Flushing with Sterile Water

IVRUS, BSN, RN · Feb 11, 2015

I am working as an educator at a hospital in a developing nation. I found early on that the nurses very seldom flush their IVs (not after giving medication, not after insertion with blood draw), but just discovered that when they DO flush them, they use straight "sterile water for injection". A quick search here and on a drug site showed that this is absolutely not acceptable. I am working with the pharmacy to source suitable normal saline for flush instead--we have NS but it comes in 250 ml bags and 500 ml bottles only--but the immediate response was "We don't have that here [in this country]." After I showed the research showing that sterile water is not manufactured for use as flush and that it's actually dangerous, the pharmacist agreed to at least check if such a thing is possible.
But until such a time as I can convince the hospital to make this major practice change (and there may be significant financial outlay involved, I have no idea), what do you think I should do? Is it better for the nurses to continue not flushing the IVs anyway, or is it better to encourage them to flush with the sterile water until the day NS might be available?
A couple of times a year we have visiting medical teams from first-world countries come to do some advanced surgeries. I asked the pharmacist what those teams use for flushes (he'd said to me yesterday, when I asked for NS to flush a central line, "oh... I think we have some left from the last American team") and he claimed they use lots of things, NS that they bring, sterile water, even LR (?). That may just have been defensiveness, but if these American and Australian ICU nurses are really using sterile water to flush, I'm alarmed! Maybe they just haven't heard of it so assume it's okay.

Sterile Water should NEVER be used as a flush solution. It has an osmolarity of 0. Therefore, every blood cell that it comes in contact with will swell and burst! I also would not advocate drawing out saline from your 250 or 500 cc bags. That is a real infection issue, as these bags do not have any preservatives in them, and I doubt that someone is drawing out 10cc or so for a flush, and then discarding the whole bag. No, he/she is probably accessing it over, and over again. At least once a day, all central lines should be flushed, unless they are valved. Valved IV catheters usually only need flushing before and after or med, or once a week, whichever comes first.

AJJKRN · Feb 11, 2015

The only time I have ever used sterile water has been when "compound mixing" a dry powdered med such as zyprexa or glucagon to IV push liquid form. We use 3cc and 10cc individual packages of sterile normal saline to flush before and after meds unless the patient has a continuous IV fluids running, this is the only way I can see LR, etc being used as a flush. Sounds like this is a product that could be donated to your facility correct?

BonnieSc · Feb 12, 2015

I know the sterile water is not acceptable--but the question is, since that's all I have at present, which is worse: not flushing at all (current practice most of the time) or flushing with sterile water? I know this seems like a ridiculous question.

No one is currently drawing NS out of 250 or 500 ml bags, either once or multiple times--they do not use NS to flush at all. NS is used only for IV fluid boluses or wound care.

While it's certainly possible that pre-filled NS syringes or something similar could be donated, we are trying to be sustainable--this is a long-term problem and I hope to find a long-term solution.

Thank you both for the reinforcement!

IVRUS, BSN, RN · Feb 13, 2015

Well, if the IV catheter is NOT flushed at intervals, you will see a lot of catheters which become clotted... And I'm sure that since you don't have NSS, you probably will find it harder still to get Cathflo for declotting purposes! Since you do have NS can you possible run the NSS at a low rate, ie 5cc/hr, so flushing isn't an issue? Now, the bag itself can only hang for 24 once spiked, but clotting shouldn't be too big of an issue then.

FlyingScot, RN · Feb 13, 2015

Well, if the IV catheter is NOT flushed at intervals, you will see a lot of catheters which become clotted... And I'm sure that since you don't have NSS, you probably will find it harder still to get Cathflo for declotting purposes! Since you do have NS can you possible run the NSS at a low rate, ie 5cc/hr, so flushing isn't an issue? Now, the bag itself can only hang for 24 once spiked, but clotting shouldn't be too big of an issue then.

Having done a few medical missions I've really had my eyes opened at how lucky we are here in the US. While it would be best to follow EBP sometimes it just isn't possible. For instance, in Peru they reused EVERYTHING! I'm talking chest tubes, Pleurevacs, IV catheters, syringes you name it. We were apalled but had to stay quiet because this was the only way they would have any supplies available. Soooo, I guess what I'm saying is depending on how medically behind the OP's country is the idea of drawing from a saline bag for flushes might be the lesser of two evils.

RunBabyRN · Feb 14, 2015

Having done a few medical missions I've really had my eyes opened at how lucky we are here in the US. While it would be best to follow EBP sometimes it just isn't possible. For instance, in Peru they reused EVERYTHING! I'm talking chest tubes, Pleurevacs, IV catheters, syringes you name it. We were apalled but had to stay quiet because this was the only way they would have any supplies available. Soooo, I guess what I'm saying is depending on how medically behind the OP's country is the idea of drawing from a saline bag for flushes might be the lesser of two evils.

This was my thinking, too. We are very lucky that we have the luxuries that we have, but this would probably be better than not flushing at all or using sterile water. Do you have alcohol wipes and good scrubbing practices to at least reduce the risk of contamination? How long would a 250 mL bag last you for something like this, do you think?

BonnieSc · May 16, 2015

Bringing up my old topic again. So far I haven't been able to get a workable small bottle of NS for flush. I reread what some of you have said about using a large bottle and drawing up the flush (pluses and minuses to that). I spoke with our ICU, which does flush with NS; they use a 500 cc bottle for each patient, draw up flushes as needed, and discard every 24 hours. But even they said it wouldn't be practical for med/surg, because we don't give as many IV meds and wouldn't use very much of a 500 cc bottle.

What if we have a dedicated 500 cc bottle in our "pharmacy" room which the nurses share to draw up flushes as needed? They would be trained to clean with alcohol before drawing up, similar to a multidose bottle of insulin. The bottle would be tossed every 24 hours.

Opinions?

BonnieSc · May 16, 2015

(Let me add: they aren't even flushing after a BLOOD TRANSFUSION. We are in dire straits here.)

FlyingScot, RN · May 16, 2015

I think that is your only choice at the moment.

BonnieSc · May 18, 2015

Thanks for the comment. I think I'm going to give this a test run with a couple of good nurses and see whether they find it workable (the nurse manager is concerned about the logistics of it).

By the way, we had one of the visiting ICU teams here for a few weeks and they laughed when I asked if it was true that they flush with sterile water like the local nurses. They bring their own saline.

Asystole RN · May 18, 2015

Bringing up my old topic again. So far I haven't been able to get a workable small bottle of NS for flush. I reread what some of you have said about using a large bottle and drawing up the flush (pluses and minuses to that). I spoke with our ICU, which does flush with NS; they use a 500 cc bottle for each patient, draw up flushes as needed, and discard every 24 hours. But even they said it wouldn't be practical for med/surg, because we don't give as many IV meds and wouldn't use very much of a 500 cc bottle.
What if we have a dedicated 500 cc bottle in our "pharmacy" room which the nurses share to draw up flushes as needed? They would be trained to clean with alcohol before drawing up, similar to a multidose bottle of insulin. The bottle would be tossed every 24 hours.
Opinions?

What I would suggest to minimize the risk of cross contamination is to have a single dedicated person draw up several flushes at a single time, kept in the refrigerator if available, and discard them after 24 hours.

This way you do not have multiple people touching a common source and since the flushes are ready made it may help with compliance.