Our practice for about 20 years has been to flush our BARD PICCs with a 10ml saline filled syringe to establish patency. Once patency has been established, medication delivery could be via a 3ml i.e. carpujet, then follow up with 10ml saline filled syringe. We used to heplock after on the open-ended catheters but this has been dropped due to the risk of HIT.
Recently nurses from our facility attended a thrombolytic lecture and was told that a 3ml syringe should never be used on a BARD PICC (speaker uses BARD caths), due to resultant litigation (she mentioned two cases, and I was not at the lecture).
This got me looking at the BARD website. The nursing guide for the power PICCs mentions 10ml before and after medication delivery along with using a 10ml syringe filled with 5ml sterile heparinized normal saline (our pre-filled heparin syringes are 10ml diameter but 5ml size). The only thing I found mentioning a smaller syringe size was under troubleshooting - catheter damage. "Rupture from attempt to irrigate an occluded catheter with a small syringe (i.e. 1 or 3 cc syringe)". To be irrigation is different than medication delivery after patency has been established.
For the Groshong NXT PICC under instructions for use it states "infusion pressure greater than 25psi may damage blood vessels and viscus and is not recommended. DO NOT USE A SYRINGE SMALLER THAN 10ML". In the patient guide under flushing it states do not use smaller than a 10ml syringe for flushing.
If we are never to use a 3ml syringe for medication delivery, this would result in the transferring of medications which is another patient safety risk.
Thoughts???? Current practice?????
I have not looked at these instructions for use recently, however, what you have written about them leaves a lot of questions in my mind. The fact is that intraluminal pressure will not reach a catheter-damaging level unless there is force applied against resistance. So the nurse would have to be forcefully flushing to overcome some type of resistance in the fluid pathway. The purpose of assessing patency with a 10 mL syringe first is to assess the patency of the line, to check for a blood return and detect any resistance. If there is a blood return and NO resistance, then I would use the appropriately sized syringe for the meds being given. I would never, not ever, transfer a drug from one syringe to another for the sake of using a larger syringe. It is time consuming, risks contamination and loss of part of the dose, and may lead to med errors due to improper syringe labeling. ISMP does not recommend syringe to syringe transfer. It sounds like these catheter instructions are written for the protection of the manufacturer - a CYA approach - without any consideration for the real world of med administration. I would educate about proper catheter assessment, and continue to use the syringe size appropirate for the med being given, 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
Lynn:
Thank you for your comments. I have been stuggling with the introduction of a new product. It provides undiluted dilaudid (0.5 mg/ml) and morphine ( 2 and 4 mg) but comes in a 1 cc dimeter syringe. I have been pushing back because not all CVC catheters we deal with are power CVC's. I also struggle with transfer into a larger syringe for the reason you mentioned. I reached out to the Angiodyamics rep but what she sent me only dealt with occlusion management and patency. I asked the rep of the Secure Syringe product about PSI concerns to the vessel and the integrity of the catheter but she was an accoutant and not a nurse. Her Clin Spec sent me an ISMP exerpt. I have looked at the 2016 INS standards and it doesn't appear there is an issue once patency has been established. Can you confirm or refute?
Thank you for your consideration. Do you or your colleagues have some evidence based info I can spring from?
Carolyn
Carolyn L Lawson, RN CCRN
Once patency has been assessed by flushing with a 10 mL syringe, found NO resistance and a blood return the color and consistency of whole blood, and the absence of any signs or symptoms of complications, you can proceed with a syringe size appropriate for the medication being used. Last week I spoke with a Bard clinical staff person who said their instructions for use have been changed to reflect the new INS guidelines and the ISMP paper on IV pushes. Just be aware that the package you open may still have the previous set of instructions as the new ones may not have worked there way into your stock yet.
Intraluminal increase in pressure requires to things to produce catheter damage - resistance from some type of occlusion plus force. When the syringe plunger is forced to overcome any resistance, then you can have a problem. But no resistance means there is no need for excessive force. Fluid flows in and the Intraluminal pressure does not change.
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
Call Bard. They are fabulous about product support. And, what is the manufacture date of the catheter? the guide may well be based on older info.