IV Push dilution methods... Is my method wrong?

[Axmann, RN, BSN, NREMT-B]

So, after perusing several methods of diluting IV push medications, I decided on the following method.

In this example, I'll use promethazine (Phenergan), 25 mg/1 mL with an order of 25 mg.

Here is the method I like to use:

1. Use a 1- or 3-mL syringe to draw up exactly 1 mL of promethazine

2. Empty 1 mL out of a 10 mL prefilled BD Posiflush saline syringe, at no time touching the threads on the syringe cap or anything that comes into contact with the fluid in the saline syringe itself.

3. Carefully Insert the needle of the 1- or 3-mL syringe into the top of the saline syringe and inject 1 mL of promethazine into the saline syringe.

4. Recap the saline syringe, at no time having contaminated the cap or tip of the syringe

5. Label the flush syringe as "promethazine, 25 mg"

When I told one of my coworkers this, she started freaking out and said "NEVER put anything in one of those prefilled syringes!" and said I should use the vials of saline instead.

I like my method as I'm never wondering exactly how much saline and drug I have in my syringe or whether I've accidentally let some of the drug flow into the saline vial. I'm also not worrying about having to inject air in the saline vial or alcohol the top of the saline syringe after opening it (as my finger sometimes slides across the top of the rubber in the saline vial as I take the cap off.)

When I asked her why she was so against it, she could offer no real explanation other than she was told not to and that I should do it her way.

I'm not satisfied by her reasoning. My state board of nursing has determined that I'm capable of exercising clinical judgment in the care of my patients, and I can't think of a single reason not to do it the way I've described when it's what works for me.

Can anyone offer some actual research as to whether this method is or is not acceptable?

[akulahawkRN, ADN, RN, EMT-P]

I would have to say that the method IVRS states is the safest one. It is safest to use an empty sterile syringe and draw from your vials using aseptic technique. Draw from the NSS first and then draw from the med next so you do not inadvertently lose some med in the NSS vial. Make sure your syringes are labeled clearly. One of the things I do is leave the needle on the syringe (capped of course) to additionally signify that the syringe has a med in it, that it's not a flush.

From my recollection, the NS flushes I used were wrapped in clear plastic and were marked "single use only" and "Normal Saline Flush" and weren't considered truly sterile. We couldn't open and drop them onto a sterile field. While the fluid inside was actually sterile, the outside, while clean, isn't considered sterile.

If you have no other option but to use a saline flush to dilute medications into, be very careful about your technique, clearly label your syringes (I usually also taped the med vial to the syringe) and use the medication immediately to help keep infection risk to a minimum. Of course... if you have a safer option, use it.

[wtbcrna, MSN, DNP, CRNA]

IVRS is the correct response. Normal Saline prefills are labeled for "flush only" and should never be used to reconstitute medication. If your institution fails to provide you NS in a vial then you must present them with the evidence to change their practice .That is what professionals do! That is what my coworker and I did and we got our NS in vials.The evidence is clear...do a search for it and you will find IVRS is correct.

What is the point evidence behind not using the pre-refilled flush saline syringes to reconstitute medicine?

[NurseSpeedy, ADN, LPN, RN]

I have not seen vials of Normal Saline in about 10 years. The prefilled flushes are the only option and I went to many different facilities working per diem. Label, label, label. Give immediately. Any please, never give Phenergan undiluted (OUCH!).

[la_chica_suerte85, BSN, RN]

When I was first starting I would have trouble making sure I didn't accidentally inject any med from the syringe into the NS vial as well. Now, it depends on what I'm doing and how much time I have, but I do it both ways. We give ampicillin in vials that require very extensive reconstitution so we still have vials of sterile water and NS so, I definitely can't reconstitute with a 10 ml flush. I guess I'm not that worried about figuring out which is flush and which is my diluted med because I won't use a flush out of the wrapper -- I've seen a lot of recapped, unlabeled flushes that have clearly been partially used just sitting next to patients' IV pumps like it's nothing and that freaks me out. But, for using an NS flush for dilution, I think it's just the "mix up" part that might occur without immediately labeling a med. Of course there can be contamination issues but that can occur with drawing up any med with any method. I mean, if your hospital provides NS and sterile H2O vials and it's by policy that they are the only means of diluting meds, then, that's the answer. If not, I don't see anything wrong with your present practice as long as you're careful with labeling.

[iluvivt, BSN, RN]

You can purchase NS prefills that can be tossed onto a sterile field but rhey are labeled as such and cost a bit more. I often find nurses tossing the regular NS prefills that only have the fluid pathway sterile onto a sterile field for port access.They simply did not read the package that clearly states it should not be placed on a sterile field.