Best way to get air out of IV tubing for IV antibiotics is ?

BiohazardBetty · Dec 18, 2012

If they have compatible fluids running, I always backprime... Spike & prime the abx w/ secondary tubing clamped, connect the secondary tubing to the primary tubing above the pump, unclamp the secondary tubing & lower the abx bag below the level of the primary bag... Gravity will prime your tubing with your primary fluid. Just make SURE the fluids are compatible & don't over fill the abx bag... You don't want to overload your pt.

Some nurses I work with hang a 100 ml bag of NS with every piggy back so they can always backprime. The things to remember w/ that are not overloading your pt- so only set the pump to flush w/ the amount of tubing you have (18mls for our primary tubing), & labeling the bag of NS w/ the time you hung it, since it must be replaced after 24 hrs (at least at my facility).

Also I've heard that hanging NS on a pt who isn't receiving NS is considered practicing outside your scope & essentially giving a pt un-prescribed meds. Anybody got any info about that? :)

Anna Flaxis, BSN, RN · Dec 18, 2012

It's not uncommon for intermittent infusion bags to be overfilled, and if that's the case with your pharmacy, you can simply re-prime the tubing using the medication you're infusing. Just go slow, and the air will move down the line along with the fluid.

Anna Flaxis, BSN, RN · Dec 18, 2012

Also I've heard that hanging NS on a pt who isn't receiving NS is considered practicing outside your scope & essentially giving a pt un-prescribed meds. Anybody got any info about that? :)

IV fluids are a medication that requires a physician's order. The practice of hanging a bag of NS to use for flushing/priming or to TKO, without a physician's order, is technically administering a medication that has not been ordered.

Protocol/standing orders are physician's orders, and flushing before and after are protocol/standing orders. However, flushing should be done using single use prefilled syringes. If single use prefilled syringes are not available, then multi-use containers dedicated to the individual patient can be used, but I doubt that's the case here.

It totally makes sense, is very practical, and saves a lot of nursing time to hang a bag of NS to use for these purposes, but it is against policy at many institutions. Just make sure your co-workers aren't out to throw you under the bus if you're going to follow this practice.

Pharmacies often overfill bags to take the priming volume into account, so check with your pharmacy and find out if/how much they overfill.

BiohazardBetty · Dec 18, 2012

IV fluids are a medication that requires a physician's order. The practice of hanging a bag of NS to use for flushing/priming or to TKO, without a physician's order, is technically administering a medication that has not been ordered.
Protocol/standing orders are physician's orders, and flushing before and after are protocol/standing orders. However, flushing should be done using single use prefilled syringes. If single use prefilled syringes are not available, then multi-use containers dedicated to the individual patient can be used, but I doubt that's the case here.
It totally makes sense, is very practical, and saves a lot of nursing time to hang a bag of NS to use for these purposes, but it is against policy at many institutions. Just make sure your co-workers aren't out to throw you under the bus if you're going to follow this practice.
Pharmacies often overfill bags to take the priming volume into account, so check with your pharmacy and find out if/how much they overfill.

Excellent advice!!! I'll check with pharmacy about this today.

MunoRN, RN · Dec 18, 2012

When used for the purpose of operating or maintaining a device, NS is not a medication, it is a device. It can be a little confusing that NS can be both a medication and device, but that's because it's not defined by the substance but by the intended purpose. This is why NS flushes are not a medication, they are regulated as a device, so long as you are using NS to prime and flush a line or maintain the line or IV, no MD order is needed.

psu_213, BSN, RN · Dec 18, 2012

If this is with a pump (Alaris or the like):

Hang NSS at 10 mL an hour. Set it to infuse a total of 10 mL. Hang your antibiotic and back prime it, set it up on the pump. Antibiotic runs in. When it is done, the NSS will again begin to infuse, but it won't be more than 10 mL. Do you need a doctors order for the 10 mL of NSS? In the most technically sense, probably. Is anyone going to care about this? No. At our facility, written policy is that all antibiotics are piggybacked into a compatible primary.

Anna Flaxis, BSN, RN · Dec 18, 2012

When used for the purpose of operating or maintaining a device, NS is not a medication, it is a device. It can be a little confusing that NS can be both a medication and device, but that's because it's not defined by the substance but by the intended purpose. This is why NS flushes are not a medication, they are regulated as a device, so long as you are using NS to prime and flush a line or maintain the line or IV, no MD order is needed.

Yes, saline flushes are a device and flushing and locking procedures are routine/protocol VAD care actions.

However, hanging a bag of saline is a different story, and one should be careful to consult their facility's policy regarding this. One could argue that using bagged NS and a pump to deliver a 10mL "flush" postinfusion is essentially the same as flushing and locking, but your particular institution may not view it that way.

At some facilities, policy may state that intermittent infusions are to be piggybacked through a compatible primary, as one poster mentioned. At other facilities, this is not the case, and hanging even a mini-bag, even if just to use for priming and flushing, may be against policy.

MunoRN, RN · Dec 18, 2012

Medications are defined by purpose, not by the container they come in, whether you're flushing with a syringe or a bag it makes no difference.

Intermittent antibiotics should be hung as a primary/secondary set up. We looked at how much medication gets lost when intermittent infusions are run as a "piggyback" and the average lost was 23cc. Even for a 100ml antibiotic that's about a quarter of the dose. Plus there's more manipulation of connections when a primary/secondary is not used which increases the chance for infection. While it never ceases to amaze me how bad some policies can be, I'm skeptical that we're so far off our game that secondary set ups wouldn't be allowed, and if that it the case it would be worth getting rid of. As a Nurse you're responsible for the quality of your own practice, following a bad practice policy won't protect you much.

Anna Flaxis, BSN, RN · Dec 18, 2012

Medications are defined by purpose, not by the container they come in, whether you're flushing with a syringe or a bag it makes no difference.

I thought NS flushes were a device, not a medication.

If intermittent bags are overfilled with priming volume in mind, which is the case at my facility, then the patient will still receive the full dose.

Also, while infusing 10mL from a pump might be an adequate flush for a PIV, it's not a substitute for pulsatile flushing, as is protocol for CVADs in my facility.

Keeping the patient tethered to an IV pole interferes with mobility, and the risk of the patient unintentionally pulling out their IV is increased. To counteract these things, you disconnect the patient from the line when it's not in use, so you end up manipulating the connections the same amount anyway.

Don't misinterpret me; I actually agree with you. I'm just playing a bit of Devil's Advocate here. I have bumped up against the policy that forbids hanging fluids when not ordered by the physician, because it makes no sense to me. It seems ridiculous that a practice that can increase RN efficiency and decrease infection risk is forbidden at my facility. The rationale I was given was that it was because of the risk of fluid overload in the event of incorrect pump programming, free flowing fluid, etc.

Whether it is a bad practice policy is debatable. Studies of PIV associated infection rates are slim. Evidence one way or the other is not conclusive, as far as I know. All we are left with is our opinion.

Regardless of what you and I might think about it, it is against policy in some facilities, and I think that bears keeping in mind. That's why I originally stated that if one is going to follow this practice (assuming it is not P&P), be careful that your co-workers are not looking for a reason to throw you under the bus.

somenurse · Dec 18, 2012

to the OP,

one other small tip, for preventing air bubbles, in iv lines, is,

when flooding the iv tubing, ensure you fill those lil compartments where the ports for secondary tubings to be attached are, with the fluid. Often, the tubing can be full, top to bottom, with fluid,

but, those ports can harbor lil pockets of air, which will make your pump beep beep beep.

Turning those ports upside down, when flooding the tubing, and flicking those lil air bubbles out, can help reduce the beepings.

MunoRN, RN · Dec 19, 2012

I thought NS flushes were a device, not a medication.

I'll restate that, medications, and what isn't a medication, is defined by...

If intermittent bags are overfilled with priming volume in mind, which is the case at my facility, then the patient will still receive the full dose.

Medication bags are typically overfilled with volume, not medication, the amount that gets lost is highly variable, from none to 34cc, so overfilling with med still would mean they'd get the wrong dose much of the time.

Also, while infusing 10mL from a pump might be an adequate flush for a PIV, it's not a substitute for pulsatile flushing, as is protocol for CVADs in my facility.

I agree with you on pulsatile flushing, although I think we're the only two Nurses who practice that. Unfortunately, the 'powers that be' have discouraged the use of pulsatile flushing despite the manufacturers recommendations and the basic laws of fluid dynamics.

Luckily, IV pumps are pulsatile, and while they aren't the same as a manual pulsatile flush, they're better than a manual non-pulsatile flush.

Keeping the patient tethered to an IV pole interferes with mobility, and the risk of the patient unintentionally pulling out their IV is increased. To counteract these things, you disconnect the patient from the line when it's not in use, so you end up manipulating the connections the same amount anyway.

This is true, although we looked at this and found that there were enough times where changing the set-up unnecessarily produced an additional tubing manipulation to justify an attempt to still limit the number of manipulations.

Don't misinterpret me; I actually agree with you. I'm just playing a bit of Devil's Advocate here. I have bumped up against the policy that forbids hanging fluids when not ordered by the physician, because it makes no sense to me. It seems ridiculous that a practice that can increase RN efficiency and decrease infection risk is forbidden at my facility. The rationale I was given was that it was because of the risk of fluid overload in the event of incorrect pump programming, free flowing fluid, etc.

As you've apparently noticed, those that write policies are sometimes surprisingly misinformed. I don't advocate just "going rogue", but bad policies should be challenged through the appropriate channels. We have a particularly "uppity" group of Nurses at my facility, so our process for fixing a bad policy is to write a position statement through our practice or research council that states how we will practice and why, and if the policy fails to keep up with good practice then we can't follow that, it works for us but other facilities are likely less tolerant of this.

Whether it is a bad practice policy is debatable. Studies of PIV associated infection rates are slim. Evidence one way or the other is not conclusive, as far as I know. All we are left with is our opinion.

The infection concern is more for central lines/PICCs, the dosing concern is related to all IVs.