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!
Flush IV lines as per your policy, the OP was asking about SQ lines which really should not have more than 2.5 mls inserted per line as it displaces too much tissue and can cause pain and inflammation at the insertion site.
I think one of the things being overlooked in this to flush or not to flush discussion by some in the always flush camp is that if the tubing has been primed with the appropriate medication and is not intended to be flushed (as some have mentioned), you are then overdosing when you do flush. Unless I'm missing something, if the tubing is primed, x amount of solution in one side = x amount of solution displaced out the other side. So, if it's been primed (we'll call this amount y) and you administer x, x comes out the other side. Now you flush, you've also just displaced y and have effectively administered x and y to the patient.
Now if the next person that comes along after the post administration flush is not also a flusher, the patient is underdosed. Tubing is now primed with saline as opposed to medication, x amount is administered. However, because y is saline, dose administered is x-y unless this person also flushes.
That's if I understand all 8 pages of this thread correctly as I have no experience with this type of device. (One of the unemployed new grads.) The other poster brought up a good point, too, regarding nurse administering what previous nurse drew up when using the primed method. I understand the intended function, but everyone needs to be in agreement with how it's being used in your facility. Accident waiting to happen.
I think we've got two separate threads going here. I believe the OP was talking about the sub_Q "buttons" where the med is delivered into the sub-Q tissue similar to an insulin injection. We have another group that is talking about actual ports and central lines. Two different delivery systems with two different sets of rules. Confusing to say the least.
What do you use instead? At our facility, 2 nurses sign off on any narcotic drawn up. Also, the only meds we have given sq (that I have experienced) are dilaudid, morphine, decadron, haldol, and ativan. I'm not so worried about compatibility problems, but you are right that there is a risk that the nurse before me could have drawn up the wrong medicine. It's low, but it's there, nonetheless. As far as I know, it's never been discovered to be a problem, though.
For patients in nursing/private homes, we tend to use SL Roxinol and Ativan, both routinely and PRN. It is generally easy to give and well tolerated in palliative pts. For pts. in an inpatient setting (where they are more likely to already have IV access,) and/or if these SL meds are not adequate, then we go to a morphine or dilaudid drip, continuous, with PRN IVP boluses.:)
Specializes in Aged Care, General Acute,Theatre,Rehab,.
Whenever a Intma Cath is used for subcut injections. It is ALWAYS flushed with 5ml NS after administering the medication. Usually Morphine.
The rationale being that some of the Morphine dose is sitting still in the line so the patient is actually not receiving their full dose. And therefore the full benefit.
Specializes in palliative care, medicine, rehab/geri.
In our facility we use an over the needle cannula for subcut locks (ie like an IV cannula where the needle is withdrawn after insertion, leaving only the plastic cannula in situ.) We always flush with at least the volume of the extension tubing, in our cases 0.4ml, for the same reason that a lot of posters have mentioned. Namely, since our tubing is primed with NS, you don't want the med to stay sitting in the tubing where it's not helping the patient. I would have the same concerns as others have mentioned about giving a med into a tubing primed with a medication instilled by someone else. You're really trusting that the other nurse got it right, and primed the tubing with what she said she did. To me, that puts your license on the line. We use a general rule that only a total of 3 ml including the flush be given at one time through a subcut lock, therefore you could give 2.5ml of medication, followed by the flush.
If you're looking for a written policy to act as a guide for developing a policy for your facility, go to www.palliative.info and click on subcutaneous cannula insertion. It gives step by step procedures for inserting the cannula, and for giving meds, etc.
After reading some of this discussion I think that people are having a difficult time distinguishing between a subq disc that some people may refer to as a "port", that is APPLIED to the skin over subq tissue and covered with an occlusive dressing like a tegaderm, and actual "ports" that are IMPLANTED subcutaneously, usually in the upper chest that are basically central lines that can be used for IV drips and chemotherapy, etc; where the fluid given enters directly into the vascular space. They are definitely two different things, but how they are referred to is where it gets confusiing. What some people refer to as a subq disc is applied over the skin in an area that would typically used to give a subq injection such as the abdomen or a thigh. For those not familiar with it, it's a disc like device about the size of a half dollar with a tiny needle at a 90 degree angle on one side with a short thin line attatched to the other side of the disc. The skin is pinched as you would if you were giving a subq injection, the needle portion of the disc penetrates the skin and the disc is applied against the skin and a tegaderm dressing is used to cover the disc and the attatched line. The only portion that's exposed is the injection hub that's attatched to the line that the syringe connects to. Each disc is intended to be used for one medication and one medication only and each disc should be clearly labeled as such, for example, one for morphine, one for ativan, etc. There are patients who may have 3, 4, 5 or even more discs applied depending on how many different meds they're getting regularly, typically many time a day. Subq discs are not intended for occasional med administration like every few days, in that case ypu can just give an injection at those times. These subq discs are intended for frequent injections with the same medication. As far as priming and flushing, prior to applying the disc to the patient the disc must be primed with the intended medication and NOT saline. In the case of a subq disc saline is not used at all. After it's primed with the desired med (morphine for this purpose of discussion), the next time you give the morphine in a quantity of a 1/2 ml let's say, when you inject the morphine into the line you're basically "pushing" 1/2 an ml into the subcutaneous tissue of the patient out the other end. The patient has now gotten their medication. No flush needed because you replaced the portion in the line with more morphine. If you flush the line you injecting saline into the sub q tissue and that can be detrimental to the tissue if done too often. Subq meds are readily absorbed, saline flush is absolutely not necessary and defeats the purpose of subq discs. On the contrary, ports that are implanted subcutaneously, like a mediport, they're implanted under the skin and the end of the line terminates in the vascular space (bloodstream) and should be flushed following use, and is a completely different thing. The use of the term "subcue" is where it gets confusing. I hope this has cleard it up for some of the readers.
I can't believe people DON'T flush! It was absolutely DRUMMED into our heads, and all your rationale is correct. I know a student RN who failed her 2nd year unit cos she kept forgetting to flush so she failed her clinical. She had to re-do it all again.
God know what has been put in the line b4 you got to it!
Carolmaccas66, please read what I wrote again, and you have to understand that a subq disc is NOT an intravenous line. It's not a "push and flush" device. You don't flush saline into subcutaneous tissue. You prime the tubing with the intended medication, and everytime you give a dose (with the same strength per ml dose), you've delivered absorbable medication into the subq tissue which is the intention. And if everyone on your unit or floor is properly educated and trained in the use of subq discs, if you use them regularly and your co-workers are properly trained in their use and intention, then you know what's in it because it will be labeled with the intended medication. But believe me I know where you're going with not being sure who did what with it before you got there. If it's not labeled and not properly primed with the intended medication then you have defeated the purpose of it. It's the responsibility of your education department to make sure everyone is on the same page with their use. If you flush a subq disc, (NOT talking about an implanted mediport), if you flush then your action is detrimental to the patient. It's the equivalent of continuoulsy putting saline into an IV line that you know has infiltrated. It's not good for the tissue, and not only that, the next time you give a med into the subq disc then chances are you may have saline which is not as readily absorbed still sitting in that space. The medication is made to be readily absorbed, straight saline is not. I do understand that there are organizations that do it, per policy. And to put it bluntly, if they don't do it properly, they're wrong and shouldn't use them.
melsch
68 Posts
Flush IV lines as per your policy, the OP was asking about SQ lines which really should not have more than 2.5 mls inserted per line as it displaces too much tissue and can cause pain and inflammation at the insertion site.