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

  1. 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?
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    About Axmann, RN, BSN, NREMT-B

    Joined: Sep '10; Posts: 86; Likes: 8

    16 Comments

  3. by   RainMom
    We don't even keep vials of saline on hand anymore, just the prefilled syringes, so I can't see how there would truly be a problem with your method. Perhaps check if this is clarified in your facility's P&P. If you must use the saline vials, draw it up first into an empty syringe before the med to eliminate contaminating the remaining saline.
  4. by   AceOfHearts<3
    According to the Institute for Safe Medication Practitices prefilled syringes should never be used to dilute or reconstitute meds due to the possibility of the flush syringe and med syringe getting mixed up.

    Is It Really Saline

    Like the PP, my facility only has the prefilled syringes for us to use. There is no other way to dilute or reconstitute meds like IV protonix, so I do the same as you. I always very clearly mark the flush that is now no longer a flush with a permanent marker before even unwrapping a new flush.


    edit: also here is an old thread with the same discussion Double usage of saline flush? (flush and reconstitution of drugs)
    Last edit by AceOfHearts<3 on Mar 11, '17 : Reason: found link
  5. by   Oh'Ello
    I also reconstitute In flushes. We don't stock saline vials....Because it's stupid. The ISMP assertion is stupid too. If I drew up 10ml of nimbex, and 10 ml diltiazem, how on earth would I know which one is which?????

    Labels that's freaking how (which is also an ISMP recommendation)
  6. by   tnbutterfly
    Moved to Patient Medications for more response.
  7. by   IVRUS
    Your practice is dangerous and is against practice guidelines. First of all, prefilled saline syringes are SINGLE use only. In addition, so is the cap that covers the male tip of the syringe. Once you draw up a medication which requires further dilution, then use an appropriate sized sterile EMPTY syringe that has appropriate graduations on it and draw it up along with NSS from a single dose vial, then discard anything remaining in the single dose vial of saline.
    Another poster on this thread remarked that ISMP guidelines were in error.. NO, not true. Practice guidelines are in place for numerous reasons, but most of all, safety and infection control.
  8. by   BedsideNurse
    We don't even stock NS vials on our unit, so everyone dilutes drugs just like that and labels whatever it is.
  9. by   NickiLaughs
    Just label the flush used for reconstitution. ....although the one with the needle on the end should be the clear indicator that the syringe has your med.
  10. by   meanmaryjean
    Your facility should have a policy. Follow it.
  11. by   wtbcrna
    It is a common practice and unless your facility has a specific policy against it there isn't anything wrong with it as long as you are giving immediately. As someone else mentioned it does leave the possibility of getting mixed up with normal flushes if not given immediately.
  12. by   gb8852
    I was taught to never give more than 12.5 mg of Phenergan IVP at once; whether diluting it or not.
  13. by   iluvivt
    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.
  14. by   akulahawkRN
    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.

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