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Raquelhoag@gmail.com's picture
Intermittent IVAB to Saline Lock

Hello everyone!

Thank you to all who made AVA conference this year a great success! Always enjoy attending and learning the most current practices in vascular access!

Quick question: Is there a reference or study on the following?

 Best practice regarding:

1) Intermittent IVPB to saline lock:  run tko/kvo fluid and keep system intact VERSUS intermittent connection and flush with saline pre post admin.

2) Recommended TKO / KVO rate

3) Back flushing secondary tubing for intermittent med admin for multiple medications

Main issue here is to keep IV tubing a "closed system" rather than reconnecting intermittantly which increases manipulation and risk for infection.

Thank you in advance!

Raquel M. Hoag, BSN, RN, CRNI, VA-BC

lynncrni
 #1 no studies to address

 #1 no studies to address this issue regarding infection risk.Keeping pt connected to continuous infusion could slow progress toward discharge if the fluids/pump, etc make it difficult for pt to ambulate. 

 

#2. No recommendations beause there should be no KVO rates prescribed. There is really no such thing as a specific rate that will keep either the vein or catheter open. All rates for all IV fluids requires a pt specific prescription - from INS standards. 

#3 No studies. This method was taught by all manufacturers of IV sets and is recommended in the INS standards as the preferred method, if all meds are compaatible. 

Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Random VAT person
#3 No studies. This method

#3 No studies. This method was taught by all manufacturers of IV sets and is recommended in the INS standards as the preferred method, if all meds are compaatible.

 

I found it once and am in process of making it our hospital policy.  Any idea where because I can't find it again.  arg...

 

thanks!

lynncrni
 If your question is about

 If your question is about finding it in the INS document, look in the standard on administration set changes. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

[email protected]
Raquelhoag@gmail.com's picture
 Thank you for your response

 Thank you for your response Lynn! I thought so but wasn't sure, but I was sure you'd respond!

Raquel M. Hoag, BSN, RN, PHN, VA-BC

WadeBoggs26
Is there some reason why the

Is there some reason why the backflush method can't be used between incompatible meds? I've always been under the impression that so long as the tubing is flushed between incompatible meds, that the same tubing and same IV can be used, I'm not sure why that would be different for secondary tubing.

lynncrni
 The main concern is

 The main concern is compatibility between the secondary med and any med added to the primary fluids. But I would also check compatibility between multiple secondary meds just to be on the safe side. Backflushing might not remove drug that has adhered to the intraluminal wall of the IV set. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

WadeBoggs26
 In the case of multiple

 In the case of multiple incompatible secondary meds, wouldn't it be just as likely that some of the drug might remain adhered to the intraluminal wall of the primary set?  When connected to the primary set, the secondary and primary are one continuous lumen.  I'm not sure why it would be different in the secondary portion of the tubing, wouldn't then also be risky to use the same primary tubing and the same IV for that matter even if your flushing between meds?

lynncrni
 You make a good point about

 You make a good point about all drugs being in the lower portion of the primary IV set. The only difference would be greater dilution by the primary fluid. We do not have any studies on this practice. This method is recommended because it means less set attachment and detachment, leading to less set manipulation, and less potential contaimination. Lynn

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

WadeBoggs26
 I agree in using a

 I agree in using a primary/secondary set up to create less set manipulation, which is why it seems counterproductive to keep changing the secondary uneccessarily.  Incmpompatible meds need to be sufficiently diluted through flushing to avoid incompatibility issues, it's this same premise that allows us to give incompatible meds simultaneously through different lumens, and the secondary blackflush is more than sufficient and often actually exceeds the flush that occurs between incompatible meds in the primary line since multiple antibiotics are often given in succession.

It would seem we're losing any advantages from decreaes set manipulation with a secondary set-up if we're changing out the secondary with different antibiotics, and we're not following the same flushing protocols we follow with the primary line for no apparent reason.

jill nolte
add a filter?

 if there is concern about incompatibles, wouldn't adding a filter be better than switching the secondary tubing?  

I've walked into many patient rooms to find an empty antibiotic bag attached to secondary tubing (often without protection of a tip cap!) waiting for the next dose, when it will be switched with the currently attached secondary tubing and used again.  If a filter would prevent this practice and protect the patient, I would add a filter. 

lynncrni
 No, filtration would stop

 No, filtration would stop any precipitate from reaching the patient;s bloodstream, but the pressence of a filter would not stop the precipitate from forming or an incompatibility happening. An incompatibility could happen without preciptitate forming. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

WadeBoggs26
 Lynn, how much are you

 Lynn, how much volume are you saying should be flushed through the line between incompatible meds?

lynncrni
 No specific volume has ever

 No specific volume has ever been established. It should be enough to thoroughly remove all of the first drug and prevent any contact between the 1st and 2nd drug. Set diameter, set length, can alter the amount. There should be no contact whatsoever between any drug that is known to be incompatible AND those where compatibility has not been established. There should be easy access to drug incompability information that is frequently updated. King is the author of a book with quarterly updated. Trissel does a lot of this work and publishes his book from ASHP, not sure of their schedule. MicroMedix also includes this information. Gahart's Intravenous Medication is updated annually. My point is that you can rely on wall posters of compatibility that are more than a year old. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

WadeBoggs26
I've seen varying policies on

I've seen varying policies on how much flush is required between incompatible meds, I think 10cc is the largest amount I've seen.  Are you saying incompatible meds can't be given through the same line even when flushed in between?

lynncrni
 No, that is not what I am

 No, that is not what I am saying. You are reading more into my statements than what is truly there. There are some fierce drug combinations that produce rapid precipitate than can easily cause a catheter lumen to occlude. Similar occlusion could occur in the IV set. These rapid changes primarily derive from a serious shift in solution pH. Thus the reason that thrombosis is not the only cause of lumen occlusion. I am saying that 2 drugs can be infused together and without flushing ONLY when you have confirmed compatibility from a recent valid source. If there is documented incompatibility, administration depends upon numerous variables - intermittent or continous, length of infusion time, frequency of administration. If there is NO documentation of compatibility between 2 drugs, you should not allow those drugs to come into any contact with each other. Imagine the vast number of drug combinations. Now you can see why this research lags behind the clinical need for the information. All of this dicussion has been focused on physical incompatibility. But there is also chemical and physioloogical incompatability presenting in different ways. Lots to know about the topic of drug incompatibility. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

WadeBoggs26
 I may not have explained

 I may not have explained that very well.  I was referring to giving two incompatible medications in the same line, but not at the same time, with sufficient flushing of the line in between the two.  To put it another way, you are saying that you can acutally run incompatible medications through the same line, so long as the line is sufficiently flushed of the previous medication prior to starting the next medication?

WadeBoggs26
 To clarify that, you are

 To clarify that, you are saying that secondary tubing can be used for multiple antibiotics, even if incompatible, so long as they are adequately flushed between medications just as thoroughly as a primary line and IV is flushed between incompatible medications.   Correct me if I'm wrong.

lynncrni
 Your statement sounds like

 Your statement sounds like you are proposing an absolute situation - a nurse can do this automatically each and every time. That is NOT what I am saying. This backpriming method of infusion has several benefits - less manipulation of the system, potentially causing less contamination and lower risk of infection and reducing the cost of giving these meds. 

The downside is that there are no published studies on outcomes with this technique. Manufacturers originally taught that this method was possible. But I will not go so far as to say that flushing adequately will be the answer for each and every combination of medications given by this method. It is the hospital's responsibility to assign this to a specific interdisciplinary committee, assess the risks and benefits, and write a policy and procedure about this. It should not be left to each individual nurse to decide if and when they will use backpriming. Even a written policy should include the requriement to assesws compatiblity for each combination. Each and every nurse doing this will be held accountable for the clinical outcome of their practice so this would mean validation of the compatibility status of the drug combinations in each situation. This requires access to the resources on compatibility which would be a frequently updated computer based system, printed books that are updated at least annually, and/or a pharmacist with knowledge of assessing compability information. 

Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

WadeBoggs26
 We have actually dealth with

 We have actually dealth with this issue in an interdisciplinary project, the conclusion was that, just like with the primary line, flushing was sufficient to allow for giving incompatible medications at different times, with the flush in between medications.  It never really went anywhere though because the INS seems to declare this unsafe, and as you and others have pointed out, going against INS standards is supposedly a legal no-no.

We do have online compatability resources available, all of which only define medication combinations as being compatible or incompatible (or variable, untested), but there is no additional information given which would allow a Nurse to differentiate between medications that would or wouldn't be safe with flushing in between, and I'm still not sure what that differentiation would be.

If I understand you correctly, the INS recommendation doesn't say it is never safe to use the same tubing/IV for multiple medications with proper flushing in between, but that it's up to facilities to define when it is and isn't safe.  Or does that only apply to the primary tubing and not the secondary tubing?

lynncrni
 I don't understand what you

 I don't understand what you are missing. Backpriming is included in the INS standard on IV Administration Sets. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

WadeBoggs26
 i am confused as to why

 i am confused as to why flushing a secondary tubing isn't comparible to flusing a primary tubing.

WadeBoggs26
 I think Lynn's given up on

 I think Lynn's given up on me, Maybe I'm just dense but I still don't get it, maybe somebody could take a stab at getting this to make sense?

WadeBoggs26
 I really would appreciate an

 I really would appreciate an answer on this if there is anyone out there willing to help; please correct what, if anything is wrong about this interpretation of the INS standard;  Factors and potential complications related to medication incompatibilies must be understood and addressed, but so long as these are dealt with sufficiently in the case of primary tubing, the same standards apply to secondary tubing, so if the same primary tubing and IV can be used for different incompatible medications given proper flushing technique under a facility's policies, it should also apply to secondary tubing.

lynncrni
 I would never be able to

 I would never be able to apply such a wide, blanket statement to all infusion combinations. I would strongly encourage you to obtain the book, Handbook on Injectable Medications, by Lawrence Trissel, published by ASHP. This book is huge and expensive, so I am hoping your pharmacy has a recent edition. You should know that this resource provides compatibility information in 3 ways - 2 drugs mixed in the same fluid container, 2 drugs in the same syringe, and giving one drug by Y-site when the second drug is mixed in the infusing solution. Compatibility make be acceptable in the syringe when it will be immediately injected, but mixed in the same fluid container for infusion over hours may not be acceptable. Y-site injection could be even further differences. So someone must be able to correctly interpret the available data for each possible combination. If there is no data showing COMpatibility, then you must always assume INCOMpatibility until the test are conducted and made available through these publications. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

WadeBoggs26
 We use Trissels online.  My

 We use Trissels online.  My question is; If, after a thorough review of compatibility considerations, it's determined that the same primary portion of a primary/secondary setup can be used to carry multiple intermittent medications given proper flushing for that combination between medications, the same secondary tubing can also be used so long as the flushing is just as adequate as the flushing that was done in the primary tubing?

In other words, if it is determined, based on the previous and next to be infused intermittent medication, that 10cc of flush is required to flush the primary line from where the secondary attaches on down to then infuse the next intermittent medication through it, would that same flush requirement pertain to the secondary tubing portion of the setup?

lynncrni
 There is no true evidence

 There is no true evidence based answer to your question. Lynn

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

WadeBoggs26
I agree there is no

I agree there is no definitive answer to this, which is why I don't understand why the wording of the INS standard seems to say the same secondary can never be used for multiple intermittent medications with incompatibilities no matter how well it is flushed.  This is particularly confusing since the INS does not place the same restriction on the primary tubing.

Have I misread the INS standard and the INS actually has no position either way?

lynncrni
 INS SOP does include back

 INS SOP does include back priming. I have no idea why are are thinking that it does not. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

WadeBoggs26
I am referring to this

I am referring to this statement: "This method was taught by all manufacturers of IV sets and is recommended in the INS standards as the preferred method, if all meds are compatible. "

Unless I am misreading this, it seems to state that backflushing can only be used in order to use the same secondary tubing if the different meds given through the secondary are compatible, regardless of whether or not the incompatibility can be negated through proper flushing.

lynncrni
 For the final time, there is

 For the final time, there is a lack of scientific evidence on clinical outcome[s] with this delivery method to support such a statement. All published literature will be searched and the evidence examined for future edition of that document. Therefore your facility must make their practices now based on their conclusions from the literature. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

WadeBoggs26
 We can't actually come to

 We can't actually come to our own decision because the INS standard appears to state specifically that all secondaries must be compatible, regardless of whether or not sufficient flusing is used.  If it's the INS's intention to leave the specific issue of backlushing between incompatible antibiotics to facilities to determine then the INS's statement needs to reflect that.  Currently, the statement does not leave any room for facilities to come to their own decision.  In other words, the INS is clearly taking a position that backflushing is never sufficient to allow multiple non-compatible medications to be infused in the same secondary tubing, and I fully agree there is no evidence to support that, so it would seem the INS statement needs to be changed.   Even more confusing that there is no difference between the physical properties of the primary and secondary tubing when connected, it's all one continuous tubing, yet the INS seems to have two different standards for each.

WadeBoggs26
 I really could use some sort

 I really could use some sort of confirmation that it's up to facilities to determine if and how the same secondary tubing can be used for multiple medications.  

WadeBoggs26
 I'm sure someone out there

 I'm sure someone out there must know the answer to this; Does the recommendation refer to the primary/secondary compatibility or to the compatibility of different secondary medications and if so is it saying that different incompatible secondaries can never be given through the same line, even if a facility determines flushing between may be sufficient, or does it leave it up to facilities to decide this?

lynncrni
 As a member of the committee

 As a member of the committee who wrote the 2011 INS SOP, the statement in Standard 43, Practice Criteria II, D applies to all infusates. Standards are never written to be procedures. Anyone using the SOP to write internal policies and procedures MUST apply the facts for their situation - type of setting, patient populations, skill levels of staff, etc - to determine how the standard is to be applied in their setting. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

WadeBoggs26
 So the INS leaves it up to

 So the INS leaves it up to each facility/service to determine if and how secondary lines can be flushed between incompatibile infusates?

WadeBoggs26
 I'm going to assume that

 I'm going to assume that it's up to facilities to determine.  

As an aside, I very dissapointed that this is how many of the INS recommendations function; they are cryptic and leave you with a worse understanding of best practice than if you never read it in the first place.  I hope in the future that the INS will make a more reasonable attempt to make recommendations that are at least coherent.  The facility I work for won't purchase the INS guidelines for their library as they have not found them to be useful, a fact I strongly protested at one point, now I understand.

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