I am actually working on a project to help determine the extent of buretrol use across the country. Some questions for you:
1. Where in your hospital do you see buretrols being used?
2. Does the unit fill a certain amount of fluid, then clamp and infuse consistently, or do you see flow through delivery (buretrol a big drip chamber)?
3. Is there a hospital policy demanding the use of buretrols? When was it last updated?
4. What are the buretrols used for? Fluid restriction (as described above), small dose medication administration, chemo?
5. Does your facility have "smart pumps" and if so are staff using their drug library when they administer meds with buretrols?
Thanks in advance!!
Peggy McDaniel RN BSN
Infusion Practice Manager, Western Region
We recently did away with most of the buretrols/solusets/calibrated chambers, except for any medications still delivered by gravity. Most of the kids have volume control handled by use of syringe pumps for infusions and intermittent medications. the syringe on the syringe pump has taken the place of the volume control chamber/buretrol. Volume control pumps are now used more for continuous infusion of large volumes, such as TPN, etc.
Anne Marie Frey RN, BSN, CRNI
Clinical Nurse Level Four
Vascular Access Service: I.V. Team
The Children's Hospital of Philadelphia
Anne Marie Frey RN, BSN, CRNI, VA-BC Clinical Expert Vascular Access Service: I.V. Team The Children's Hospital of Philadelphia [email protected]
Hi Anne Marie,
I am curious as to why large volume fluids are still infused with a calibrated chamber set. Do you think this is because the nurses do not trust the accuracy of the pump? I know these sets would limit the volume of a possible run-away infusion. Instead of getting a whole bag the patient would only get the equivalent of 1-2 hours of fluid, thus preventing fluid overload, etc. Or is there some other reason or rationale for their use? Thanks, Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway, M.Ed., NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Office Phone 770-358-7861
That is exactly why I have asked. I can see the use in gravity situations and if the clinicians really put just 1-2 hours of fluid in and clamped to prevent flow through consistently. Often, where buretrols are used across the board you see them hanging as large drip chambers. I am very curious as get feedback from clinicians that they have to have them but then practice is seen. I'd like to understand more. Thanks!
I really want to stop using volutrols - I use them with Peds and in my NICU - every infant, child is on a pump, and by policy NICU rate and VTBI must be the same (10 ml/hr/10 ml VTBI) and for peds it is 2x the rate 25ml/Hr, 50 ml VTBI - so what I am looking for is any evidence anyone has out there to validate the safety of pump administration without a Buretrol - or evidence that it is in fact safer - anyone have anything? Thanks
I have never seen any evidence to support either approach. Maybe the peds people will know something about new evidence.
We are currently reviewing this exact topic in our organisation and to date there is very little documented evidence to support a move from the use of burettes (or vice versa as it appears they have just been included once the implementation of pumps came into our routine clinical practice), however I have been able to find a small piece written here (in Australia) about the unsafe practice of administering medication to the burettes and the increased risk of medication error and infection. I am keen to remove them from routine practice, they are an additional attachment to the giving set and all of our patients have volume controlled pumps and anecdotally I have heard the staff open the roller clamps to let the fluid drip to the chamber anyway so the long-term argument about fluid management and safety is not strong enough when practice doesn't reflect the theory.
I am keen to hear from others as I will be concentrating on reviewing and writing this policy over the next few months.
Clinical Nurse Consultant
the Children's Hospital at Westmead - Australia
We have a policy that allows for only 2 hours of fluid in the soluset at one time--in that way it is a safety precaution and it is a throw back to years past when every patient did not have a pump or pumps were not as reliable. The soluset is used as a "big drip chamber" when the rate of fluids exceeds the volume of the soluset. However the soluset is still there to deliver meds.
We will be switching to the Alaris pump this year and I anticipate that will bring changes in our fluid and med delivery system.
Just curious as to what the most current practice is regarding use of Buretrols in the NICU. I strongly feel that this is a safety factor. My hospital is considering cutting them for cost savings. I know that IV pumps have an error rate of about 5% according to my research, which is 5% too much in a premature or sick neonate. Anyones practice are thoughts will be appreciated.
Kim Steuber RNC
Clinical Coordinator - NICU
It is interesting to note the the Institute for Safe Medication Practices' (ISMP) only significant comment on buretrols/solusets seems to indicate by its tone that buretrols are the exception, not the norm (which is what I have found in my practice in various (pediatric and general ER) locations in Texas):
Safety Brief: Volume control set safety. Hospitals that still use BURETROL or SOLUSET volume control sets (VCS) should examine how they are being used to deliver IV medications in patient care units, including the emergency department. Of concern is the lack of identifying the drug placed in the VCS—particularly in an emergency—as well as the potential for chemical inactivation or precipitation that may occur in the VCS or IV tubing when multiple medications are administered using the same set. If VCS are used, ensure that staff label the chamber when medications are added, check incompatibilities with pharmacy before adding the drug, and maintain sterile technique.
Buretrols were invented prior to the introduction of IV pumps and (as was stated by others) were necessary to prevent fluid overload in (primarily) pediatric patients via free-flow. Currently, if intravenous pumps were to fail at all it would be a "fail-secure" failure, meaning it would not allow any fluid to flow - which is much better than if the nurse fails using a buretrol and the system is allowed to free flow. (Interestingly, these failures are usually the result of battery failures due to frequent and complete draining of the battery due to not plugging the device in - resulting in the battery being unable to maintain a full charge.) If there is some residual concern about the reliability and accuracy of the pumps, it is ironic that most clinical settings that still use buretrols require them to be run on these same pumps, thus negating any alleged added protection from the buretrol set. (I would however, like to see the data for the alleged 5% failure rate for IV pumps currently on the market. I am a little concerned that this is another healthcare/nursing "urban-legend".)
Essentially, all pediatric IVs should be run on IV pumps for safety, and never via gravity (with the possible exception of trauma/fluid resucitation in older children). This should eliminate the need for buretrols. All IV meds can safely be administered via secondary lines using 50ml or 100ml "mini-bags", or via syringe pumps.
Buretrol IV pump sets cost up to 5 times more than regular pump tubing. Since there is no evidence-based or best-pratice guidelines recommending the use of buretrol, I would dare to suggest that they are an out-dated nursing practice. (Arguably, they could be kept in stock for emergencies/disasters or extended power-failures when IV pumps for every pediatric patient may not be an option.)
Craig R, RN, BScN
Here is an interesing quote from a clinical pharmacist in the NICU at Johns Hopkins in Baltimore, Maryland:
"Q: What other technology does Hopkins use to improve medication safety in pediatric patients? Wesolowski: We have a syringe-pump committee that was formed to standardize i.v. drug concentrations for infusion. When I started on the committee back in 2000, we were using a Buretrol (Baxter Healthcare, Deerfield, IL) system with Imed (Alaris, Dublin, OH) pumps. A lot of erratic levels were being reported for aminoglycosides and vancomycin. One of the nurses theorized that the drug was getting stuck in the tubing because the flush volume was not adequate to clear the line. We proved this by doing a dye study. The tubing took up about 20 mL of fluid, and the nurses weren’t adequately flushing the drug through the line so the patients weren’t getting a full dose. So we switched to syringe smart pumps and developed standard concentrations for our i.v. drugs. Everything now is in a ready-to-use concentration. Before, we would send the concentrated drug and the nurse would put it in the Buretrol chamber, dilute it to the appropriate concentration, and set the infusion rate. The nurses would often need to look up drug information or call the pharmacy for help. All our pediatric nursing units use the syringe pumps now. The tubing only holds about 1–2 mL of fluid, so much less saline has to be flushed through the tubing to deliver the drug. And the syringe pumps have formularies that list the different drug concentrations we use. Now, the nurses no longer have to look up drug references or call the pharmacy and ask how fast to infuse a drug or what to dilute it in. Once they find the drug on the pump’s menu, they punch in the patient’s weight and the dose in milligrams, and the pump automatically checks the dosage and calculates the infusion rate. I think the pumps, with their huge safety features, have improved the delivery of medications. I also make preprinted recipe labels for the pediatric i.v. medications. The labels give exact instructions for how to reconstitute the medication, how to dilute it, and what size bottle to use. I put places on the labels for the lot number and for people to sign when they compound the medications. There are about 200 recipes stored on the pharmacy computer system. We had about 10 dilutions before we went live with the smart pumps so this was a huge increase."
It certainly makes a good arguement for syringe pumps for those concerned about accuracy of small doses and fluid restriction in neonates.
Another good reason to consider to consider pumps over buretrols for neonates.
These two studies indicate that you have to flush 2-3 times the deadspace in the tubing to adequately flush the medication through:
And on another note, I was just reading a coroner's inquest from a homicide case report yesterday in which they were able to collect residue in the buretrol from the previous 3 meds given - after it was flushed and maintenance fluids were running. That was not the point of the inquest, but it should raise some serious red flags!
Craig Rowe, RN, BScN