Diluting Meds in Flushes? *poll*

[CWATT]

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

 

[Summit]

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.

 

[zacdav89]

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.

 

[Summit]

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.

 

[zacdav89]

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

 

[E tank]

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.

 

[Carlos Danger]

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.

 

[NomadicMedic]

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

 

[Akulahawk]

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.

 

[Akulahawk]

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.

 

[Ensihoitaja]

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.

 

[Akulahawk]

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.

 

[Ensihoitaja]

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.

 

[Bullets]

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

 

[NPO]

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.

 

[Akulahawk]

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.

 

[Akulahawk]

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...

 

[NPO]

. 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.

 

[Akulahawk]

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.

 

[NPO]

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.