Very Confused About Flushing IV Lines And Bolus Administration

[Demareseitipota]

Hello and first of all sorry for my bad English. I am a nurse student in Italy and right now I am on my first year. So, to get to the point quick.. From what I have learned ,we use Saline flashes(3 to 5ml) before and after we administer a  bolus medication via an iv line. The reason for that is to keep the line patent and free from blood clots, medicine, etc. 

Now to get to my question. My(excellent) teacher has told me that you do that ONLY if the patient has a venous catheter without being connected to an iv bag,meaning without taking any iv fluids at the moment.Just a catheter itself on his hand without a bag solution. 

 But.. another teacher taught me to do flushes before and after bolus medicine administration not only to patients I mentioned above,but also to patients that they receiving iv fluids(lets say n/s, or ringers lactated or electrolytes or whatever it doesn't matter). My question is just  WHY. Supposedly, the Saline flushes are used to keep the iv line patent, but if the patient is taking iv fluids this means that his line is, obviously, patent and I can just give the bolus medication without flushing before and after. 

From a little research I did on the internet, I found that you are supposed to flush the iv line before and after bolus medicine administration to patients that are receiving a solution via a bag, just to make sure that INCOMPATABILITY between medicines and the solution won't happen. 

THIS DOESN'T MAKE SENSE AT ALL. Let's say I do what the teacher has taught and what the internet articles advice. 

So for example, I have a patient that right now, is receiving Ringers Lactated iv. 1) I stop the infusion,2) I flush,3) I give the bolus medicine 3)I flush again and 4)I start the infusion again.Did I prevent the possible incompatibility? Of course not!! The medicine and the solution are gonna meet and mix up inside his blood system/inside his veins literally the next second as soon as I let the Ringers solution to run again into his vein. So if the medicine I just gave is incompatible with the solution, incompatability will happen anyways, flushing or not flushing, the medicine will mix up with the solution inside his blood system in seconds. 

This drives me insane cause I don't know what teacher to listen to. Personally, I think that we need to flush iv lines that are not connected to any bag infusion.The reason is to prevent blood clots. 

I find it insane to flush an iv line that is connected to an infusion bag(N/S, dextrose etc it doesn't matter). The patient will not form blood clots, and speaking for incompatibility between medicine and solution.. It will happen inside his blood system flushing or not flushing. 

I hope you all understand what I am saying and again, sorry for my bad English. 

[Wuzzie]

First of all your English is just fine. You should be proud of it! Second the reason we worry about incompatibility is when incompatible medications come in contact with each other while in the IV tubing (not the vein) because they can do something called precipitation. See the picture below.

Now imagine those clumps going into the bloodstream! That's why we flush before and after even if there is a running IV. We don't worry about that happening in the vein because the speed of circulating blood just doesn't allow it to happen.

 

 

[Nurse Beth, MSN]

The Infusion Nurses Society 2016 Standards recommends flushing before and after medication administration when accessing a saline lock, but not when giving IVP meds via an infusion.

The purpose of flushing is not to check for precipitation but to confirm patency and help maintain patency (so use pulsatile flushing technique).

This is from my memory, I will check the Standards later today when I get to work to see if there's anything else helpful to your practice.

Ciao! and I love your country ?

[Wuzzie]

2 minutes ago, Nurse Beth said:

The purpose of flushing is not to check for precipitation but to confirm patency and help maintain patency (so use pulsatile flushing technique).

I never said it was to check for precipitation please don't muddy the waters for a poster whose native language is not English. We most certainly flush to avoid incompatibilities especially if we have limited access regardless of what the INS (which FTR I hugely respect) says. 

[Demareseitipota]

I didn't know that! Let me ask you a few questions if I may.

1)what if those clumps enter the blood system? Is it possible for the patient to die or to have an allergy shock?

2) I still don't understand why medicine/solution incompatability, according to what you told me, won't happen inside the blood system of the patient. It can possible happen inside the iv tubing but not inside the blood curcilation? Why? As far as I can understand if you put 2 incompatible medicines inside your blood circulation, at some point, meaning in just a few seconds, they will meet and mix up. 

And 3) I still cannot see why one of my two teachers who is a true professional I can promise that.. told me NOT to flush an iv peripheral that has a solution running before and after bolus administration. I asked her many times and her answer was << Nothing will really happen if you don't flush a line that has a *solution running*before-after you administer a medicine bolus.For example, if the patient has an iv bag with N/S 0,9% and electrolytes or chemotherapy medicines inside, you give the bolus medicine(she referred to an antibiotic I don't remember its name) without doing ANY flushing to the line. You flush the line ONLY if the patient has just an iv catheter on his hand with no fluids running, no bags, no nothing.just a peripheral catheter. (in English you call that a port if I am not wrong?) 

My teacher has been doing that for over 35 years and nothing happened as she said. She really found it crazy when I asked her about flushing peripheral lines that have fluids running. 

Thanks for your kind words, I am still learning you language and I try my best! I hope I didn't make you tired with my questions. 

[Wuzzie]

43 minutes ago, TheUserYouKnowNothingAbout said:

1)what if those clumps enter the blood system? Is it possible for the patient to die or to have an allergy shock?

The clumps won't cause an allergic reaction but they are a foreign body that will act like a embolus. They can obstruct blood vessels and potentially cause death depending on the vessels involved. 

43 minutes ago, TheUserYouKnowNothingAbout said:

2) I still don't understand why medicine/solution incompatability, according to what you told me, won't happen inside the blood system of the patient. It can possible happen inside the iv tubing but not inside the blood curcilation? Why? As far as I can understand if you put 2 incompatible medicines inside your blood circulation, at some point, meaning in just a few seconds, they will meet and mix up. 

Because the blood circulates too quickly for the medications to be in contact with each other long enough to cause a problem. It's not even a few seconds of contact. In an IV tubing it's much longer.

43 minutes ago, TheUserYouKnowNothingAbout said:

3) I still cannot see why one of my two teachers who is a true professional I can promise that.. told me NOT to flush an iv peripheral that has a solution running before and after bolus administration.

So, here's the thing. There are always situations where things are going to be done differently because of variables. For instance, if I'm running plain NS and have to give an IV push antibiotic that is compatible with saline I probably won't flush before and after. However, if I'm running TPN/Lipids and the compatibility isn't clear I will flush before and after. It is your responsibility to make sure what you are giving is compatible with what you have running. If it is, then flushing before and after is not necessary. If it isn't then flushing is required. Sometimes you have so many medications that getting additional access makes sense. Sometimes you're lucky just to get one line in. It all comes down to using good nursing judgement. With a saline lock (IV with no fluids running) the flush before the medication is to assess patency and the flush after is to assure all of the medication is infused so you must always do it. 

By the way, you are using good nursing judgement and critical thinking skills by asking these very smart questions. 

[Demareseitipota]

6 hours ago, Wuzzie said:

Because the blood circulates too quickly for the medications to be in contact with each other long enough to cause a problem. It's not even a few seconds of contact. In an IV tubing it's much longer.

In my country we administer push meds via a three way. So here is what I ask

I have a patient that has Ringers lactated or Saline running into his veins via an IV bag.. I want to push/bolus an antibiotic. Let's say I do what my teacher always does. I don't flush. I just stop the flow, I open the 3way cup, I administer the antibiotic, I close the 3way cup and I start the ringers flow again. No flushing. 

Let's say some of the incompatible with the ringers solution antibiotic has stayed inside the IV tube. 

How is the incompatible medicine(the antibiotic I just gave) is gonna enter the blood circulation and supposedly cause a possible harm? The 3way IV tube doesn't have actual patency to the patients vein,we literally can see the tube with our eyes. It will not come in contact with the IV bag solution(ringers). 

Second, let's say that this incompatible push antibiotic comes into contact with the ringers solution inside the IV tube(again,I don't get how this can happen) They mix. From what you are saying, the speed of blood circulation doesn't allow incompatible meds to do harm. So, the ringers and the antibiotic come in contact inside the tube and seconds later they enter the blood system together/mixed. How can that be a problem? 

I am so sorry if I don't seem to understand something, I know it's a so simple thing, I am just confused cause I hear different things from different teachers. I would appreciate if you could explain what I ask in simple words since English is not my native language as you mentioned before. I really hope you feel what I am asking even if I am expressing myself with some difficulty. 

[Wuzzie]

29 minutes ago, TheUserYouKnowNothingAbout said:

The 3way iv tube doesn't have actual patency to the patients vein,we literally can see the tube with our eyes. It will not come in contact with the iv bag solution(ringers). 

That depends on where your three-way is (we call them stop-cocks) in the line. Is it connected directly to the hub of the IV? We don't do that in the US. If it is connected directly to the hub of the IV then you are correct. There is no chance of precipitating from incompatibility because there is no mixing of the substances in the IV tubing so flushing would not be necessary. 

Dipende da dove si trova la tua strada (li chiamiamo "stop-cocks") in linea. È direttamente collegato al perno della IV? Non lo facciamo negli Stati Uniti. Se è collegato direttamente all'hub della IV, è corretto. Non vi è alcuna possibilità di precipitarsi dall'incompatibilità perché non vi è mescolamento delle sostanze nei tubi IV, per cui non sarebbe necessario procedere a un flusso di scarico.

29 minutes ago, TheUserYouKnowNothingAbout said:

So, the ringers and the antibiotic come in contact inside the tube and seconds later they enter the blood system together/mixed. How can that be a problem? 

It is a problem if they mix higher up the IV tubing from the hub of the IV catheter because clumps form in the tubing and can go into the bloodstream. 

È un problema se si mescolano più in alto I tubi IV del motoscafo del catetere IV perché si formano delle conifere nei tubi e possono andare nel flusso sanguigno.

 

I really hope the translator didn't use bad words. ?

[Demareseitipota]

EXACTLY, in my country, the stop cock 3way is directly connected to the iv catheter hub. This is how we push meds. So THAT IS my question. Why this teacher told me to flush the line (via the 3way) before and after the bolus administration? The bag iv solution and the bolus medicine (that supposedly has remained inside the 3way tube) will never come in contact! So why? 

[Wuzzie]

17 minutes ago, TheUserYouKnowNothingAbout said:

So why? 

I have no idea why she would say that. It isn't necessary. She may have been taught incorrectly. 

Also, how was my translation? ?

[Demareseitipota]

Haha good enough!! So, in the US how do you guys use the stopcocks? Where exactly? I find it really interesting that each country use devices in a different way

[Wuzzie]

I can’t speak for all parts of the country but in general we add a short extension tube (some IV catheters come with them attached) to the hub. They are often called j-loops. Our IV tubing has multiple ports that we can access for IV push medications. The use of stop-cocks is common in the critical care units to allow multiple compatible infusions to be connected to one site. We connect 2 or more of them to create a “manifold” (pictures to follow). We use them in the chemotherapy units for push medications especially when we need to keep checking for a blood return while pushing. If an IV does not have fluids infusing they are said to be “locked”. We add a special cap, sometimes called a clave,  to the end of the extension set that we can use for intermittent medications.