IV Push Med Question

[guest1122560]

Hello there, I am wondering if it is acceptable to draw up an IV push medication that is to be diluted in normal saline with a pre-filled normal saline flush? Or should I pull the normal saline from a single use vial of normal saline? I have seen in practice people using IV flush syringes to draw up IV push meds. I'm just wondering what is the best practice? Does anybody have any evidence base articles about it?

[kayji, BSN]

What are your concerns about using a flush syringe? Try to think about what you need to accomplish when diluting IV meds and whether flushes or single use vials affect the outcome.

As for articles, you could try researching with your school's library resources.

[guest1122560]

I just want to make sure I'm following best practice. I have watched a lot of videos on diluting IV push meds and they draw from a vial of NS. In clinical I've seen nurses use the flushes. 

 

 

[Rose_Queen, BSN, MSN, RN]

What would be the difference between the contents of the flush syringe versus the contents of a vial of saline?

I've only used a vial for reconstitution purposes because we don't stock flushes in the OR for the circulator who is reconstituting and dispensing medications to the sterile field. (Anesthesia does have them, but we don't have access to their Pyxis). When I did my senior capstone in PACU, they would utilize the flush syringes to dilute the morphine (this was pre-single dose tubexes)

[JKL33]

The ISMP has condemned the practice of diluting medications in a saline flush syringe, for various reasons.

You can read about it here and other places.

Among the reasons are safety concerns (particularly that of not correctly re-labeling the syringe after medication has been added to it) and then the technical matter that the prefilled saline syringes are FDA approved as devices for a particular use. I personally believe that some of ISMP's arguments against this are weak, but my opinion is not exactly relevant to your question. ?

[Lunah, MSN, RN]

On 4/11/2021 at 1:18 PM, JKL33 said:

The ISMP has condemned the practice of diluting medications in a saline flush syringe, for various reasons.

You can read about it here and other places.

Among the reasons are safety concerns (particularly that of not correctly re-labeling the syringe after medication has been added to it) and then the technical matter that the prefilled saline syringes are FDA approved as devices for a particular use. I personally believe that some of ISMP's arguments against this are weak, but my opinion is not exactly relevant to your question. ?

I feel like the infamous vec that should have been Versed was drawn up in an unlabeled flush syringe, if I recall correctly. I agree about the weakness of some of reasoning, though. I would also be concerned about being able to measure small-volume doses in a 10ml flush, so I definitely wouldn't use a prefilled flush for that. 

[JKL33]

4 hours ago, Pixie.RN said:

I feel like the infamous vec that should have been Versed was drawn up in an unlabeled flush syringe, if I recall correctly.

I think you're right.

Trying to recall...I'm about 99.99% sure I have never failed to relabel a syringe. Even the thought of it makes me uncomfortable. Actually I used to tape the empty vial to the syringe, and if I'd only used a portion of the med from the vial I'd write the amount on the "tape-tab" I fashioned while wrapping the tape. ???‍♀️. But more recently I have made an effort to be more judicious about what I dilute to begin with.

[JKL33]

I do agree with their concern about syringes being unlabeled/not labeled properly. Even in the ED there's almost never a need to go so fast that there isn't time to throw some kind of label onto a syringe that isn't going to be immediately pushed.

It's some of their other warnings that seem like they're meant to shore up their position...I tend to feel that the labeling issue can stand on it's own rather than trying to make a case that dilution itself is generally an unsafe practice.

[0.9%NormalSarah, BSN, RN]

I use saline flushes to reconstitute when I know I will use the whole syringe, such as with protonix and IVP antibiotics.

With dilution, I would typically just use a new syringe and draw up from a vial because it’s typically small volumes I’m diluting and the flush syringe is too big for me to be accurate. 

As a side note, I also wrap my empty vials around my syringes in the case of intubation, conscious sedation, etc, any time I won’t use it all or right away, or if I’m handing the syringe to another nurse for use. 

[TriciaJ, RN]

11 hours ago, Pixie.RN said:

I feel like the infamous vec that should have been Versed was drawn up in an unlabeled flush syringe, if I recall correctly. I agree about the weakness of some of reasoning, though. I would also be concerned about being able to measure small-volume doses in a 10ml flush, so I definitely wouldn't use a prefilled flush for that. 

And the vec was supposed to have been reconstituted with sterile water, according to the package insert that was used.  I researched what difference this would make and apparently vec and NS create a more painful shot than sterile water.  This is not at all germaine to the OP's question, but I felt compelled to mention it.

I know I've used saline flushes to draw and dilute medication.  Not only was it easier, but more chance of maintaining sterility if leaving something in the container it's already in.   I always injected immediately.  I did not know about the ISMP position.

[NurseShamshey, RN, EMT-P]

I used to do this all the time when I worked on the ambulance (most people didn't even dilute stuff, they just pushed it). And in nursing school I was taught to dilute in a flush. Once I started my job, I was told it's against our policy to do that. I haven't done it since and use a vial. If that's what my hospital wants, that's what I'll do. But it's not wrong to dilute in a flush. The only reason it's looked down on is because people don't label it so you can't "prove" what's in it. Well personally, if I know I'm going directly to a room and won't run into anyone else, I won't label my 1 syringe of benadryl or toradol at 3 am either! (Bad habits. I know!)

[lmichelle25, BSN, RN]

My school taught us to draw up the med and then squirt out a mL or whatever from the flush and then stick the needle with the med in the flush to dilute. I see people do this at my hospital also, but I would ask the instructor so you 100% know what they want you to do.