IV Push med– do you always have to pull back for blood return? - page 2

I'm really confused. Some resources say to pull back on plunger for blood return before pushing med, while others say flush with saline and then push med (without mentioning a need to check for blood... Read More

  1. by   Daisy4RN
    Every nurse knows the fall back position of polices/procedures. That being said, there is also real world nursing. If a line flushes well with no problems then I would go ahead and give the IVP med unless it is a vesicant in which case you do need to see a good blood return. If nurses only had 1 patient you might be able to do everything by the book, definitely not with multiple patients. And as someone else posted, its not only the nurses time (to start a new IV), but near impossible on certain patient's. You will not always get a blood return on a good PIV.
  2. by   Lauraingalls
    I have never pulled back for a blood return when giving an IVP med... I make sure it flushes but didnt pull back for blood return. Not done on our OB unit
  3. by   nehneh14
    Quote from ~Mi Vida Loca~RN
    So back to my question, is it of your opinion that if there is not free flowing blood flow when you draw back that it's not a patent line??

    I am well aware about resistance when flushing and all of that. I have had problems when people come in with their PICC line and had to get a cathflo order from the doc.

    But I know for a FACT you can have a patent line without free flowing blood return. I have seen it often on already established IV's (of a few hrs because I work in an ER setting) and rarely on a newly inserted IV's. Flushes great. Bolus goes in great. No infiltration. No pain. Can even visualize the flush going in under U/S. But no blood return. Not getting free flowing blood when drawing back does not automatically mean it's not a patent line.
    Absolutely true. Have had to use many a patent IV through which I could not get blood. On many patients you protect that IV with your life and if there is no sign of infiltration or extravasation, you use that line. Having said that, I always checked for a blood return, but not having one does not necessarily mean you shouldn't use it. Of course, you have to comply with your own facilities policy, but experienced RNs know that what a policy says can be contradictory to what is actually most beneficial to the patient.
  4. by   IVRUS
    Quote from Lauraingalls
    I have never pulled back for a blood return when giving an IVP med... I make sure it flushes but didnt pull back for blood return. Not done on our OB unit
    This is truly frightening to me!!
  5. by   IVRUS
    Quote from BSN16
    Went to this website, could not access anything. Also checked up to date to find anything about how lack of blood aspiration in PIV means an not functional PIV, still nothing. If i were to take your word for this, this would be completely absurd to have to pull/restart IVs on all patients who have lines that do not aspirate back blood.
    Well, I'm sorry you didn't get to the website. Yes, there is a dollar amount attached to the standards, but imo, well worth it. Also, check out one of the other leading INFUSION gurus, if you don't want to take my word for it.
    Previous Posts - Lynn Hadaway Associates, Inc.
    This has the info by one nurse educator who helped write the standards, and is called in on many IV court cases.
  6. by   MunoRN
    Quote from IVRUS
    Yes, We all know that short term peripheral IV catheters have fibrin building up quickly, frequently leading to withdraw occlusions, BUT todays standards of practice say that if one cannot get a free-flowing blood return from ALL IV catheters, you have a non-functioning IV catheter. Resite it in that case. More and more research is done and that research is where STANDARDS OF PRACTICE are from. Check Infusion Nurses Society: www.ins1.org for they are the organization which publishes these standards. This organization is cited in courts of law whenever a case involving IVT is seen.
    Lack of blood return in a peripheral IV is not an indicator that the IV should not be used, it's actually a fairly normal finding in an otherwise well functioning peripheral IV. As an assessment parameter, it's not particularly useful, since a well functioning PIV may often not draw blood, and it's certainly possible for an infiltrated IV to have blood return. To re-site a PIV many times every day would likely cause more potential for harm than using an otherwise functional and normal site just because it lacks blood return.

    The Infusion Nurses Society makes practice recommendations, those recommendations however are not equivalent to a legal standard of care, since that is something that is broadly accepted as the only appropriate course of action. If a recommendation is not widely followed, then it's not a legal standard of care. I've looked at the policies on this of more than 30 facilities and organizations, and have yet to find a single one where a peripheral IV is to be discontinued because it lacks blood return (which means it's far from being a legal standard of care). The one exception being infusions that should generally be given centrally but for whatever reason are being peripherally, in which case it's not uncommon to find policies that there must be blood return, but using a peripheral IV for this purpose is relatively uncommon.

    The INS potentially plays an important role in guiding IV therapy practice, but the baseless threats about legal standards of practice aren't the way to get broad support in the nursing community, consistently well reasoned and supported practice guidance are.
  7. by   MunoRN
    Quote from IVRUS
    Well, I'm sorry you didn't get to the website. Yes, there is a dollar amount attached to the standards, but imo, well worth it. Also, check out one of the other leading INFUSION gurus, if you don't want to take my word for it.
    Previous Posts - Lynn Hadaway Associates, Inc.
    This has the info by one nurse educator who helped write the standards, and is called in on many IV court cases.
    Lynn actually only argues that blood return is a requirement for infusing vesicants, not other infusions.
  8. by   IVRUS
    Quote from MunoRN
    Lynn actually only argues that blood return is a requirement for infusing vesicants, not other infusions.
    YOU obviously did NOT read what she wrote, but rather love forming your own opinions.
    She wrote:
    The 2016 Standards now call for obtaining a blood sample from a peripheral catheter during the dwell time instead of during the insertion procedure. Studies are showing that this is a successful practice. If the peripheral catheter will yield a blood sample, it can easily produce a blood return for patency assessment. As I mentioned, technique can be the cause of failure to obtain a blood return. First and foremost, use a slow and gentle technique to aspirate from the catheter. Pulling hard and fast on the syringe plunger can pull the vein wall over the catheter lumen. Next, change to a smaller syringe as aspiration with a smaller syringe produces less pressure and better results. That is opposite from what happens with injection where a larger syringe is recommended. Finally, put a tourniquet on the arm above the catheter tip to see if there is a blood return. If all of these techniques fail to produce a blood return, do NOT use the catheter. (Feb 2016)
  9. by   IVRUS
    Quote from MunoRN
    Lack of blood return in a peripheral IV is not an indicator that the IV should not be used, it's actually a fairly normal finding in an otherwise well functioning peripheral IV. As an assessment parameter, it's not particularly useful, since a well functioning PIV may often not draw blood, and it's certainly possible for an infiltrated IV to have blood return. To re-site a PIV many times every day would likely cause more potential for harm than using an otherwise functional and normal site just because it lacks blood return.

    The Infusion Nurses Society makes practice recommendations, those recommendations however are not equivalent to a legal standard of care, since that is something that is broadly accepted as the only appropriate course of action. If a recommendation is not widely followed, then it's not a legal standard of care. I've looked at the policies on this of more than 30 facilities and organizations, and have yet to find a single one where a peripheral IV is to be discontinued because it lacks blood return (which means it's far from being a legal standard of care). The one exception being infusions that should generally be given centrally but for whatever reason are being peripherally, in which case it's not uncommon to find policies that there must be blood return, but using a peripheral IV for this purpose is relatively uncommon.

    The INS potentially plays an important role in guiding IV therapy practice, but the baseless threats about legal standards of practice aren't the way to get broad support in the nursing community, consistently well reasoned and supported practice guidance are.
    Have you ever been called in as an expert in Infusion Therapy, Muno... Obviously not, because you would then know what the Courts look to for proper standards of care with infusion.
  10. by   Daisy4RN
    From Lynn Hadaway article:
    The nurse can not rely exclusively on the presence of absence of a blood return before using the peripheral catheter. There could easily be a second puncture in the posterior vein wall and still get a blood return OR there could be a small catheter occluded by aspiration technique. For these reasons, the assessment must also include observing the appearance of the site, including comparison to the opposite extremity; palpating for change in temperature or induration; and patient complaints about the site.

    This states what should be done, and what most bedside RN's are already doing to assess the PIV (using blood return as 1 part of the entire PIV assessment). It is unreasonable to think that any bedside RN has time to run around and start a new PIV just because there is no blood return, not to mention the pain/discomfort to the patient. Of course, vesicants (Vanco, chemo etc) are a different story.
    Last edit by Daisy4RN on Apr 15 : Reason: sp
  11. by   IVRUS
    Quote from Daisy4RN
    From Lynn Hadaway article:
    The nurse can not rely exclusively on the presence of absence of a blood return before using the peripheral catheter. There could easily be a second puncture in the posterior vein wall and still get a blood return OR there could be a small catheter occluded by aspiration technique. For these reasons, the assessment must also include observing the appearance of the site, including comparison to the opposite extremity; palpating for change in temperature or induration; and patient complaints about the site.

    This states what should be done, and what most bedside RN's are already doing to assess the PIV (using blood return as 1 part of the entire PIV assessment). It is unreasonable to think that any bedside RN has time to run around and start a new PIV just because there is no blood return, not to mention the pain/discomfort to the patient. Of course, vesicants (Vanco, chemo etc) are a different story.
    What is imperative here, is that one looks at the articles in chronological order, as I said before, standards change with further research. And yes, all of the above in her article are duly important too.
  12. by   PsychNP2Be2017
    Quote from IVRUS
    What is imperative here, is that one looks at the articles in chronological order, as I said before, standards change with further research. And yes, all of the above in her article are duly important too.
    In chronological order, the article referenced in your response here is the most recent that she has posted regarding assessing patency of a vein/peripheral IV, unless you have access to articles she has posted that the rest of us do not. This was also a blog article, not peer-reviewed research; before you bring it up, while she has co-authored infusion research, I cannot locate any that she has done in the past three years. In the ones she has been a part of in the past 6 years, none of them are in regard to assessing vein patency. In the ER, I have used many peripheral IVs that have minimal blood return, but flush wonderfully, are not cool to the touch, have no redness or swelling, and there is no complaint of pain (you know, ALL the signs of extravasation) and I have yet to see any detrimental effects to the patient due to my doing so. I have also placed vesicants through these same peripheral IVs. Ideal practice? Of course not. Sometimes a necessary evil? Yes. I also do not have the time to continuously restart all the peripheral lines in the ER that will flush well, but won't aspirate a "good" blood return; I would never get anything else done.
  13. by   CCU BSN RN
    I've worked at 2 major hospitals and been told at both not to check for blood return on PIVs because it can cause them to clot off and blow, and absence of blood return does not inherently mean you're not in a vein, esp with a smaller IV such as a 22 or 24.

    This is were you must use those assessment skills you were taught. Flush the line. Feel the IV. Assess for leaking, pain, edema. If you inject 3-10cc into someone's subcutaneous tissue, you should be able to tell.

    If it is cool to check for blood return in PIVs, why wouldn't it be okay to do all of our blood draws through them? Just as a follow up.

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