Question about a recent patient

[Graduatenurse14]

Hi, I'm a new RN on a busy med-surg floor. I had a patient with a double lumen PICC. One was running IVIG and the other was simply getting flushed q shift. I went to flush it but it wouldn't flush, I repositioned the arm but it still wouldn't flush. I waited a bit and tried again but nothing worked so instilled Cathflow per policy.

It worked after that and to make sure it was kept open, I flushed with 10 ml NSS q hour. Should I have just asked the doc to start NSS at a KVO rate? He really needed the IVIG so I didn't want to risk losing the second lumen if the first one somehow went bad.

I don't recall if I've even seen (in my limited career!) someone with a PICC running at a KVO rate. Is this done?

THANKS!!!

[IVRUS, BSN, RN]

At times, keep vein open rates (KVO) may be done with PICC's, however, please remember that this is an incomplete order. KVO can be anything from 0.2 cc/hr to 50cc/hr. Unless the facility you work for has a P&P for what KVO means to that facility, then do not accept your MD's order without getting clarification. "Hey doc, can that be 10cc/hr, 20cc/hr" etc. My thought on the subject here is first, did you have orders to flush q hr? And, was your NSS preservative free? If not, and you have either a neonate or an elderly person, NSS in your multidose vials have a preservative in it which can be neuro-toxic to both of these groups of individuals. Was the use of Heparin flush contraindicated for this patient? Allergy wise, or seconday to HIT?

[Graduatenurse14]

My thought on the subject here is first, did you have orders to flush q hr? And, was your NSS preservative free? If not, and you have either a neonate or an elderly person, NSS in your multidose vials have a preservative in it which can be neuro-toxic to both of these groups of individuals. Was the use of Heparin flush contraindicated for this patient? Allergy wise, or seconday to HIT?

No order to flush q hr. Isn't that where nursing judgement and interventions come in? I didn't know I needed an order for this.

I was using the standard 10 ml NSS syringes and don't know if it has preservatives. Does it?

It was Alteplase not Heparin and he had no contraindications: no allergies, no HIT.

I'll clarify what KVO is there.

I have soooo much to learn!!!

[melizerd, ASN, RN]

We have a prn order for flushing all lines, 2ml for PIV and 10ml for ports/piccs. So I wouldn't need anything else to flush at my discretion.

My floor sees piccs/ports a lot so we do occasionally have people with a kvo style order (usually 10ml/hr NS) for a difficult lumen.

[IVRUS, BSN, RN]

No order to flush q hr. Isn't that where nursing judgement and interventions come in? I didn't know I needed an order for this.

I was using the standard 10 ml NSS syringes and don't know if it has preservatives. Does it?

It was Alteplase not Heparin and he had no contraindications: no allergies, no HIT.

I'll clarify what KVO is there. I have soooo much to learn!!!

If it were a prefilled syringe, single use, in its dust cover, or sterile package, then it probably does NOT have preservatives in it. Those will be in your multidose, 30 cc vials of NSS. Normally, one has orders to flush the line, and each lumen with XYZ mls of NS before and after the Intermittent medication, as long as compatibility exists. Therefore if you flush it more frequently, where is your order to do that? Now, as melizerd said, if you have an order that says flush the IV with 2mls of NSS before and after AND PRN... you are covered.

[Graduatenurse14]

I found out that 30 ml/hr is KVO at my facility.

I'm not sure if I had a PRN order to flush but of course I had the order to flush to asses patency q shift and before and after med administration.

These are little things that can turn into big things for new nurses! As I said above, I have soooo much to learn!!