Questions about IV Meds

Esme12, ASN, BSN, RN · Feb 24, 2012

I'm a 4th semester RN student in the middle of my med-surg rotation, and I've run into a few different situations in clinical in the past few weeks where I am wondering the "right" way to do something and no policy seems to exist. I am curious to hear how other nurses handle these situations in real life, so I figured this is the perfect place to ask! :)
Sorry to write a novel, but thanks for reading and I appreciate your input! :)

First, there was a situation where there were multiple IV push meds ordered for a pt with a double lumen PICC line receiving a heparin drip through the medication port (she didn't have any other IV access). What I ended up doing was stopping the heparin drip for over ten minutes, detaching it from the medication port, flushing the line, pushing the meds (flushing again after each one was given of course), and then reattaching and restarting the heparin drip. It seemed really cumbersome to do it that way, she missed getting her full dose of heparin while it was detached/paused, and I wondered afterwards if I was supposed to have a witness just to restart the heparin drip (it was paused, so I didn't have to re-enter anything, just push start). I also wondered if she should have had a peripheral line in addition to the PICC for IV push meds?

Ok. Whether or not the patient needs a peripheral line depends on the patient, the patients veins, and the policy of the particular facility. What does your instructor say? Technically the "red" or lab draw port can be used for IV push meds by MD order and facility policy if you ever become desperate. The main reason the port is left alone is to maintain the integrity of that lumen so that labs can be done and that lumen doesn't become clotted off . Now, the procedure you followed is the correct procedure to follow. It does seem cumbersome now....but you will improve with experience and time. Stopping the heparin for that short period of time has little to no effect on the patient as heparin has a short half life and the interruption will not cause a fluctuation in the therapeutic level of the heparin that can be measured. Whether or not you need a witness to turn the heparin back on depends on individual facility policy.....what is imperative here is to remember to turn the pump back on once reconnected.

The second issue I've run into a few times is where I'm supposed to give a very small dose of an IV push med (usually Ativan) that, even when diluted, equals only 0.5 ml. How on earth do you reliably push that small of an amount over 2 minutes, especially since it's supposed to be in a 10 ml syringe (although I cheated and used a 3 ml syringe the last couple of times)? Besides pushing the plunger only a fraction of a millimeter every few seconds, it looks like most of the dose just sits in the saline lock and doesn't even get into the vein until it's flushed.

Well. What does your instructor say. In the real world of nursing the emphasis here is that the med needs to be given slowly. Over about a minute. The amount of time over which Ativan should increase with the dosage given IV. I am not sure I would dilute Ativan in 10 cc's of saline. The proper dilution of ativan is to have a 1:1 concentration. If you have 2 mg per ml you would mix with 1cc of saline. You can technically mix it to have any concentration, but this is one of those "after nursing school" moments that in actual practice it is done very differently and is perfectly safe and standard of care......unless there is a policy stating otherwise. You must always abide by the individual facility. The important thing to remember is when you are flushing after administering the drug to a capped IV is to administer the flush slowly as if you are still giving the med because, just as you thought, the med is sitting there and you don't want to bolus it in.

"Immediately prior to intravenous use, ATIVAN Injection must be diluted with an equal volume of compatible solution. Contents should be mixed thoroughly by gently inverting the container repeatedly until a homogeneous solution results. Do not shake vigorously, as this will result in air entrapment. When properly diluted, the drug may be injected directly into a vein or into the tubing of an existing intravenous infusion. The rate of injection should not exceed 2.0 mg per minute." http://www.globalrph.com/lorazepam_dilution.htm

The other issue I am curious about is the compatibility of certain meds with NS. At both the hospital where I work as an LVN and the hospital where we have clinicals, I have never seen vials of D5W freely available to flush IV's with. Everyone just seems to use prefilled NS syringes no matter what the drug (as far as I've seen, anyways). IV Bactrim, for example, is only compatible with D5W according to my med book. Even so, I was told by my instructor that it still gets flushed with NS because the compatibility refers to what it is mixed in, not what it is flushed with. Is this correct, and how do nurses handle this in real life?

ALL saline locks are flushed with saline. It is the most compatible with all drugs and doesn't act like food for bacteria to feed off of and start infection. MOST incompatibility is for the stability and effectiveness of the drug being given. The saline used to flush is not included in the calculation of the stability of the drug as the amount of saline in miniscule and brief. Saline is salt (sodium) and water both of which are key components of the human body. Again the contact if so brief that the stability of the drug is not an issue. Saline is used.

Then I also began to wonder, for the drugs that are only supposed to be mixed with certain solutions such as D5W, does it require a separate or Dr's order for that solution in order to be mixed? Or is it a "given" when the order is written (kind of like routine NS flushes for all saline locked pt's)?

NO separate order is necessary for what a drug needs to be mixed in. The manufacturer states how the drug is to be administered and diluted/reconstituted and this then becomes the accepted standard of care and policy by which the med is to be diluted and given.

I hope this helps clarify things for you.

morte, LPN, LVN · Feb 24, 2012

Don't sub the 3 ml syringe for the 10 ml syringe, according to persons whom know more than I, the 10 ml results in lower pressure.

I'm a 4th semester RN student in the middle of my med-surg rotation, and I've run into a few different situations in clinical in the past few weeks where I am wondering the "right" way to do something and no policy seems to exist. I am curious to hear how other nurses handle these situations in real life, so I figured this is the perfect place to ask! :)
The second issue I've run into a few times is where I'm supposed to give a very small dose of an IV push med (usually Ativan) that, even when diluted, equals only 0.5 ml. How on earth do you reliably push that small of an amount over 2 minutes, especially since it's supposed to be in a 10 ml syringe (although I cheated and used a 3 ml syringe the last couple of times)? Besides pushing the plunger only a fraction of a millimeter every few seconds, it looks like most of the dose just sits in the saline lock and doesn't even get into the vein until it's flushed.
Sorry to write a novel, but thanks for reading and I appreciate your input! :)

Esme12, ASN, BSN, RN · Feb 24, 2012

Don't sub the 3 ml syringe for the 10 ml syringe, according to persons whom know more than I, the 10 ml results in lower pressure.

It does.....the 10 cc syring is bigger and therfore more difficult to use with one hand versus the 3 cc syringe that fits comfortably and you are able to exert more hand pressure to deliver the med.

RN/Mom · Feb 24, 2012

Thank you for your replies! You've answered my questions and then some :)

IVRUS, BSN, RN · Feb 24, 2012

If the patient had a second lumen, I'd use that port for my IVP medication.

Also, IF using the same lumen as the Heparin, the Heparin does not need to be turned off for 10 minutes. ONE minute is all you need to clear it from the vessel if YOU ARE DRAWING LABS. If you are just giving IVP medications, once compatibility is ascertained, and if the IVP med is compatable, don't disconnect the heparin gtt, but rather use a side port to give the push medication over the time frame needed.

If it is NOT, then flush the line with the appropriate solution to rid the line of the Heparin and then give the push med and then flush again.

In the case where the push medication is NOT compatible with saline, then you must ascertain patency with the SALINE, then flush with D5W then give your med, then again with D5W then finish with NS again.

Yes, your instructor was right in the respect that the line still gets flushed with NS, but only to assess line patency. Then it MUST be flushed with the appropriate flush solution that is compatible. D5W can be drawn up under a hood in the Infusion pharmacy and given to you for the patient's needs.

Also, give the ativan in a 3cc syringe... THAT IS PERFECTLY OKAY, as long as you've assessed patency first. If the line is open, as assessed when flushing, you will not be flushing against pressure, as there is no occlusion. So, always flush with a 10cc barrel syringe diameter or larger, but then when it is known to be open, use the appropriate size syringe to administer the med.

Will your instructor know all of this... or will the hospital policy differ from this. That is the million dollar question, but I'd be leary of working somewhere that doesn't have policies in place to protect you and your patient.

RN/Mom · Feb 25, 2012

Also, IF using the same lumen as the Heparin, the Heparin does not need to be turned off for 10 minutes. ONE minute is all you need to clear it from the vessel if YOU ARE DRAWING LABS. If you are just giving IVP medications, once compatibility is ascertained, and if the IVP med is compatable, don't disconnect the heparin gtt, but rather use a side port to give the push medication over the time frame needed. If it is NOT, then flush the line with the appropriate solution to rid the line of the Heparin and then give the push med and then flush again.

So you're saying if the meds were compatible with the heparin, I didn't have to pause the heparin drip at all? I could have just allowed it to continue to infuse and pushed each med I needed to give in another port of the IV line that was delivering the heparin (flushing after each)? Would I have had to pinch the line above the port (if yes, wouldn't that make the pump alarm)? Sorry if I'm misunderstanding you or making you repeat yourself, but I want to make sure I understand how to do this both safely and efficiently in the future! Also, and I don't know if it's relevant, but I think this pt's heparin drip was running at 7 ml/hr.

Also, give the ativan in a 3cc syringe... THAT IS PERFECTLY OKAY, as long as you've assessed patency first. If the line is open, as assessed when flushing, you will not be flushing against pressure, as there is no occlusion. So, always flush with a 10cc barrel syringe diameter or larger, but then when it is known to be open, use the appropriate size syringe to administer the med.

That is basically what I did. Thank you for explaining the rationale, now it makes a lot more sense to me! :)

Perpetual Student · Feb 26, 2012

I too would've just used the second lumen. Less hassle that way.

So you're saying if the meds were compatible with the heparin, I didn't have to pause the heparin drip at all?

Yes, that is what she said and she's correct.

I could have just allowed it to continue to infuse and pushed each med I needed to give in another port of the IV line that was delivering the heparin (flushing after each)?

Yes, after verifying compatibility. If they were all compatible with heparin, but not necessarily with each other you could flush in between.

Would I have had to pinch the line above the port (if yes, wouldn't that make the pump alarm)?

No, assuming you're using a pump that prevents back flow. If the rate is slow, like the 7 ml/hr you mentioned, you want to flush the line a bit more briskly after pushing your additional drugs if they are meds you want in right now (e.g. pain meds, that Ativan for the bucking patient, etc.). Try to use the port closest to the patient in this instance.

Every time you disconnect and reconnect tubing you're increasing the risk of infection. And increasing the potential you'll get called away and forget to restart the drip.

RN/Mom · Feb 26, 2012

I too would've just used the second lumen. Less hassle that way.
Yes, that is what she said and she's correct.
Yes, after verifying compatibility. If they were all compatible with heparin, but not necessarily with each other you could flush in between.
No, assuming you're using a pump that prevents back flow. If the rate is slow, like the 7 ml/hr you mentioned, you want to flush the line a bit more briskly after pushing your additional drugs if they are meds you want in right now (e.g. pain meds, that Ativan for the bucking patient, etc.). Try to use the port closest to the patient in this instance.
Every time you disconnect and reconnect tubing you're increasing the risk of infection. And increasing the potential you'll get called away and forget to restart the drip.

Thank you so much for replying! You've answered all my questions! :)

Isthisforreal? · May 10, 2012

You rock!

kyrn80 · Dec 7, 2012

I know I'm late with this answer, but wanted to respond, the ONLY syringe that can be attached to a PICC line is a 10ML syringe. This is because of the differences in pressures generated by various syringes and the end of the PICC line can be disrupted. This may be for smaller doses, you have to measure your med into a 1ML syringe, push it into the 10ML syringe and then dilute with NS (or whatever the appropriate dilutant is). This is not per hospital policy, this is a MUST with PICC lines everywhere.

IVRUS, BSN, RN · Dec 7, 2012

I know I'm late with this answer, but wanted to respond, the ONLY syringe that can be attached to a PICC line is a 10ML syringe. This is because of the differences in pressures generated by various syringes and the end of the PICC line can be disrupted. This may be for smaller doses, you have to measure your med into a 1ML syringe, push it into the 10ML syringe and then dilute with NS (or whatever the appropriate dilutant is). This is not per hospital policy, this is a MUST with PICC lines everywhere.

If you have ascertained that the line is open, patent after flushing with a 10cc syringe BARREL or larger, than any syringe can be used for precise dosing. That is immediately s/p flushing.