Saline locks and intermittant infusion question

iluvivt, BSN, RN · Oct 2, 2012

First of all many places DO NOT hang a medication line. I see this in the ICUs a lot but not elsewhere. Let me get the terminology straight for you. If you have a primary line with D5 and 1/2 NS infusing with 20 meq KLC at 125 cc per hour and you have a compatible antibiotic you could hang that abx as a secondaty or piggback it into the IV. . This entails hanging the abx above the pump and into the first injection site. You will not see much run as a gravity infusions anymore due to the safety culture these days. You may see gravity set up as in dial a flow tubing in clinics and in home infusion and ambulatory infusion centers .

Now if you have ANY locked VAD (venous access device) such a saline loc or PICC and you have an intermittent infusion..that would be called a primary intermittent infusion. If you have any locked VAD and you are getting ready to infuse something you should verify the patency of that line with an appropriate flush of NS, and in rare case it may be D5W if the drug is only compatible with that and not NS).. Yes flush,verify patency and infuse the medication.

Now if you have a medication bag or a large volume parenteral infusion going and you are going to piggyback an infusion into that you do not need to verify patency if you have an infusion going without any problems such as frequent occlusion alarm or something of that nature. . If you have a dual lumen VAD,say a dual lumen PICC and you are going to use the locked lumen than yes you would am not sure exactly what you mean by verify

How is it that you can use a primary line to verify patency? Do you mean by creating a pressure difference? You need to check patency with a fluid filled syringe of NS. You need to feel how easy or not it is to instill the flush as well as that will give you a valuable piece of information. If it flushed with resistance how are you going to check that with a primary bag of IVF.

I am certain the rational for using a primary med bag of IVF is to limit the amount of access into the VAD thus potentially decreasing infection risk. I does however have drawbacks as well as it is not always the best way to decrease infection risk. I hope that answers it for you b/c I am not sure what you mean by using the bag for a flush.

Armygirl7 · Oct 2, 2012

How is it that you can use a primary line to verify patency? Do you mean by creating a pressure difference? You need to check patency with a fluid filled syringe of NS. You need to feel how easy or not it is to instill the flush as well as that will give you a valuable piece of information. If it flushed with resistance how are you going to check that with a primary bag of IVF.

Yeah that's really the nugget right there. By using a syringe flush I can get a better feel for patency and I have the option of pulling back and checking for blood return which helps to verify the access is indeed in the vein.

In our ER we still do a certain amount of piggybacking via gravity without the pump. Many of our patients are receiving IV fluids and if you can't find a pump you just have to piggyback the med, lower the main-line fluids, and titrate accordingly when there are no pumps to be found! If IV fluids are running consistently or have been ordered KVO rate then obviously I wouldn't need to flush when hanging meds piggyback, I just assess the line, site etc.

My pockets are always full of flushes. Some people's lines clog just in the five minutes they may have been detached from mainline IV fluids for a test or to ambulate, so a flush is one of my best friends. Flushes and alcohol pads. Scrub that hub!

lemmyg · Oct 2, 2012

Okay. Thanks to both of you for all the input! I think where I got messed up with the whole thing is that we have had an instructor tell us that you can assess patency by applying pressure to the vein above the cannula and watch to see if the drops stop in the drip chamber. We are taught to always piggyback, but this is because unfortunately we only have gravity poles to practice with (even though most agencies use pumps in our area) so we would be starting NS with any medication. Now that I have read that comments using saline flush every time makes sense (unless primary ALREADY running), this way you can get a sense of resistance. Also I am sure there is hospital policy on this which I will look up next time I am in clinical (by the way - not actually doing IVs in clinical yet). Thanks again

iluvivt, BSN, RN · Oct 3, 2012

OK ..I see where you are going with this. The wording was just throwing me off.... an old nursing trick,which I never use by the way, is to apply a tourniquet well above the IV site (for PIVs only) and if the infusion STOPs you can assume your cannula is still in the vein and if it keeps running you need to be very suspicious that is out or partially out of the vein. Remember that assessment of any PIV or VAD for that matter is not just collecting one piece of information. You need to assess for pain,redness,swelling at site and along the course of the vein and in the arm,compare to the other arm,feel the site for any coolness or tenderness,check to see how long it is in place, ask pt if site is causing any pain or discomfort,look at what has been infusing through it,notice if it is in an area of flexion,check blood return and check for a CDI dsg. Now with all that said,remember with a PIV a blood return DOES NOT guarantee that you are totally in the vein and all is OK. Lots of nurse get confused when trying to understand this concept. A blood return is nice to see on PIVs but you may not always get one and that does not mean you cannot use the line and that it is not in the vein, Conversely a blood return may be present and yes your IV site can be going bad and could be infiltrating or extravasating .This is because the cannula can be partially in the vein thus your blood return and partially in the tissue.