I cannot find a protocol anywhere at work, and googling it has not helped. I work in a SNF. We use a lot of subcutaneous ports for morphine, etc in dying residents. Some nurses flush the tubing with saline after giving the drug, some don't. I always flush, and my rationale is this: If you don't flush, the medication stays in the tubing and the patient doesn't get it. And as is often the case, if multiple drugs are given through the port, for instance, I gave morphine an hour ago and now I'm giving Ativan, if I didn't flush, I'm essentially giving the morphine and the Ativan just sits in the tubing. A couple of nurses have challenged me on this because they were taught not to flush, but like I said, I can't find anything at all in writing, so I'm going with my gut. I wasn't taught anything about SQ ports in school, so I really don't have a frame of reference, other than using the same rationale for this as flushing IV tubing after you push a drug...because otherwise the pt doesn't get the correct dose. Anyone have any resources? If I'm wrong I'd like to know! Thanks!
Nursechie. Again, the practice you describe sounds unsafe to me...
1. No med should be left in the tubing for two reasons. a) it is not getting to the patient, and b) it deteriorates the tube. Also, subcut doses are so small that 2-3 ml in the tube could be half the dose prescribed. Imagine the initial dose being 5 mls and 3mls of that is just sitting in the line for the next one to be pushed through. If i were in pain i would want all that was prescribed-not a fraction thereof.
2. Because it is common practice to use the same SC set for more than one drug (on your ward it may not be but what about casual staff ect), leaving a med in the line means a high risk of mixing drugs.
Im afraid logic and best practice stipulates...flush drug flush.
The original posting is for Palliative Patient and this was the Protocol approved by the Health Authority in BC. The manufacturer of the subcutaneous port was also consulted with regards to the concern you mentioned on the drugs staying on the tube.
The PURPOSE of the subcutaneous is not to inflict pain on the patient every 30 minutes or every one hour ( remember, this patient is also palliative) You cannot flush the tubing with NSS every half an hour or so as the site is not going to last and you have to continually change the site to ensure maximum absorption in the SQ.
Yes, there is always that 0.33cc of meds on the tube, But when you give the meds, full dose is received by the patient as long as the tube was PRIMED.
It is NOT A COMMON practice where we work to use the subcutaneous port with different meds, as you mentioned - it is very unsafe.
I think, that each place has to have a clear protocol with regards to the use of this port, especially if there is any casual staff, if some nurses are flushing and the other's are not , then the patient is either getting too much or too less of the prescribed meds.
I work at an inpatient hospice facility. We use SubQ sets almost exclusively for medications and our protocol calls for a 0.5cc flush after each application (not necessarily after each med, since some are compatible). Hope this helps.
Have you talked to a pharmacist? They are usually the most up to date on medication administration. the protocol may be different if you are using pre-packaged meds versus pulling up the medication yourself. Personally, if giving more than 1 med in a line, I would flush to make sure I don't have an incompatibility problem.
i am still a nursing student and i must say i totally agree with your rational, but the way i was taught here is that we dont flush SQ locks. and the reason is because if a patient has a SQ lock we only give the same med through it. for example i had a patient who had a SQ lock for dilaudid, the nurse labels it as dilaudid, and thats the only thing that can be given though it. so it doesnt matter if the med sits in the tubing, because the next time you give it it will still be the same amount and any other SQ med must be given by injection, I am sure you must do it differently, but thats how i was taught.
I did a quick search to see if I could come up with any manufacture recommendations or policies for intermittent subcutaneous injection sites (not IV). Most of the policies I saw were similar, stating that it is not necessary to flush if only giving one medication through the line, and is not usually recommended. If giving more than one medication you should consider starting a second line, or else you must flush. Hopefully these links work as examples although we now use needeless butterflys so we cannot flush prior to inserting the line.
Where we work the policy is One line per medication, well marked with medication name, medication strength (mg/ml) date of initiation and initial of who started the line. We prime the line with the medication and do not flush between doses. The lines are changed approx every 3 to 5 days, or if the sites get red or sore. I don't believe we have ever had a problem with medication errors using this method.
I always flush, both for the reasons you gave and also I worry if I have say morphine sitting in the tube and i give something else, haldol, ativan, lasix, etc. I worry that if the two mix in the tube it will precipitate
You did the right thing by flushing! Please continue to flush in between any medications with either water for injection or normal saline (as per your local policy). If not, as you quite rightly said, you'd be administering 2 drugs together. What if the 2 drugs are incompatible?
Working in your department carries a lot of pressure and demands accuracy because even though the patients are dying, it's how, why, when,what and who that the relatives and managers jump on.
Similar to adding normal saline with Cyclizine and Midazolam in a syringe driver for a dying patient (incompatible- attributed to patient's rapid deterioration and nurse responsible ended up filling an incident form, retraining on iv giving study day and supervised practice for 6 months).
I hope this has laid more emphasis on your question. So in the absence of any written policy,with the exception of ILOPROST VIA PERIPHERAL CANNULA, I will flush in between medications.
I think the best policy that your facility could go to would be to simply apply more than one more set if more than one medication is going to be pushed. That way, you don't have to worry about it! :) When it comes to patient comfort, flushing is not ideal. You want as little tissue displaced as necessary.
If it were me, I would flush unless my supervisor specifically told me not to. And in that case, I would ask for a policy so that there is no question. The potential for drugs that are not compatible being in the tubing at the same time is scary to me.
Ahhhh....so i assume that the first dose is a larger stat dose --so the patient gets full benefit.
col3
19 Posts
Nursechie. Again, the practice you describe sounds unsafe to me...
1. No med should be left in the tubing for two reasons. a) it is not getting to the patient, and b) it deteriorates the tube. Also, subcut doses are so small that 2-3 ml in the tube could be half the dose prescribed. Imagine the initial dose being 5 mls and 3mls of that is just sitting in the line for the next one to be pushed through. If i were in pain i would want all that was prescribed-not a fraction thereof.
2. Because it is common practice to use the same SC set for more than one drug (on your ward it may not be but what about casual staff ect), leaving a med in the line means a high risk of mixing drugs.
Im afraid logic and best practice stipulates...flush drug flush.