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

[missjune]

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 return).

Also, is it ok to recap a saline syringe? Or do we have to use a new one for flushing afterwards?

Thanks so much for reading!

[ThePsychWhisperer, BSN, MSN, APRN, NP]

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 This was also a blog article, not peer-reviewed research; before you bring it up, while she has co-authored infusion research, I cannot locate any that she has done in the past three years.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.

[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.

[Medic/Nurse, BSN, RN]

There is a policy specific to YOUR employer/unit/population served. This is YOUR guiding principle of practice PROVIDING it does NOT violate the state NPA, state or Federal law (not myth, conjecture, Society best "practices"). The end.

Now, if something goes HORRIBLY wrong and you failed to follow policy (didn't assess pre & post, wrong med, etc., dilution or something, or if you try to withdraw blood (thinking its a "best practice" tho not policy and does cause a extravasion that is undetected) and patient recalls the whole thing -- yeah, things will go sideways.

Carry malpractice coverage.

Common sense is uncommon.

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I can say -- the 1st nurse that pulls a dumb*** and tries to draw blood off an established saline lock to give me a scheduled pain med only should I find myself admitted post spine surgery and "blows" my IV that necessitates a restart and delays medication --- I will be less than satisfied. Way less than satisfied. I'm a very effective complainer.

Sure, you might "know" a lot in that moment. But, is drawing back blood on a 24 hour old saline lock to give a dose of a narc ONLY in a post spine surgery patient in an established saline lock a "best practice" in all cases? I think not. Risk v. Benefit. Med is not vesicant. IV start is difficult. Pain treatment delayed. No biggie to you, big deal to me.

*******************************************************

FTR -- I've never seen a P & P that requires all PIV sites of any duration have blood return in all cases before any administration of any medication. Period. I'm okay being corrected, but without citation.

:angel:

[IVRUS, BSN, RN]

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.

Her blog spans info from 2017 and goes back several years. One must look at the published dates and use the "previous" button on the bottom of the page sited to see ALL the info. All of Lyn's thoughts come from the numerous studies she has either conducted herself, or from other's who've done the painstaking research themselves.

[Semper_Gumby]

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.

The special care nursery where I used to work always said not to check for blood return before giving IV meds due to the risk of clotting off IVs in babies that could be difficult to stick or maintain an IV in (we used 24g IV catheters, and only did peripheral IVs, no central lines). None of us wanted to replace a functioning IV in a baby if we didn't have to, anyway!

At the hospital I just left, I was not taught to check blood return before IV med administration either (on babies or on the antepartum or postpartum moms). Perhaps the people who wrote those studies would be willing to come restart all these IVs that don't get blood return but flush fine, and then we can watch our HCAHPS (sp?) scores drop due to cranky patients mad that they had to have their IVs restarted half a dozen times.

[~Mi Vida Loca~RN, ASN, RN]

I stand by my previous post; when it comes to Central lines, mid lines, PICC lines. That is not my area of expertise. When it comes to inserting PIV's I have always been one of the best in my various hospitals. I was a patient for many years before becoming a nurse and I always was stuck so many times and still am to this day so it was my mission to become phenomenal at placing IV's and I am. I have never had any problems with my IV's and not just mine, I am the go to person for everyone else that can't get them either.

There have been a few very rare occurrences that I could not obtain getting blood when placing the IV. (had my flashback, just couldn't get anything back for labs) but the IV was patent and worked great without any problems. Then there have been times that after the initial placement again the IV worked great but couldn't get blood from it after that initial time. Again, IV worked great and patient had no problems with it.

My hospitals have never had a policy that if you couldn't draw back blood on the IV you had to start a new one. That would be absolutely absurd if you can verify patency another way (and you can) and we aren't talking about chemo and vanco etc. etc.. The most common size IV's I start are 20's, & 18's. Very rarely a 22 and I can't even remember the last time I started a 24. I have had a 16 gauge that worked fantastic but wouldn't draw. As far as court is concerned you're expected to follow your hospitals policy.

[ThePsychWhisperer, BSN, MSN, APRN, NP]

Her blog spans info from 2017 and goes back several years. One must look at the published dates and use the "previous" button on the bottom of the page sited to see ALL the info. All of Lyn's thoughts come from the numerous studies she has either conducted herself, or from other's who've done the painstaking research themselves.

I understand that the blog spans several months and years...I looked at ALL of them after the article that was quoted earlier in this thread; the one when you mentioned needing to read in chronological order. If this is the case, then reading anything earlier than the quoted article would be asinine, since better-informed research should really be more recent, right? All I'm saying is that I would prefer some peer-reviewed research on the matter to tell me I'm wrong before I change my current practice that, up until now, has in no way harmed a patient. So far, you just continue to quote someone that wrote about this in a blog, and has not published any peer-reviewed research on this in about the last 10 years. The only thing I can find that she mentions this in the past ten years is in her article Infiltration and Extravasation, in which she states that:

Check for a positive blood return using gentle aspiration from the vein into the syringe. Slow or inadequate blood return could indicate a problem with the location of the catheter, although a small vein with a large catheter may not produce adequate blood return—that is, brisk, free-flowing return of blood rather than pink-tinged fluid. Flushing the catheter with normal saline while palpating the site also makes detection of swelling at the catheter tip easier.

I could just as easily publish a blog devoted to eating French fries every day because potatoes are a great source of potassium. Please provide links and research backing up your statements. Until then, we will just agree to disagree.

*edit*

I went back and looked again and found this in another one of her articles:

Aspirate from the catheter before injecting a vesicant and look for a brisk blood return. Hold the vesicant and assess catheter placement if you don't see blood return. Lack of blood return doesn't always indicate extravasation. Blood return may be impeded if the vein is small or the catheter lumen is pressed against the vein wall. Likewise, the presence of blood return doesn't necessarily mean the catheter is properly placed; the catheter could still be partly eroded through the vein.

This actually backs up my thoughts on the matter, and states that even if you get good blood aspirate, the catheter may not be properly placed; you cannot go on the fact that you may be able to aspirate blood alone.

[Wolfe24]

In almost 9 years of nursing, I've never attempted to aspirate blood prior to administering medications. I didn't learn to do that in school nor has it ever been a part of policy at any of the hospitals I've worked at. On that note, I have never seen my coworkers ever attempt to get blood return either (obviously not including PICCs or central lines, etc). Its quite easy to assess the patency of a line and getting blood return isn't necessary. I like to put my finger a few inches above the vein I'm flushing and you can feel the fluid flushing through easily. If the site isn't swollen, cool, painful, etc, and you can feel the flush going through, you're almost guaranteed to be good. Also, if someone has little tiny veins and all you can get is a 22g in them, it's going to be hard to get blood back sometimes, even on the initial stick.

[Goldenfox]

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.

With a central line, yes. But assessing backflow as a best practice standard for peripheral IVs is ridiculous. Trying to pull back to get blood blow on a PIV is likely to cause pressure interference that will collapse the vessel and blow the line. Why would a nurse want to put a patient through that---especially if the patient is a difficult stick? Even if the line is perfectly patent, one will not always be able to pull back and get blood flow.

I would love to see the research behind this so-called best practice.

On second thought, I already have a good idea what the research data will show. I looked up this nursing society, and I see that one of their biggest corporate sponsors is Braun---a company that manufactures and sells IV equipment. Of course they want bedside nurses to keep re-siting patients with their stuff.

[HeySis, BSN, RN]

I like to put my finger a few inches above the vein I'm flushing and you can feel the fluid flushing through easily. If the site isn't swollen, cool, painful, etc, and you can feel the flush going through, you're almost guaranteed to be good. Also, if someone has little tiny veins and all you can get is a 22g in them, it's going to be hard to get blood back sometimes, even on the initial stick.

^^^ This, this is what I have been doing for over twenty years. It was what I was taught in IV certification as an LPN and retaught when I did my RN very recently.

Not only can the catheter be up against the wall of the vein, but it could also be against a valve, both will make getting blood return impossible, while still able to flush and infuse. And we can see some of our elderly patients, their veins are knotty and twisted, which makes starting an IV a challenge and getting blood return nearly impossible after the first flash.

[MunoRN, RN]

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)

I am familiar with Lynne's various attempts to justify her recommendation, which it should be noted have never included any supporting evidence and she doesn't appear to make any claims that relevant evidence exists. While her blog provides some insight, a discussion board which she frequents is far more useful, but for whatever reason we aren't allowed to reference that site here, but I would guess you're familiar with it. It includes a number of threads on this topic and she appears to lose the battle in each of them. In these discussions when presented with the flaws in her position she has frequently declined to assert that blood return is necessary to use a PIV.

When the new emphasis on blood return in a PIV was added to the 2016 INS recommendations, we took a pretty thorough look at it. Our EMR comes pre-built with blood return as part of all IVs including peripherals, so we pulled the data, except for large guage IV's in the EJ or AC, about 2% of our PIV's had blood return at the second entered assessment (typically about 8 hours after insertion). We brought this to our manufacturer reps (both BD and B Braun), both stated that these are normal rates in blood return post insertion of a PIV for these sites and gauges, and that PIVs are not intended to have reliable blood return for an extended period after insertion due to a number of factors.

As with any decision related to patient care, we weighed the risk of harm and potential benefit.

The potential harm of changing IV sites potentially as often as every few hours includes delayed treatment and ineffective drug therapy due to gaps in IV access, increased risk of adverse events related to IV insertion, increased reliance on sub-optimal IV locations which carry higher rates of adverse events, and that time spent on additional IV rotations impairs the nursing staff's ability to provide effective care and keep their patients safe.

I'm open to an argument that establishes a benefit that outweighs these risks, but have yet to hear one.

[MunoRN, RN]

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.

As part of my particular job role I am familiar with what a legal standard of care is, which is typically one of the first things a hospital lawyer will make sure you're aware of when prepping for a deposition. A legal standard of care is a high bar, failure to meet the standard of care is negligence would typically result in the loss of a nursing license and potentially criminal charges as well. These are actions that by definition are extremely rare, if it's far easier to find practitioners who don't believe lack of blood return in a PIV is an absolute contraindication to using the IV than it is to find those who agree with that, then it's clearly not a legal standard of care.