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poor access, give medication through butterfly?

I have a question, we have a patient on kepivance, which must be given direct IV undiluted, which is an amount of .93 mls. In order to properly draw up an acurate dose, we need to use a 1 cc syringe. We don't want to use the 1 cc syringe in his PICC line, and we can not get a peripheral IV into him.


It was suggested to use a butterfly to gain access, give the drug, and remove it. One of our managers has issues with this, as using a steel needle to give medications is not appropriate.


Any thoughts on this? any other suggestions on how we can administer the medication?



Good question! I just read

Good question! I just read the monograph in Gahart's Intravenous Medications about this drug. If your patient is getting 3 daily doses before and 3 after the other therapy, that is 6 additional venipunctures. If it were me, I would object to being stuck when I have a PICC in place. Is this prepared in the pharmacy and they have chosen this size syringe? Who is giving the dose - IV nurse or staff nurse? The drug monograph talks about flushing before and after with saline and no contact with heparin. I know the possible dangers of using a 1 ml syringe on a PICC, but would want to know what type of PICC it was - silicone or polyurethane? Do you have problems with resistance or lack of blood return? Does it flush easily without any signs of resistance? If there are no issues with the PICC and this syringe is in the hands of experienced IV nurses who know the risk and know when to stop, I would say use the PICC after careful assessment of patency with a 10 ml saline syringe first. These small syringes are frequently used in neonatal PICCs. The issue is force applied to the small diameter syringe meeting resistance. Then an untrained, busy staff nurse just applies more pressure to overcome the resistance and ruptures a silicone PICC. To me a polyurethane PICC with this small syringe in the hands of IV nurses should be the best way to avoid making additional venipunctures.

Using a metal needle to give medications is not a problem as long as the qualified nurse remains with the patient during the entire push or infusion. I would never use a metal needle for an infusion of even 5 minutes and leave the patient for fear of infiltration. Years ago, we thought of butterflies as having an internal infection prevention mechanism - they infiltrated too fast to become infected!

The drug monograph did not have any information about the irritant nature, no mention of it being a vesicant, and the pH is 6.5. So far it sounds acceptable through a butterfly, but I would not want to use his veins for this and have the discomfort of that many additional venipunctures, especially with a PICC in place. Tough choices! 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

Thanks for your response

Thanks for your response Lynn,

It has been a difficult issue with us. No one watned to give it through the butterfly, but we just could not have a peripheral IV stay in place, no matter what we did. It is frustrating having a PICC and not being able to use it!

The PICC is a groshong, and we've had many problems with them, as well as busy nursing staff, so I'm afraid to allow them to use the small gauge syringe on this patient.

We reconsitute and prepare the medication, so with the small amount, have to use the smaller size syringe. 0.93 is an odd amount to draw up.

As you said, this is a very difficult choice! We are actually looking at a syringe transfer device right now, so hopefully that will help. THanks so much about your answer as well to the medication in a steel needle. I think the confusion was that we never give a vessicant this way, but this particular drug doesn't seem to be an issue.

We contacted the manufacturer, but they haven't been much help. As we are seeing this drug much more often, I hope we can figure out an appropriate way to give it for all of our patients.



I would agree with Lynn to

I would agree with Lynn to assess the PICC for patency with a 10 ml saline flush.  Once this is done, if the drug is given slow IVP via a 1 ml syringe there is minimal risk of rupture.  I think the risks of trying to transfer that small a volume of drug from one syringe to another adds an infection control risk.  Plus what volume of drug are you losing in the transfer?  Seems to me it would be safe to use a 10 ml to assess and flush, followed by the smaller medication syringe, followed by another saline syringe.  I have not seen any reports of a catheter rupture with a smaller syringe when the catheter is patent.  Does anyone know if there are any?

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