The instructions have recently changed. Now the package insert for all I.V. fat emulsion (e.g., Intralipid, Nutrilipid) states to use a 1.2-micron filter for all infusion. Previous instructions were not as specific, stating that filters were not recommended or that a filter of less than 1.2-micron pore size was not to be used. This brings up several questions about the most appropriate filtration for infusing all parenteral nutrition solutions. When all components are admixed together in one solution container (ie, 3-in-1 or Total Nutrient Admixture), the recommendation has always been to use an in-line 1.2-micron filter for infusion. IVFE will not pass through filters with a smaller pore size. The concern was and still is cracking the fat emulsion, possibly resulting in a fat embolism. What about filtration for a 2-in-1 solution containing protein, carbohydrates, and other additives? The practice has been to use a 0.2-micron filter on this solution to ensure removal of all particulate matter and microorganisms. IVFE was piggybacked below the filter or given through a separate catheter with no filtration. Now the IVFE requires a 1.2-micron filter regardless of where it is infused. There are several options for configuring the filters. According to 2016 INS Standards of Practice and a 2014 ASPEN guidelines document, a 0.22-micron filter is needed for the 2-in-1 PN solution due to particulates from the compounding process and microorganisms that could enter the system. To follow these new IVFE manufacturer instructions, 2 filters of 2 different sizes must be used - a 1.2-micron filter on the IVFE and a 0.22 micron filter on the 2-in-1 PN. The other option would be to use a 1.2-micron filter in the system and infuse both 2-in-1 PN and IVFE thru the same filter. This could be considered the same as infusing a 3-in-1 PN solution thru a 1.2-micron filter. To make the clinical decision about filters, I would want to know what filtration, if any, was done by the pharmacy during the compounding process. If pharmacy is filtering, what pore size filter is being used? To reduce microbial contamination, I would strictly enforce the policy of NOTHING being injected or piggybacked into this system and the system would ONLY be taken apart when it is time to change the entire administration system once every 24 hours. The number of venipuncture attempts to insert a short peripheral catheter is a critical factor in the ultimate health of your patient’s veins. The 2016 Infusion Therapy Standards of Practice call for no more than 2 attempts per clinician with a limit on the total number of attempts to 4. After 4 unsuccessful attempts, it is time for a careful assessment of VAD needs and discussion with the patient’s providers to decide on the most appropriate options. Many experts would argue that 4 attempts are too many! Think about those 4 veins that have been punctured, damaged and will now have a small amount of scar tissue.
We have all encountered those patients with difficult venous access – no peripheral veins can be seen or palpated. Or the veins that can be felt are hard and rope-like meaning they are sclerosed. I have often wondered how many failed venipuncture attempts these patients have endured. Many healthcare issues cause damage to the vein wall – some within the patient’s control such as smoking and some due to chronic illnesses such as diabetes. The number of patients with chronic diseases requiring frequent venipuncture is growing. Blood sampling, receiving diagnostic tests such as CT scans with I.V. contrast, or courses of antibiotics for frequent infections translates to numerous venipunctures. But failed venipuncture attempts are directly related to the skill and judgment of the clinician. Vein damage occurs regardless of whether the attempt was successful or not. The goal is vein preservation so that peripheral veins remain available for the entire lifetime. Many times, a central venous access device is needed for no other reason than an absence of peripheral veins. A CVAD carries the greatest risk of bloodstream infection and vein thrombosis, so the goal is to use them ONLY when the length, frequency, and characteristics of the infusion therapy demand the tip location in the superior vena cava. By protecting patient’s peripheral veins, these goals are possible. Never make a venipuncture attempt blindly, without being able to see or feel a vein in good condition. Assess both extremities for the total number of sites available. If there are very few sites, and you do not think your venipuncture skill is sufficient for the level of difficulty, call the infusion/VA nurse or another clinician with more experience and inform them that near-infrared light or ultrasound may be needed. Consider the length of therapy and the characteristics of the prescribed medications. Don’t stick a vein in a finger or some other odd location just for the sake of saying you can do it. And finally work to change those terrible policies requiring that the patient’s nurse make a certain number of attempts before they call for assistance. These policies add to the problem of vein wasting and ignores the goal of peripheral vein preservation. This issue continuous to cause much confusion among nurses and others using any type of vascular access device (VAD). You were probably told that ONLY a 10 mL syringe or a syringe with a barrel the same size as a 10 mL syringe could be attached to any VAD. So you have been transferring small volume medications to a larger syringe to follow this rule. Now it is time to learn the facts so you can base your practice on evidence. It is true that a larger syringe size (ie. 10 mL) will generate less pressure on injection than a smaller syringe (ie, 3 mL or 5 mL). That was the basis for the outdated “rule” about only using a 10 mL syringe. But the issue is actually catheter damage and syringe size is only one factor, and I would hasten to add, not the most important factor! Catheter damage depends on 2 things happening.
Two important documents now address this issue. The 2016 Infusion Therapy Standards of Practice states that the functionality of all VADs should first be assessed with a saline-filled 10 mL syringe. Patency is confirmed when there is NO resistance, a blood return that is the color and consistency of whole blood, and the absence of any signs or symptoms of VAD complications. Pay attention to any complaints the patient may have. Strange sensations in the chest, neck, shoulder or extremity are not normal and require further investigation. If the VAD is patent, proceed with giving the medication in a syringe that is appropriate for the dose of medication being given. Yes, that means using a 3 mL syringe. The Infusion Therapy Standards can be purchased here. The second document is from the Institute for Safe Medication Practices, Safe Practice Guidelines for Adults IV Push Medications. This document contains lots of great information about avoiding unnecessary drug dilution. It strongly states to NOT use a prefilled flush syringe to dilute medications, providing the reasons for this. There is also similar guidance on assessing VAD patency with a 10 mL diameter-sized syringe and to use a syringe appropriately sized for the medication, pointing out the risk associated with a syringe-to-syringe transfer of the drug. This document is a free download. Many new documents are now available to guide your clinical practice, including those we discussed in this week’s blog message above. You may have many questions about these or other new guidelines documents. Lynn Hadaway has been an author on many of these documents and can help you to understand their content. We are setting aside time each month for discussing your questions. Register for our monthly video conference session on Thursday, April 14 at 12 noon ET. Submit your questions before the scheduled day. Join the conference with Lynn Hadaway to get more information, explanation, and clarification on your questions. |
Author: Lynn HadawayLynn Hadaway is an international thought leader in infusion therapy and vascular access, having been in this practice for more than 40 years. Her experience comes from hospital-based infusion teams, device manufacturers, and continuing education services. Her journal and textbook publications are extensive. She also maintains board certification in infusion nursing (CRNI) and nursing professional development (RN-BC). Categories
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May 2019
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