# Diluting Meds in Flushes?  *poll*



## CWATT (May 7, 2018)

Years ago I was shown to dilute Diphendramine in a 10ml Saline flush (1ml drug + 9ml saline).  Recently however I was told that’s bad practice and to always draw my fluid from a saline bag.  The person correcting me suggested there was something in the saline flush that could interact with the drug (citrate perhaps???).  

What are peoples’ opinions about this?  Is it a safe practice?


- C


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## Summit (May 7, 2018)

That's BS.

Diluting withe a flush is fine, arguably preferable from a safety standpoint, and certainly faster, easier, and less wasteful than wasting a bag of NS.


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## zacdav89 (May 7, 2018)

If I am giving a lot of meds pushed I will fill the syringe from a running iv if it's already there and it's clearly just saline. There is no reason to not use a saline flush for med administration.  The only reason one would advise not to use a flush is that They are exponentially more expensive then a syringe and volume of saline used.


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## Summit (May 7, 2018)

zacdav89 said:


> The only reason one would advise not to use a flush is that They are exponentially more expensive then a syringe and volume of saline used.


10ml flush is probably around 40 cents while an empty 10ml is around 20 cents.


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## zacdav89 (May 7, 2018)

Summit said:


> 10ml flush is probably around 40 cents while an empty 10ml is around 20 cents.


I was told that flushes cost more by hospital admin once. I stand corrected. That would be the only reason I could think of why someone would say not to use flushes


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## E tank (May 7, 2018)

This was probably a solution looking for a problem on a national scale through some self appointed nursing or pharmacy organization. A couple of years ago, when our pharmacy decided to flex its muscles, I was handed a flyer (that I immediately threw away) that "prohibited" the use of pre-filled saline syringes for this type of use. I was using it to mix vecuronium because it was such a great step saver. The pant-suit RN's with clip boards and whistles said I couldn't do that because "someone" (still never found out who) might confuse my vecuronium for NS because that's what it said on the syringe (despite the bright red sticker with bold black letters that said "VECURIONIUM". Other people messing with my stuff aside, I asked what is stopping someone from confusing a plain  10 cc syringe with the bold black letters on a bright red field for something else. Lacking an answer, they went to pick on someone else and I use pre-filled syringes for diluting antibx, ketamine, some narcotics...the list goes on. They're really convenient. Just label them.

BTW...those pre-filled syringes are preservative free.


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## Carlos Danger (May 7, 2018)

First, because they are preservative free and once the cap is taken off they are supposed to be used immediately, rather than sitting around for even a few minutes. Second, the syringes aren't sterile so some say the risk of contaminating your meds is higher. Lastly, they are significantly more expensive than regular syringes.

Are any of these good reasons? Not IMO, but if you really dig into it, those are the reasons you'll find. I remember going through this years ago at one of my HEMS programs. 

We actually just recently got these where I work; I haven't used them in years. So far the only thing I use them for is diluting powdered meds - mainly vec and ancef.


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## NomadicMedic (May 7, 2018)

I use it when giving 10mg:1ml morphine. Makes it a lot easier to give a couple of MG.


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## Akulahawk (May 7, 2018)

I use saline flushes to dilute some meds quite a bit. While the outside of the flushes aren't sterile, the contents are, therefore they don't go on a sterile field. Mostly what I use them for is to dilute small volumes of a medication that needs to be given over a couple minutes, or if I need to have a better measure of control over the rate I give it. I've had patients ask for Benadryl to be given fast... I won't do it because I know _why_ they want it pushed fast. They usually don't like me too much once they realize they're not going to get it rapid IVP. Sometimes I'll put the med into a 10 ml syringe, evacuate the air out of it, then dilute using the saline that's in a running line, but much of the time, my patients just have saline locks. 

One of the things that irritate me greatly right now is that we don't have very many saline vials nor do we have many lidocaine vials. We give a lot of our antibiotics IVP over 3 minutes, preferably diluted in 10 mL sterile water. NS will work in a pinch, but it's less preferable. Why do I bring up lidocaine? Well, ceftriaxone hurts a LOT if not diluted with lidocaine and given IM. I've only given it twice with sterile water in my career so far and that's only because there was no way I could get lidocaine to dilute it with. My patients were warned but even then it's still darned close to torture to give it without lidocaine.


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## Akulahawk (May 7, 2018)

NomadicMedic said:


> I use it when giving 10mg:1ml morphine. Makes it a lot easier to give a couple of MG.


Agreed. The volume of that concentration of morphine is just too small to give it slowly-ish or to reliably give a couple mg at a time. A bump at the right (or wrong) time easily results in a mg or more.. being inadvertently given.


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## Ensihoitaja (May 7, 2018)

zacdav89 said:


> I was told that flushes cost more by hospital admin once. I stand corrected. That would be the only reason I could think of why someone would say not to use flushes



We’ve been looking into doing more saline locks, rather than hanging bags on all our IVs. According to our admin, as of 5 years ago it was dramatically more expensive to use a lock and flush rather than a bag. As of last year, it’s now marginally cheaper to use a lock and flush, so your info may have been correct at the time.


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## Akulahawk (May 8, 2018)

Ensihoitaja said:


> We’ve been looking into doing more saline locks, rather than hanging bags on all our IVs. According to our admin, as of 5 years ago it *was dramatically more expensive to use a lock and flush rather than a bag*. As of last year, it’s now marginally cheaper to use a lock and flush, so your info may have been correct at the time.


I suspect that has more to do with billing than the cost of the dripset in use at the time vs claveport adapter/short extension set. If you start a line and you have a fluid running, that's probably a different (higher) charge than just doing a saline lock.


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## Ensihoitaja (May 8, 2018)

Akulahawk said:


> I suspect that has more to do with billing than the cost of the dripset in use at the time vs claveport adapter/short extension set. If you start a line and you have a fluid running, that's probably a different (higher) charge than just doing a saline lock.



I don’t remember the exact figures, but it was actual item costs.


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## Bullets (May 8, 2018)

Weve been doing push dose drugs in 10ml flushes coming on two years now without issue. Dont see any reason why diluting in 10ml flushes would be an issue for anything. 

Someone is pulling your leg


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## NPO (May 9, 2018)

Summit said:


> 10ml flush is probably around 40 cents while an empty 10ml is around 20 cents.


Perhaps some places. When I was a medic students doing clinicals I asked for some flushes and was told a flush was $14 at the hospital. (Maybe that's the billed cost.) But as a result, the flushes were locked in narcotics boxes and nurses caught with them in their pockets were chastised.


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## Akulahawk (May 9, 2018)

NPO said:


> Perhaps some places. When I was a medic students doing clinicals I asked for some flushes and was told a flush was $14 at the hospital. (Maybe that's the billed cost.) But as a result, the flushes were locked in narcotics boxes and nurses caught with them in their pockets were chastised.


Yeah, that's probably the billed rate for a "non-sterile" flush. A "sterile" flush probably does cost that much. My suspicion is "someone" in the billing department noticed that nurses (and darned near everyone else) use non-sterile flushes for just about anything and everything to do with an IV line. If you lock them up like narcotics, you need to have a record of who is pulling from that box, what's being removed, and which patient it's for. Easy way to generate multiple $14 charges, even if it's for giving a single med through a lock. You flush to ensure the line is patent ($14). You give the medication and then you flush to ensure all the med is in and the lock is properly secured ($14). That's $28 to use the lock for one med. If you dilute the med in a flush that's another $14... Flushes tucked away in a pocket is revenue that's "lost" because it's not being tracked.


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## Akulahawk (May 9, 2018)

Oh, and just for giggles, look up how much your department charges to start an IV line, if there's a separate charge for that. Way back when, in the time that I was a young-ish pup, an IV start generated a roughly $50-$60 charge, and included all supplies. At the time, an angiocath was about $2.50, basic IV dripset was about $4, and a 1L bag of NS was about $3.The "start kit" ran about $9. The last time I looked at a "hospital charge" for an IV start was a couple years ago and that was around $150 or so... for the same supplies. Of course we can't bill for an infusion unless we have a "stop time" documented too...


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## NPO (May 9, 2018)

Akulahawk said:


> . If you lock them up like narcotics, you need to have a record of who is pulling from that box, what's being removed, and which patient it's for. Easy way to generate multiple $14 charges, even if it's for giving a single med through a lock. You flush to ensure the line is patent ($14)



It wasn't an Omnicell or Pyxis it was just a lexan box with a key coded lock. So no tracking when someone went in and out.


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## Akulahawk (May 9, 2018)

NPO said:


> It wasn't an Omnicell or Pyxis it was just a lexan box with a key coded lock. So no tracking when someone went in and out.


One of the places I worked as an RN didn't have an Omnicell or Pyxis either. All our access to the lock box for narcotics was hand-logged and each item in that box had a count. If something was off, it had to be reconciled and a full count was done every time there was an off-going shift. Very low-tech and reasonably easy to figure out who pulled what. The automated stuff is a little easier to work with but user-error can cause headaches that are a bit more difficult to deal with.


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## NPO (May 9, 2018)

I'm just saying, in my example, patient billing by accounting for each pull of an item wasn't the reason for locking up the flushes. They were not tracked. Just locked up.


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## Summit (May 9, 2018)

NPO said:


> Perhaps some places. When I was a medic students doing clinicals I asked for some flushes and was told a flush was $14 at the hospital. (Maybe that's the billed cost.) But as a result, the flushes were locked in narcotics boxes and nurses caught with them in their pockets were chastised.


$14 for a flush???

That would have to be the billed cost, just like an ambulance service might bill $25 for some tylenol pills that cost $0.02 each.

Seriously... just google this stuff. There are publicly listed prices for flushes at $0.45/flush for a box of 30 or $0.25/syringe for a box of 200 10ml leuer locks syringes.

Now a hospital supply contract is going to get a large price break over that.

And the way a hospital looks at cost is that an extra 10 or 20 cents for flush is more than offset by the saved labor and reduced infection risk of the prefilled flush vs drawing up from saline bags, plus the cost of the saline bags for patients who don't have one spiked.

It is my observation that most healthcare professionals that aren't prescribers (eg us RNs and Paramedics) have no clue what things actually cost or are actually billed for (or actually reimbursed at) in healthcare. It is because we don't typically care about specific costs... yet we are happy to accept and repeat whatever nonsense we are told.

This is similar to the argument I had with someone the other day about the cost of sterile vs nonsterile 2x2s. They were convinced there was some astronomical difference.


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## hometownmedic5 (May 11, 2018)

I rarely dilute meds in this fashion. If I’m administering narcotic analgesia to a really old or really young person, i will draw it into a flush so I can have a bit more control over the rate of administration, but the rest of the meds I give that I would dilute I’m much more likely to dump them in a 50ml bag and go that route. I routinely have transport times <10 minutes and a high standard to meet as far as accomplishing things en route, so I need my hands to be doing other things.


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## Tigger (May 11, 2018)

hometownmedic5 said:


> I rarely dilute meds in this fashion. If I’m administering narcotic analgesia to a really old or really young person, i will draw it into a flush so I can have a bit more control over the rate of administration, but the rest of the meds I give that I would dilute I’m much more likely to dump them in a 50ml bag and go that route. I routinely have transport times <10 minutes and a high standard to meet as far as accomplishing things en route, so I need my hands to be doing other things.


I'll do this or push something into a running line slowly.


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## NPO (May 11, 2018)

Tigger said:


> I'll do this or push something into a running line slowly.


This is what I was taught in paramedic internahip.

In school they teach us to pinch the line and give it slowly. My preceptor's perspective was that, when you do that all you're doing is priming the tubing with your medication, then when you let go of the line and open it back up, it's administered at the rate you have you fluids running. 

His pearl was, give it slowly and watch the drip chamber. As long as it's still dripping it's not backing up, and you know how quickly or slowly you're giving the med.


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## Seirende (May 12, 2018)

Akulahawk said:


> I've had patients ask for Benadryl to be given fast... I won't do it because I know _why_ they want it pushed fast. They usually don't like me too much once they realize they're not going to get it rapid IVP.



I do not know why a patient would want diphenhydramine to be pushed rapidly. My drug book says to give it at 25mg/minute, but it doesn't say why. Would you mind explaining?


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## DesertMedic66 (May 12, 2018)

Seirende said:


> I do not know why a patient would want diphenhydramine to be pushed rapidly. My drug book says to give it at 25mg/minute, but it doesn't say why. Would you mind explaining?


You can get high if you take enough for push it fast.


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## NomadicMedic (May 13, 2018)

Who wants to get high on an anticholinergic? That’s absolutely no fun at all.


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## Bullets (May 13, 2018)

Seirende said:


> I do not know why a patient would want diphenhydramine to be pushed rapidly. My drug book says to give it at 25mg/minute, but it doesn't say why. Would you mind explaining?


It makes you hallucinate


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## jwk (May 13, 2018)

Akulahawk said:


> One of the things that irritate me greatly right now is that we don't have very many saline vials nor do we have many lidocaine vials. We give a lot of our antibiotics IVP over 3 minutes, preferably diluted in 10 mL sterile water. NS will work in a pinch, but it's less preferable. Why do I bring up lidocaine? Well, ceftriaxone hurts a LOT if not diluted with lidocaine and given IM. I've only given it twice with sterile water in my career so far and that's only because there was no way I could get lidocaine to dilute it with. My patients were warned but even then it's still darned close to torture to give it without lidocaine.



That brings up another issue.  I know a fair number of people that add a little lidocaine to propofol (not a great practice for a number of reasons) but not for other medications, and certainly not as a diluent.  Our hospital pharmacy nazis would have a fit, and I'll play devil's advocate - is it good practice to dilute any drug with any other drug, IF they haven't been tested for compatibility?  Most package inserts will specify what a drug should be diluted or reconstituted with - whether sterile water, saline, D5, or whatever.  I'm sure none have been tested with lidocaine (which is why I don't mix it with propofol).  I don't have an issue with giving lidocaine before giving a potentially painful drug (although I don't really think it helps much) but mixing them is potentially problematic.


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## Carlos Danger (May 13, 2018)

jwk said:


> That brings up another issue.  I know a fair number of people that add a little lidocaine to propofol (not a great practice for a number of reasons) but not for other medications, and certainly not as a diluent.  Our hospital pharmacy nazis would have a fit, and I'll play devil's advocate - is it good practice to dilute any drug with any other drug, IF they haven't been tested for compatibility?  Most package inserts will specify what a drug should be diluted or reconstituted with - whether sterile water, saline, D5, or whatever.  I'm sure none have been tested with lidocaine (which is why I don't mix it with propofol).  I don't have an issue with giving lidocaine before giving a potentially painful drug (although I don't really think it helps much) but mixing them is potentially problematic.



Has any harm ever come of the practice?


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## E tank (May 13, 2018)

jwk said:


> That brings up another issue.  I know a fair number of people that add a little lidocaine to propofol (not a great practice for a number of reasons) but not for other medications, and certainly not as a diluent.  Our hospital pharmacy nazis would have a fit, and I'll play devil's advocate - is it good practice to dilute any drug with any other drug, IF they haven't been tested for compatibility?  Most package inserts will specify what a drug should be diluted or reconstituted with - whether sterile water, saline, D5, or whatever.  I'm sure none have been tested with lidocaine (which is why I don't mix it with propofol).  I don't have an issue with giving lidocaine before giving a potentially painful drug (although I don't really think it helps much) but mixing them is potentially problematic.



This compatability issue speaks exactly to my post above about pharmacy and nursing using BS as a cudgel to assert some kind of leverage in their worlds. Just got an "incompatable with LR" chart all nice and laminated hung onto my anesthesia machine 2 weeks ago. Know what's incompatible? Rocuronium, cis-atricurium, remi-fentanyl, a bunch of antibiotics that I use regularly and the list goes on. The problem is that the "tests" are about as removed from a full flowing IV line as you can get and don't in the least reflect day to day practice of the use of LR or these drugs. Some OR nurses still get worked up over blood and LR.


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## jwk (May 13, 2018)

Remi said:


> Has any harm ever come of the practice?


Don't know - like I said, I'm playing devil's advocate.  You and I both know that mixing anything with propofol is technically a huge no-no due to infection control concerns.  Yet I see lidocaine and ketamine mixed all the time.  I would not use lidocaine to reconstitute powdered meds.  I don't think it's good practice, but whether there's any harm in it I just don't know.


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## NomadicMedic (May 15, 2018)

jwk said:


> Don't know - like I said, I'm playing devil's advocate.  You and I both know that mixing anything with propofol is technically a huge no-no due to infection control concerns.  Yet I see lidocaine and ketamine mixed all the time.  I would not use lidocaine to reconstitute powdered meds.  I don't think it's good practice, but whether there's any harm in it I just don't know.



When I was working in an Urgent Care we used Lido to reconstitute Ceftriaxone all the time.


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## Akulahawk (May 15, 2018)

jwk said:


> Don't know - like I said, I'm playing devil's advocate.  You and I both know that mixing anything with propofol is technically a huge no-no due to infection control concerns.  Yet I see lidocaine and ketamine mixed all the time.  I would not use lidocaine to reconstitute powdered meds.  I don't think it's good practice, but whether there's any harm in it I just don't know.





NomadicMedic said:


> When I was working in an Urgent Care we used Lido to reconstitute Ceftriaxone all the time.



Whenever possible, I will use 1% lidocaine to reconstitute Ceftriaxone if I'm going to be giving it IM. I will NOT use lidocaine as a diluent for IV administration as 100 mg of lidocaine isn't exactly a small dose and it doesn't hurt to give ceftriaxone by IV.


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## Brandon O (May 15, 2018)

These are technically not sterile.

That being said, it's probably about as sterile as many instances of venous access...


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## E tank (May 17, 2018)

Brandon O said:


> These are technically not sterile.
> 
> That being said, it's probably about as sterile as many instances of venous access...




The NS in the commercially prepared "flush" syringes isn't sterile?


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## Brandon O (May 18, 2018)

E tank said:


> The NS in the commercially prepared "flush" syringes isn't sterile?



The exterior of the syringe is not sterile. Extruding some of the (sterile) saline and using that space to pull up a medication involves "doubling back" over a portion of the draw, therefore exposing the internal chamber of the syringe to its non-sterile exterior.


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## Summit (May 18, 2018)

Brandon O said:


> The exterior of the syringe is not sterile. Extruding some of the (sterile) saline and using that space to pull up a medication involves "doubling back" over a portion of the draw, therefore exposing the internal chamber of the syringe to its non-sterile exterior.



It is no different than drawing up into an empty (internally) sterile syringe wherein the plunger draws across the sterile-but-now-exposed internal barrel.

The portion of the internal barrel of a 10mL (internally sterile) flush that becomes exposed to air when extruding some saline WAS STERILE and becomes no less sterile than in the above and arguably more sterile than a sterile drape exposed to air as when the fluid is redrawn into either syringe, the barrel casing plunger shaft offer protection and so does the double o-ring of the plunger offer a squeegee effect for air deposited material. 

It is certainly a contributing rationale to using drawn up meds ASAP.


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## E tank (May 18, 2018)

Summit said:


> It is no different than drawing up into an empty (internally) sterile syringe wherein the plunger draws across the sterile-but-now-exposed internal barrel.



Well, not really. Nit picking here (REALLY nit picking) but packaged empty sterile syringes are just that. You can dump them onto a sterile surgical field. Pre-filled NS flushes cannot be used for that purpose. That said, there is a big difference between drawing something up with a non-sterile exterior unit and giving it immediately and letting it sit and colonize for a period of time. At the end of the day, as regards the way we are discussing it here, it doesn't matter.


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## Summit (May 18, 2018)

E tank said:


> Well, not really. Nit picking here (REALLY nit picking) but packaged empty sterile syringes are just that. You can dump them onto a sterile surgical field. Pre-filled NS flushes cannot be used for that purpose. That said, there is a big difference between drawing something up with a non-sterile exterior unit and giving it immediately and letting it sit and colonize for a period of time. At the end of the day, as regards the way we are discussing it here, it doesn't matter.


Yes we agree. I was pointing out that the _interior_ of the pre-filled NS barrel that was covered by the sterile saline but becomes exposed when the plunger is depressed is still as sterile as any other freshly exposed sterile field for the intent of pulling the plunger right back when drawing up.


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## E tank (May 18, 2018)

Summit said:


> Yes we agree. I was pointing out that the _interior_ of the pre-filled NS barrel that was covered by the sterile saline but becomes exposed when the plunger is depressed is still as sterile as any other freshly exposed sterile field for the intent of pulling the plunger right back when drawing up.



ah...got it.


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## Brandon O (May 18, 2018)

I agree it is probably not a big deal and I do it too. Still, it's a consideration.


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## ParamagicFF (May 22, 2018)

My agency was without prefilled epi 1:10 for close to a year. We used flushes to dilute 1:1 ampules. I don't see a problem with it.


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## Colt45 (May 27, 2018)

There is  no problem with it. Some of this detailed sterile not sterile makes me laugh. There are moments when it matters but to the extent that has been discussed here. Eh. Most likely not a big deal.


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## phideux (Jun 6, 2018)

The only thing I can ad is if you are drawing your meds up in a flush, and pushing it through a lock, the patient is not getting the full dose of meds until you break out another flush to push the remaining meds out of the lock.


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## E tank (Jun 6, 2018)

phideux said:


> The only thing I can ad is if you are drawing your meds up in a flush, and pushing it through a lock, the patient is not getting the full dose of meds until you break out another flush to push the remaining meds out of the lock.



Don't know what this means, but an empty 12 cc syringe plugged into an IV line port to aspirate IV fluid from a bag to then bolus anterograde IV is a verry efficient way to flush and expidate  onset of Rx.


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## Carlos Danger (Jun 7, 2018)

Colt45 said:


> There is  no problem with it. Some of this detailed sterile not sterile makes me laugh. There are moments when it matters but to the extent that has been discussed here. Eh. Most likely not a big deal.


Not sure what's worth laughing at here. Most likely not a big deal, you are right - I think that's pretty much the consensus that we've come to. 

But how do you come to that conclusion without looking into it (discussing it with informed others)? Were you just born with this knowledge?


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## Colt45 (Jun 8, 2018)

Remi said:


> Not sure what's worth laughing at here. Most likely not a big deal, you are right - I think that's pretty much the consensus that we've come to.
> 
> But how do you come to that conclusion without looking into it (discussing it with informed others)? Were you just born with this knowledge?



You don't come to that conclusion without learning the concept or what a flush is. What normal saline is. How it acts when introduced to the circulatory system. I laugh cause it's  a basic concept that most basic emt education should cover. And they only assist with prescribed medication. In hospital, in sterile environments like SDS that stuff really matters. In the field you make it as sterile as possible and call it a run. Doesn't mean you disregard sterality.  It's a basic concept that has been taken to a funny extreme. That's why I laugh. Not because it isn't something to learn.


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## Carlos Danger (Jun 9, 2018)

Colt45 said:


> You don't come to that conclusion without learning the concept or what a flush is. What normal saline is. How it acts when introduced to the circulatory system. I laugh cause it's  a basic concept that most basic emt education should cover. And they only assist with prescribed medication. In hospital, in sterile environments like SDS that stuff really matters. In the field you make it as sterile as possible and call it a run. Doesn't mean you disregard sterality.  It's a basic concept that has been taken to a funny extreme. That's why I laugh. Not because it isn't something to learn.


The question was about patient safety as related to the sterility of prefilled flushes. I don’t recall the sterility of specific pharmacologic items being covered in my EMT class. It’s a good enough question that it comes up pretty routinely in various clinical circles. Glad we could provide you with some comedy, though.


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## Tigger (Jun 11, 2018)

Colt45 said:


> You don't come to that conclusion without learning the concept or what a flush is. What normal saline is. How it acts when introduced to the circulatory system. I laugh cause it's  a basic concept that most basic emt education should cover. And they only assist with prescribed medication. In hospital, in sterile environments like SDS that stuff really matters. In the field you make it as sterile as possible and call it a run. Doesn't mean you disregard sterality.  It's a basic concept that has been taken to a funny extreme. That's why I laugh. Not because it isn't something to learn.


I think we know what NS is, it's about how the device is prepared not the solution though.


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