IV Flushing & clots

[SN22RN]

Hello,

I was wondering how often or common is it to dislodge a clot from flushing IPIDs? I'm a nursing student and I've had a couple of patient's that I've had a hard time flushing their ipids. I would let my instructors know and they would come in and just push harder and flush the IV. What I think in my head is (OMG, what about dislodging a clot!). I had another instructor tell me to push on the flush (and I pushed some but I didn't push THAT hard) so I told her I can't push anything through. So, she told me to pull back on the syringe a little and then try flushing. So, I pulled back on the syringe a little bit then was able to flush the ipid. What's everyone else's experience with flushing? Do you push harder on ones that seem "stuck." It scares me to do that, but my instructors don't seem as concerned as I do?!

If someone were to dislodge a clot from flushing a peripheral IV site, how quickly can someone die after dislodging the clot?

[hodgieRN]

When talking to pts about flushing iv's, I like saying "it's a tiny bit of sludge and flushing it keeps the iv open."

The main concern with clots is when you pull a sheath. Anyone ever had to pull a sheath and it wont aspirate the 10 mls of blood required? I hate that! There's a big kink in it and nothing happens when you pull back.

[procrastinator911, BSN, RN]

cayenne06 said:

I have no idea, but I remember the first time I saw an air bubble go into a patient's IV site.... pt was fine but I just about died from fear! I really thought they were going to keel over and die. And this was in a clinic setting, so there wasn't even a code team near by to ease my mind.

I am curious about this as well.

oh my goodness, this happen to me today. I almost lost my mind (I'm a student as well). I told me instructor and asked if this was OK, she said it was fine. I still told my nurse, and she said it was fine....still freaks me out though

[procrastinator911, BSN, RN]

thank u

[ticurr9]

Ginnym1981, that's exactly how I was taught too in school. However when I first started out, I too freaked when even after "priming" the flush, I seen a large air bubble/pocket in the solution itself. My preceptor told me at the time it was harmless. Even after 23 yrs, I'm still extremely cautious and diligent about air bubbles. If I can get 99.9% of them out, I will try without any significant waste. And guess what? My patients are always happy too because they all seem to have horror stories to share about knowing someone who has been harmed by air bubbles (whether factual or exaggerated).

[AliNajaCat]

It's worth it to stop, take a deep breath, and think about normal vascular anatomy. Let's follow a little clot from the end of the angiocath in your patient's arm and see where it goes, shall we?

Up into the venous system, vena cava, right atrium, right ventricle, pulmonary artery, LUNG. Then what?

Nothing, that's what. Your pulmonary vasculature is designed to be a strainer for all sorts of such events-- you have been shooting little clots into your venous system since you were big enough to fall-down-go-boom as a toddler. Did you know that heparin was originally isolated from beef lungs? Why do you think there's heparin in lungs? To prevent those teeny clots there from getting bigger, pending the natural mechanism we all have for dissolving them.

Likewise a little bubble, or even a whole couple of cc's of air. Even a bigger one will break up in the turbulence of the blood flow through the big vessels and chambers of the heart and become lots of little ones. There are even vascular studies where they do this on purpose. The little bubbles fetch up in the capillaries in the lungs, and then what? The itty bit of gas in them diffuses into the alveoli, and that's that.

As you can see, there is no way you can cause your patient to have a stroke like this.

Exception: Someone who has a defect (hole) in an intra-atrial or intraventricular septum (ASD or VSD) with a right-to-left shunt, or has a congenital single ventricle. In those cases it is possible for a clot or bubble to zip through to the aorta and out the arterial system and cause a stroke (or an infarct somewhere else). Even then, except for the single ventricle, since the pressures on the left side of the heart are waaaaay higher than on the right side the chance of something traveling from the right side to the left is pretty minuscule. (remember: The LV makes the BP of 140/76 you measure in the arteries, and a normal pulmonary artery systolic pressure is less than 30 mmHg). .So if there's any shunt through such a septal defect, it's pretty much always left-to-right.

There are people who have strokes when for some reason their right-sided pressure exceeds left, as in the case of the professional football player at the bottom of the pile who has a hitherto-unsuspected ASD and shoots a clot through to the left side. That's a cause of strokes in young people; even they have been using their lungs to strain out little lots all their lives until they found themselves with their chests compressed under a ton of NFL players. They get their ASDs or VSDs sewn up and go on about their lives with no more risk of subsequent stroke than the general population.

Children with congenital heart defects that cause right-to-left shunting must be religiously protected from air or clots in the venous side. Left-to-right, not an issue.

I hope this gets everybody to calm down about little clots and air bubbles in IVs. To do real damage you need really big clots (like a big honking DVT) or a considerable shower of smaller ones (DVTs again) to cause a significant pulmonary embolus. And you'd need at least 20-30 cc of air to disrupt enough blood flow to the lungs to make a difference.