tpa in a small syringe

[sistrmoon]

How is your tpa supplied? I was always taught you should never use smaller than a 10 ml syringe on a PICC(May cause rupture), but our tpa comes often in a 3 ml syringe. Should it be transferred before using?

[MunoRN, RN]

If there are entire facilities whose policy allows for syringes less than 10cc under appropriate situations then it's simply not the standard of care, particularly when supported by 'established' experts. This does bring up the standard of care/EBP conflict, it's often the standard of care or in this case a quasi-standard of care that gets in the way of good practice. I had a patient a while back with hyperkalemia, and as always the MD ordered kayexalate. I pointed out that multiple sources, including Cochrane, don't recommend kayexalate for hyperkalemia. His response was that he was well aware he shouldn't be ordering kayexalate, the problem is as he put it;"I'm held to what every other idiot doctor would do, which is order kayexalate". Sometimes it takes people more influenced by good patient care than self protection to bring the standard of care in line with EBP, although this isn't that extreme since the use of 10cc syringe isn't as widely accepted as the use of kayexalate and therefore doesn't pose the same 'standard of care' dillema.

A smaller than 10cc syringe can also be used safely on non-patent lines, there only needs to be an understanding of the multiplying effect the syringe size has. This isn't really any different than with 10cc syringes where practitioners should also have an understanding of how much plunger pressure produces what sort of psi, if that's possible, then it's also possible to understand the amount of pressure on a 3cc syringe that produces an equal psi.

[IVRUS, BSN, RN]

Agreed, BUT it is much harder to flush a larger diameter syringe if there is a clot at its end, then it is to flush aN IV catheter with a 3cc syringe. Using "normal" hand strength, you'll meet resistance which should tell you to STOP. The ease in which one can depress a 3 or 5 cc syringe barrel can be the issue.

Now, once there is no resistance to your flushing, then use whatever syringe is needed to give the medication.

[Esme12, ASN, BSN, RN]

it is best to check and follow your facilities policy for flushing a clotted line with TPA

http://nursing.uchc.edu/nursing_standards/docs/Central%20Lines%20-%20Alteplase%20Instillation%20for%20Catheter%20Clearance.pdf

[sistrmoon, BSN, RN]

I already checked my facility's policy and nowhere does it specify size of syringe for occluded central lines, only type of substance in certain situations and amount/times you can repeat and dwelling times.

Typically when we use tpa on a line it isn't completely occluded(impossible to flush) but is difficult to flush with no or sluggish blood return of flushes fine with no or sluggish blood return.

The 5 or 3 ml syringes the tpa comes from at our pharmacy are not large barrel.

It's important to remember that no syringe barrel size is actually protective. All the syringe barrel size does is change the ratio of force applied to the plunger to force created. You can easily create excessive pressure with a 10ml barrel size and you can also remain well below the pressure limits with a smaller barrel syringe; the difference in ratio can easily be undone with difference in force applied to the plunger.

Thank you!!

People quote these dogmatic rules as though they're passed down from on high without seeming to realize what it actually means.

The issue is simply the amount of pressure inside the PICC line... if it is excessive, the line can rupture.

Back to basic physics: Pressure = Force / Area

That is, for a given force that the nurse applies to the plunger, the pressure increases as the area of the plunger decreases.

To make matters a bit worse, the area of the plunger decreases as the square of the diameter... remember the area of a circle... A = pi * R^2

The volume of the syringe means nothing... the diameter of the barrel and the force applied mean everything.

With gentle technique and a freely flowing line, a small-barrel syringe will work fine... as long as you actually *think* about what you're doing and *pay attention.*

Likewise, if you've got a "stiff" line and/or you're pushing aggressively, you can generate a lot of pressure even with a 10- or 12-cc syringe.

[IVRUS, BSN, RN]

I don't understand oppositional defiant behavior! Why try to cause confusion?

Once patency has been determined, then yes, one may use whatever syringe size that is needed to give the prescribe medication/dose.

Lynn Hadaway is an expert in Infusion therapy. She doesn't merely "tout" herself as an expert, her education and research have elevated her to this position. I think you are being disrespectful to her. She has worked so hard to provide knowledge and excellence in patient care as it pertains to Infusion therapy. When one "touts" themselves as seemingly knowing more than her that says a lot about their character or lack thereof.

[MunoRN, RN]

Agreed, BUT it is much harder to flush a larger diameter syringe if there is a clot at its end, then it is to flush aN IV catheter with a 3cc syringe. Using "normal" hand strength, you'll meet resistance which should tell you to STOP. The ease in which one can depress a 3 or 5 cc syringe barrel can be the issue.

Now, once there is no resistance to your flushing, then use whatever syringe is needed to give the medication.

"Normal" hand strength is by no means a standardized measurement. To use any size syringe safely there must be understanding how much perceived pressure = what actual quantifiable pressure, it doesn't matter if it's a 10cc syringe or a 5cc syringe. If it was simply not possible to exert excessive pressure using a 10cc syringe then that might be different, but it is absolutely possible to exert excessive pressure using a 10cc syringe.

[MunoRN, RN]

I don't understand oppositional defiant behavior! Why try to cause confusion?

Once patency has been determined, then yes, one may use whatever syringe size that is needed to give the prescribe medication/dose.

Lynn Hadaway is an expert in Infusion therapy. She doesn't merely "tout" herself as an expert, her education and research have elevated her to this position. I think you are being disrespectful to her. She has worked so hard to provide knowledge and excellence in patient care as it pertains to Infusion therapy. When one "touts" themselves as seemingly knowing more than her that says a lot about their character or lack thereof.

I thought that was actually a pretty good attempt to avoid being judgmental. But since you brought it up, no, I don't find her level of understanding of factors involved in infusion therapy to be at the upper expert level. I do give her credit though for often changing her views based on having the obvious pointed out to her, although in theory she should be the one pointing out the obvious. I would hope those who utilize practice recommendations would at least be a little careful when using recommendations that so frequently change based on fairly well established realities, such as recommending that any IV for any type of infusion be D/C'd if there is no blood return, which she backtracked on as recently as...today.

[IVRUS, BSN, RN]

Muno,

She did NOT backtrack on her views... But rather stated that a blood return should still be assessed for, among other factors, such as the tourniquet test, before IVT should be continued. How can you argue with that?

[MunoRN, RN]

Muno,

She did NOT backtrack on her views... But rather stated that a blood return should still be assessed for, among other factors, such as the tourniquet test, before IVT should be continued. How can you argue with that?

She contradicted her recently stated views, maybe we have a different version of "backtrack".

Her current position still leaves the issue that blood return is actually an effectively useless assessment, but it's still better than her position up until at least 3 weeks ago which was that no IV with any type of infusion could be used if there was no blood return, and was seemingly oblivious to what is common knowledge for the community that she is supposedly a leader of; PIV's will very rarely have blood return even when they are actually appropriate to use. That sort of sums up the frustration, a leader that struggles just to keep up with those they are supposedly leading, may not be well suited to being a leader.

[blondy2061h, MSN, RN]

Who on earth is Lynn Hadaway?

[Esme12, ASN, BSN, RN]

An authority/educator on IV therapy...

Lynn Hadaway has more than 35 years experience in infusion nursing and adult education. Her experience comes from multiple acute care settings, healthcare manufacturing, continuing professional education.

]She holds two national certifications -- infusion nursing from the Infusion Nurses Certification Corporation and professional staff development from the American Nurses Credentialing Corporation. She also holds a Masters in Education from the University of Georgia.

Her publications include many aspects of vascular access devices, anatomy and physiology, infusion and vascular access complication management, nursing diagnoses, legal and regulatory issues, and principles of adult learn