I am wondering if any nurses have a guideline or a supported practice at their institutions where either based on the rate of infusion or the volume of infusate, do they not flush the remaining medication in the primary tubing (connected to a flush bag and the venous access device) after the secondary tubing (on which the infusate is hung) empties? We use Alaris Pumps where I work. Also, if only a primary line is used and hung by gravity, when the infusate container empties, do they flush any remaining medication in the tubing into the vein. The concern is the added time of infusing the remaining medication into the patient with low infusion rates of say 125 ml/hr or less. I would appreciate any sources of information or existing practices supported by your institution. Thank you.
For all configurations of administration sets and pumps, you need to estimate the volume remaining in the set from the point of connection for the piggybacked secondary set down to the catheter hub. What percent of the total volume of drug is remaining in the set if flushing is not done? For a direct connection of an intermittent medication on gravity infusion, the percentage remaining in the set without flushing is very small. But for a secondary connected to the pump it would be a very high percent, sometimes as much as 50%. You simply cannot leave this large volume uninfused and inside the set. The pump should be programmed to resume the saline carrier fluid at the same rate as the medication. After all medication has been infusion from the set, your policy could be set to allow a very slow rate to continue, eg. 5 to 10 mls per hour on adults. Or you can disconnect the set from the catheter hub after infusion is finished. Or you could infuse by gravity without the pump. Decisions your applicable committees should make when writing your policy..
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
Hi Lynn,
I am at a loss to find a citation for the above information. I have been looking for hours. When we upgraded pumps, I was asked to consult re the automated flush program. Our pumps can be programmed with the medication programming to deliver the flush at the same rate as the medication. We program the volume. I recommended your above recommendation, with a flush volume of 25 mls (our tubing's priming volume is 19 mls) as per INS 2021. In a separate conversation today with the educator, I discovered she is only teaching that way for patients with continuous infusions. For intermittent set ups she is recommending that when the volume absorbed alarm rings, that nurses just go in and stop the secondary program and flush the remainder in at a faster rate, since the monographs frequently provide a time variation (ex. 15 minutes to 30 minutes). Her rational is that it is faster this way. I see this as a nursing "work around". She would like some "evidence" of this. I will show her your above remarks. Your name does carry some weight.
Do you know of a reference for this? The closest I have found is under the heading Flush the Line in ISMP's Additional Strategies to Improve Complete Delivery of Small-Volume Intermittent Infusions, April 8, 2021.
I so appreciate all that you do to support evidence informed safe practice.
With warm regards,
Kerry McDonald, RN, CVAA(c)
K. McDonald RN, CVAA(c)
Not quite sure if you are talking about a primary intermittent set with a carrier fluid and secondary med piggybacked and all going through a pump. Or if you are talking about a primary intermittent set with med infusing only through a single set by gravity. The pump set and the volume it holds is the critical element. First and foremost the patient must get 100% of the medication volume into the bloodstream at a consistent rate. After this has happened there must be some type of flush and lock for the VAD if you disconnect the continuous infusion. Here are a couple of studies that might help.
1.Doesburg F, Oelen R, Renes MH, Bult W, Touw DJ, Nijsten MW. Towards more efficient use of intravenous lumens in multi-infusion settings: development and evaluation of a multiplex infusion scheduling algorithm. BMC Medical Informatics and Decision Making. 2020;20(1). doi:10.1186/s12911-020-01231-w.
2.Giuliano KK, Blake JWC, Butterfield R. Secondary Medication Administration and IV Smart Pump Setup. The American journal of nursing. 2021;121(8):46-50.
3.Pinkney S, Fan M, Chan K, et al. Multiple intravenous infusions phase 2b: Laboratory study. Ontario health technology assessment series. 2014;14(5):1.
4.Cassano-Piché A, Fan M, Sabovitch S, Masino C, Easty A, Team HTSR. Multiple intravenous infusions phase 1b: practice and training scan. Ontario health technology assessment series. 2012;12(16):1.
5.committee Ohta. Multiple intravenous infusions phases 2a and 2b: OHTAC recommendation. . In. Toronto: Queen’s Printer for Ontario; 2014.
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