new piece can be eliminated with appropriate planning. When a continuous set is disconnected it stands a good chance of contamination on the male luer end during the disconnected time. How are these continuous sets managed while disconnected? What is happening to that male luer end? Are the nurses trying to hold the male luer while doing another task? Do they drape it somewhere without a sterile end cap? Does the patient leave the room and become separated from this container and set?
Maybe I am still not understanding your questions. Or maybe your practice is vastly different from what I am used to. Not sure what else I can say to address your questions. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I agree with reducing, preferably eliminating, the number of times a continuous set is disconnected or manipulated in any way which is why the 24 hour rule for any line that is disconnected at any time is questioned by staff for which I have no answer. I agree that when a continuous line is disconnected there is a risk of contamination, but there is also a risk of contamination when changing tubing, and I'd argue it's when changing tubing that the greatest risk of contaminating the male end occurs. The study you referred to would only seem to reinforce that.
So the gist of the question I get from staff is that if we know changing tubing carries a risk of contaminating the system, why would we do that more often? If we introduce 100 bacteria with each tubing change, why put 400 bacteria into a line over 4 days when it could just be 100?
That is the reason for extending the life of continuous IV sets. It began with a 24 hour limit and has now extended to no more frequently than 96 hours and at least every 7 days, according to CDC. Changing the conitnuous set at 96 hours is not the cause of contamination. With that you are disconnecting the old and reconnecting a new sterile male luer end of a new set. If you are frequently disconnecting the used sset and then reconnecting that same used set, the question is how is that male luer end managed and protected while it was disconnected. I also strongly believe that the presence of a needleless connector in the continous system is an unknow factor for contamination. And the presence of this connector facilitates easy connection and disconnection, leading to the probablity of increasing intraluminal contamination. These needleless connectors were designed for intermittent infusion, not for continuous infusion. My preference would be continuous sets locked directly male to female luer without a needleless connector, never disconnected before it is time to change to a new set. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Maybe I'm misundstanding you, but according to the CDC changing sets can cause contamination. The reason for extending the duration of IV tubing to 72 hours or more was that there is no evidence that more frequent changes reduce the effects of the contamination that has been shown to occur when changing tubing, and actually a couple of the studies they referred showed an increase in CLASBI's when tubing was changed more often; directly linking tubing changes with contamination and resulting infections. The study you referred to would only seem to confirm this.
Even without evidence it should be pretty clear that changing tubing sets poses a risk of contamination, arguably more than disconnecting and capping a line. While the tubing is sterile in the package, it goes through numerous high risk actions, particularly the tip which would seem to be confirmed by the study you referred to. Once you introduce bacteria into an IV/bloodstream it can't be removed by changing the tubing, you can only add more bacteria to the IV/bloodstream by changing tubing so there needs to be a very good reason to do so.
I'm not sure what you mean by 'needless connectors', it sounds like what I usually hear referred to as 'prn adapters'. My understanding was that it is considered bad practice to connect tubing directly to an IV hub since then the hub is subject to contamination and manipulation (which then leads to mechanical phlebitis) when unavoidable tubing changes occur.
Needleless connector is now the generic term used for the category of devices attached to the catheter hub to facilitate connection of sets and syringes without the use of needleless. I think PRN adapter is actually a trade name for one of the old brands that was designed for use with needles.
My interpretation of studies on IV sets is quite different from yours. Yes, the studies may use the term "changing the IV set" but the task of connecting a new set after removing the old set from the catheter hub is not the primary concern. The concern has always been the fact that IV solutions can support the growth of organisms, especially those containing glucose. Add this fact to the number of times the set is entered for injecting or piggyback medications. These entries can introduce organisms into these fluid highways containing solutions that will support the growth of organisms. Look at how these studies were done by culturing fluid taken from the set. To my knowledge none have actually cultured the bioburden on the male luer of the set. The question is what is the maximum length of time that we can use one set without this risk of contamination and subsequent infection potential. These studies are all getting very old now. Practice has changed with the use of needleless connectors on each and every catheter hub. This was NOT the practice before these devices were mandated through the OSHA BBP Standard. I still believe that the act of disconnecting an IV set for any period of time carries the greatest risk of contamination and totally depends on how that male luer is protected. The only acceptable method for its protection is a new sterile dead end cap and limiting its use to 24 hours. We definitely need more studies on our current practices. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
While there are a few solutions that can support the growth of organisms, most IV fluids can't actually support the growth of organisms, even those that contain glucose (by which I assume you mean dextrose). It's been fairly well established that common IV solutions cannot support the growth gram positive bacteria. There is some conflicting evidence that gram negative bacteria can form biofilm in solutions containing 10% or more dextrose, although even then it hasn't been shown to grow to such numbers where cell detachment can occur and contaminate/embolize downstream.
In a small subset of IV solutions (lipid emulsions, blood, etc) bacteria and biofilm can proliferate, which is the only reason why it may be worth the extra contamination opportunities posed with more frequent set changes with these solutions. In other solutions however, the evidence tells us that we are only risking the introduction of more bacteria every time a set is changed without any benefit to cancel out that potential harm to the patient; in other words we're not removing any bacteria from the system by changing the set, we're only risking adding more bacteria to the system.
I think you're using two very different standards to compare disconnecting an inermittent line and hanging a new IV set. I agree that we should always plan for the worst-case scenario, which when disconnecting a line could mean it doesn't get capped and the tip becomes contaminated. Although you seem to be ignoring the same premise in hanging a new set. The tip can end up in the garbage can or sink while priming, and then hung on the IV pole only to fall to the floor while the set is put through the pump, then snaked through a jumble of lines, wires, and tubing before finally being connected. In my experience this happens much more often than forgetting to cap the end of a disconnected line, yet you seem to be going out of your way to ignore that any of those factors occur.
As someone who has gone to great lengths to encourage evidence based Nursing practice (which I had thought included the INS administration set change recommendations although I am feeling I may have been betrayed on that), I'm disapointed to hear that the primary reason for keeping the 24 hour change rule for non-lipid/blood solutions is that this is how we've always done it. Sacred cows make the task of encouraging good practice difficult. It's absolutely appropriate to compare the evidence that the 24 hour set change was based on to current evidence and what can be inferred from current evidence, but to overrule both of these because the 24 hour change frequency was a habit, and a sacred cow, is dissapointing.
The bottom line would appear be that we know contamination can occur whenever components are exposed to potential contamination, so those opportunities should be limited, and creating more opportunities is only acceptable when an adminsitration set is capable of "self-contaminating" the set and sytem through the growth of bacteria and biofilm.
I think we have about exhausted this topic but I did want to clear up some confusion. The following is taken from the chapter 37. Infections Due to Infusion Therapy, by Dennis Maki, MD, and Leonard Mermel, DO, 2 internationally known epidemiologists. This chapter was in the book Hospital Infections published in 2007, the only version I have in an e-format. I have copied and pasted the relavent information. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
The pasted relevant information is showing as a broken link. I can access some portions of what you're referring to and noticed that the Maki, Mermel reference also states that commonly used IV fluids do not support the growth of gram positive biofilms and that while gram negative organisms can grow to a limited degree, it's not enough to produce cell detachment.
Maybe you could just post the page number of the passage you're referring to, or chapter/section?
Sorry that what I tried to copy and paste did not actually get pasted. I have that problem a lot on this site. The passage came from the textbook, Hospital Infections, chapter 37 Infections Due to Infusion Therapy, authored by Dennis Maki, MD, and Leanard Mermel, DO, 2 leading epidemiologists. Pages 611-647, published in 2007. This chapter contains a section on Bloodstream Infections from Contaminated Infusates and a subsection on Growth Properties of Microorganisms in Parenteral Fluids. Basically, aerobic gram-negative bacilli are capable of rapid growth at room temperature in IV solutions - in dextrose this is primarily tribe Klebsielleae, in lactated ringers it is pseudomonas, enterobacter or serratia, and sodium chloride allows growth of most bacteria. These authors also state, "The likelihood of fluid becoming contaminated during use is directly related to the duration of uninterrupted infusion through the same administration set and the frequency with which the set is manipulated."
Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Suppose there is not a primary infusion? For example: say the patient gets intermittent antibiotics q8 hours only. We are contemplating whether it is best to hang a "medication line" that is kept at KVO. However is an MD order required for this? Thanks, Kristi
We are developing a midline policy. Do any other institutions restrict midline placement to a patient that's been afebrile for 48 hours?
Thank you,
Kristi
For intermittent medications, I much prefer to hang them directly to the VAD without any type of carrier fluid or primary fluid infusing. We are experiencing a severe protracted shortage of some IV fluids such as NS and LR, so now is not the time to be using these fluids for this purpose. Also, I believe that being connected to a constant infusion would slow down the hospitalized patients ability to get up, walk, and get ready for discharge. Using a carrier fluid could make sense for critical care patients getting numerous piggybacks, but when there is only one or two IV meds, I do not think it makes sense at all. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I understanding it is recommended to hang new IV tubing with any new site (peripheral or a new central line) but what about the IV solution. For instance, if a solution was hung not long prior to the new site, is it acceptable to spike that fluid bag to the new tubing or does the IV solution/medication need to also be new?
I am not aware of any research addressing this issue. In my opinion, it would be better to have a new fluid container as well as new IV set. But with the shortages of some IV fluids these days, that might not be feasible. I would assess each situation. First I would not hang a new container if the site was questionable in any way. I would assess the site and make a decision about changing everything before I hung a new container. If there is a container that has been infusing for several hours and it has 3/4 to 1/4 of the fluid remaining I would use it on the new site and just change all of the IV set. If there is less than 1/4 of fluid remaining, I would prefer to start with a new container. This is not an evidence based answer but only my opinion. The emphasis should be on avoiding these situations by thorough site assessment before hanging a new container. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you for your answer. I did a literature search and could not find any information regarding the IV solutions. I agree with your opinion and this is the practice I have suggested to our staff. There are several fluids that are in shortage and are very expensive. There are some circumstances when the peripheral IV is still looking good when a PICC is inserted. The patient may be needing more access or going home with the PICC for long term antibiotics. I advise the nurse to go ahead and finish the solution infusing through the peripheral as long as it remains ok, then change everything (tubing and fluid) when the next bag is needed.