Pre-filled saline syringes and checking central line blood return

[greenterra]

Elsewhere on allnurses.com, a poster pointed out that one of the reasons why nurses shouldn't use prefilled normal saline syringes for diluting IV medications was that, in many cases, only the saline and interior of the syringe is sterile-- if the plunger isn't sterile, when you push out saline to make room for the medication, microbes on it can contaminate the barrel, and when you pull up the med, the diluted medicine contacts the contaminated barrel.

Doesn't the same thing happen when we use pre-filled syringes to check blood return on a central line? We're taught to flush the line with a couple of ml's of saline (which could theoretically contaminate the inside of the barrel), then pull back to aspirate blood and verify blood return (which brings the sterile saline into contact with the contaminated barrel) then continue to flush.

BTW, our sterile syringes are packaged in plastic labeled "DO NOT PLACE SYRINGES IN STERILE FIELD", which suggests to me that after the contents are sterilized, the syringe is processed in a non-sterile environment, so the plunger shaft is non-sterile.

Should I be paranoid about flushing with pre-filled syringes?

[lpnflorida]

you do not pull the blood up into the barrel of the syringe when you are checking for a blood return no matter what type of syringe you are using.

[greenterra]

Yes, it's true we're not talking about pulling blood into the syringe. The question is whether microbes would "fall off" the plunger and contaminate the barrel when you push, and then contaminate the saline when you pull back to check blood return.

Presumably this isn't an issue with non-flushes because they are completely sterile until removed from the package?

Page three of this article implies this issue when diluting meds with prefilled saline syringes: www.ismp.org/newsletters/nursing/Issues/NurseAdviseERR200702.pdf

[lpnflorida]

I must be missing something. All of our prefilled syringes come prepackage in individual plastic wrapping. As far as I know that is sterile. Are your syringes packaged differently than this?

[lpnflorida]

I now understanding what you are asking. Fortunately I have/had a prefilled normal saline syringe in my lab coat. I do see where the outside packaging states do not lay on a sterile field. however the barrel and contents are sterile. Assuming you properly clean off the hub of the central line and maintain a sterile technique it should not be a problem.

[lpnflorida]

Additional information regarding the type of prefilled syringe we use at our facility. We were taught, keep our fingers off anything but the plunger end, (have no idea what that very end is actually called at this moment,) we would not be touching anything which could lead to contamination of so called barrel

Device description,

The proposed device is an extension to the Kendall Monoject PreFiII TM ADVANCED TM

Flush Syringe line is to include one or more PreFill syringe configurations equivalent to

those already marketed by ( actually company name removed) with the syringe delivered to the customer in

a package that will maintain the sterility of the syringe exterior surface

[greenterra]

Additional information regarding the type of prefilled syringe we use at our facility. We were taught, keep our fingers off anything but the plunger end, (have no idea what that very end is actually called at this moment,) we would not be touching anything which could lead to contamination of so called barrel

Thanks for all the information in your posts, lpnflorida!

Additionally, I've looked around the internet some more. It looks like many nurses are OK with using prefilled syringes to aspirate, and (if syringed is immediately relabeled) to dilute meds, and almost no one indicates concern about non-sterility of the plunger or "dry side" of interior barrel.

Although popularity doesn't equal best practice, there doesn't seem to be any documentation or evidence showing that this isn't appropriate practice by manufacturers or anyone else.

I may try to repeat the post with a subject which would get the attention of infection control nurses to see if anyone has seen any research about this.

Thanks again!

Greg

[TXstudentRN]

I must be missing something. All of our prefilled syringes come prepackage in individual plastic wrapping. As far as I know that is sterile. Are your syringes packaged differently than this?

Nope - they come in the plastic wrapper, but look on the side. It was about a year or so ago I know that the brand we use changed their wrapper to emphasize where it says "Do not place syringe on sterile field"... before we had nurses putting them on a sterile field to access ports, etc.

I always wondered this same question, regarding where the sterility begins/ends - I'm glad you asked! I just don't see why it would be that difficult to make it all sterile, and avoid the problem altogether. I mean they make syringes sterile, and sterile saline, why can't they be sterile together? Mystery to me...

[RazorbackRN, BSN, RN]

Obviously, the plastic overwrap isn't sterile. The syringe itself isn't sterile either, because it has been placed in only a plastic overwrap which isn't a completely air-free seal. However, the internal contents of the syringe (including the plunger, NS, and the inner surface of the syringe) are sterile.

If you look on the Kendall website, (which is the co. that manufactures Monojects), you will notice that they guarantee sterility of the fluid and the fluid path. The same is true for the BD brand according to their website.

[RazorbackRN, BSN, RN]

I just don't see why it would be that difficult to make it all sterile, and avoid the problem altogether. I mean they make syringes sterile, and sterile saline, why can't they be sterile together? Mystery to me...

Why would they need to make them completely sterile? Unless you are needing the exterior of the syringe to be sterile, then it doesn't make sense and surely wouldn't be cost effecient. I would think it would be better to just draw up your saline from the sterile vial in a sterile syringe for the instances when you needs a sterile exterior.

[lpnflorida]

Why would they need to make them completely sterile? Unless you are needing the exterior of the syringe to be sterile, then it doesn't make sense and surely wouldn't be cost effecient. I would think it would be better to just draw up your saline from the sterile vial in a sterile syringe for the instances when you needs a sterile exterior.

You make a good point, then of course that entails dropping the syringe onto a sterile field giving you time to put on your sterile gloves to maintain sterility of the outside of the syringe. I can't see that happening on a regular basis outside of surgery, or the for the syringes which come in the setup kits for certain procedures done on the floors.

[greenterra]

Why would they need to make them completely sterile? Unless you are needing the exterior of the syringe to be sterile.

Well, if you are aspirating to verify the central line is correctly placed, you are bringing the sterile saline in the syringe back over an area of the barrel interior which was just below the non-sterile plunger, and been next to the non-sterile end of the rubber stopper.

Typically one would then continue to flush with the same syringe to clear the central line of blood, but this might not be advisable with a non-sterile flush, as discussed above.

Is this a theoretical problem or a practical problem?