Our attorney adivises us the TKO is not a legal order. A rate needs to be attatched to this order for it to be a legal order.
That is exactly correct. A KVO or TKO rate is not a legal order as there must be a rate specified for each patient. I also do not understand the need for any slow KVO rates. First there is no such rate that is scientifically shown to keep open any vein or catheter lumen. Second, if the patient does not require a specific amount of fluid, why not just cap the lumen and use it intermittently, thus allowing the patient more freedom of movement and a quicker discharge from the hospital.
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
I'd like to revisit this discussion. Somewhere along the way our institution adopted a policy that if a peripheral IV or CVC is accessed more than 6 times in 24 hours there should be a running IV with slow maintenance fluids at 25ml/hr. I'm told there was evidence that stated that this would reduce the risk of infection as you weren't breaking the system multiple times. In my mind, we are still "breaking the system" when a piggyback or IV med is given only this way it's being done through the running IV as opposed to the hub of the catheter. Could you weigh in on this please. I am wondering if we need to reconsider this policy or if there is evidence/recommendations that says that what we are doing is apporopriate.
Also, are there any recommendations or evidence on the minimum flow rate that should be run through a peripheral line and CVAD to keep the line open?
I appreciate your help with this.
Wendy Douglas BS, RN VA-BC
I am afraid you are looking for evidence that does not exist. The 6 times in 24 hr and 25 mL/hr was a judgement made by your facility. A reasonable decision but not evidence-based. Unfortunately there are many practice decisions that are not supported by evidence. Regarding breaking your system, my question for you would be -- are you connecting and disconnecting the secondary piggyback sets from the continuous primary set with each dose? If you are that is what should be changed. Allow these sets to remain connected for the full 96 h of set use as stated in the INS Standards. This decreases the manipulation of the system. With this practice the only manipulation would be to add a new fluid container with each dose. Leave the empty one hanging until time for the next dose. There is no evidence establishing a flow rate that will maintain patency of a peripheral or central VAD. There is some evidence from the ambulatory pump manufacturers used in home care about the very low rates that can be programmed between medication doses. But that data would only apply to their brand of small ambulatory pump. For gravity infusion or pole mounted volumetric infusion pumps there is not minimum rate because there are far too many variables.
Robbin George RN VA-BC
There is no evidence that this low flow rate helps to maintain catheter patency, however I can understand the need to piggyback a PCA or multiple medications into an infusing line. I have seen hospital policy make an attempt to write a so-called KVO rate, but there is no science to back it up and it ignores the individual patient needs. I do not think it is an acceptable method for addressing this. All orders must include a rate specific to that patient written by the physician or NP with prescriptive authority. Lynn
I had a discussion about this with Samantha Keough with the AVATAR group at AVA2017. She suggested there are components of the inflammatory process that are continuously washed away with a slow TKO and would help reduce the risk for phlebitis. TKO never made sense to me as the vein is open, catheter occlusion is the risk. With proper flushing and clamping sequence this becomes a non-issue but after my discussion with Samantha I'm curious to know more.
That may be a theory worth investigation but it does not address the question of what exact rate. I still maintain that there are too many variables for one rate to maintain patency on all VADs and veins.
we actually did talk about that. catheter gauge, vein to catheter ratio, even the viscosity of the patient's own blood could play a part. I agree it will be next to impossible to assign an exact rate with all the variables. What interested me was the concept of preventing phlebitis with a slow continous infusion. It will be a long time before we fully understand how to implement this if it's even worth doing.