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IV Tubing ..The debate from Canada


I work in the community setting doing homecare visits.

Our clients (patients)can receive their iv  med via Cadd pump with a CVAD - usually a PICC line.

We do not give lipids , tpn. We give Vanco,ceftriaxone, cefazolin to name a few.

Here is our policy-

Flushing -

Flush   turbulent with  0.9%  NaCl  -  10  mls  before  and   at  least  20  mls  after  (2  or  3  -10ml  syringes) with  intermittent  use;   •  With  continuous  use,  flush  turbulent  with  at  least  20 mls  0.9%  NaCl,  after  checking  blood  return, when  changing  tubing  and  caps.   (72-96 hrs)

Tubing changes-

Change continuous tubing  every 72-96 hrs  Change intermittent tubing  every 24  hrs   (for  both primary  and secondary  IV sets)  Intermittent are  those infusions where  the tubing  is disconnected until  the  next dose  and  the CVAD is flushed  and locked.  

We have in the past had frequent issues with our PICC lines not giving blood return or Flushing well.New policy  developed /updated to discard the blood filled syringe  post  blood check and changed to microclave clear neutral caps.On the whole, less issues.

However some staff , on a continous infusion, will still check for blood return and flush daily or twice daily-if we are replacing a bag at 12 hours because they want to "maintain patency and kvo isn't enough pressure  to clean the PICC line."

Our policy also indicates checking blood return and flushing prior to each med administration. .and their rationale on a continous infusion . "Adding a med bag to a pump line  is  administering" ..


Vanco is "stickier and potential for precipitate to form..frequent flushing is required." 

Our policy clearly states on continous infusions  to  check blood return and flush  with cap and line changes every 72-96 hrs.

I believe the continous infusion   being flushed more freguently -now warrants a intermittent line change  frequency .Every 24 hours.

Isn't the very reason we change intermittent tubing because of the frequent disconnect and reconnect? And potentail for infection due to opening the system. 

Does it matter how long it has been disconnected. .say 3 access patency of a PICC.Once you apply  the fresh new fluid path  system is no longer considered a continous tubing if it is opened ? 3  min or 12 hours. It's has now been opened.

Am I wrong in thinking this?

Please point me in the correct direction if I am wrong in my thought process.

I appreciate any and all comments.

Thank you  in advance for your help 







 I think you have several

 I think you have several issues going on. I am the first one to preach about the need for blood return, but there is a point where it might be doing more harm than good and you may have described it. 

First you must understand the limitations on available studies (the real evidence). All available studies are from hospital based continuous infusions. The studies either stated they did not address medication sets or were silent on the issue. These decisions must be made based on what studies we have, plus basic principles of infection prevention. Opening a continuous infusion by disconnection every 12 or 24 hours is far too much manipulation. I don't think studies would show that contamination is a direct correlation to the time it is apart. The act of disconnection, how the male luer end is managed while it is disconnected, and the reconnection process is what increases the risk of contamination, IMHO. 

I am assuming you are talking about using some type of CADD pump for all infusions. Is this the actual brand of CADD Prism or CADD Legacy? The sets for these may not have an injection site that allows you to check the blood return without any set disconnection. If you are using another brand of ambulatory pump the sets may or may not have an injection port. Blood return should be done before each dose of medication along with saline flushing to assess for patency. In home care in the US, most nurses are concerned about patients/families doing this and knowning how to understand what they are seeing. In home care, we are usually not talking about severe vesicants as what is given in the hospital. So assessing for patency is done by the nurse on routine weekly visits. Remember in home care, the patient is giving their infusions, not the nurse. Sometimes a patient will get a CADD due to their inability to see, perform, or learn the process for giving IV meds and the nurse may go out daily to change the CADD bag. But aspiration for a blood return is only done when it is time to change the set. 

According to CDC and INS, set change for continuous infusion is done NO more frequently than 96 hours. So changing it more frequently at 72 h is no benefit. 

Flushing to "clean the PICC line" is a concept that must be dispelled. There is no way to do that as there will always be fibrin and biofilm on the intraluminal catheter walls. This stuff sticks firmly and there is no actual evidence that flushing will remove it. And there is a question about whether encouraging the shearing off of this material is a good thing as it will be injected into the bloodstream. 

To assess patency, all you have to do is to see blood in the external catheter or extension leg that is the color and consistency of whole blood. There certainly is no need to withdrawn a syringe full and discarding it can easily cause iatrogenic anemia from blood loss - lots of evidence about this problem in hospitalized patients. I would stop this blood wasting immediately. 

Your focus for PICC lumen occlusion is only on the possible intraluminal cause of blood reflux. Microclave is labeled as a neutral device, but are you also using a tradtional syringe that will encourage blood reflux due to the compresssion of the gasket at the end of the plunger rod? If using a prefilled saline syringe, check the product literature to see if they claim elimination or reduction of syringe induced reflux. If this is not present, the manual flush should always stop when .5 to 1 mL of flush solution remains in the syringe as this will prevent gasket compression and rebound reflux. 

Tip location is a cause of intravenous thrombus at the tip. So ensure that the tip is correctly placed to reduce this risk as an intravenous thrombus will easily prevent backflow of blood from the catheter. 

I think you should educate to reduce the extreme frequency for checking blood return; check for blood return by the nurse only when the set is changed at intervals no more frequently than 96 hours, and stop wasting all that blood. Lynn



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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

IV tubing: the debate from Canada

Our procedure for tubing changes for community-based clients is: tubing change q96 hrs if on a continuous infusion. The VAD is flushed when the tubing is changed or sooner if the infusion is delayed or the patient is indicating occlusion alarms. If the system is interrupted prior to the 96hrs, the tubing is changed and the frequency reset. We developed an algorithm to support principles of line preservation, infection control and min. disruption. LMK if you'd like a copy.

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