Flush After IV Meds at the Same Rate You Give the Med

You’ll hear more about safe IV flushing strategies in adults.

In a recent error, a patient stopped breathing when he accidentally got the neuromuscular blocker rocuronium...after he was extubated.

It turns out rocuronium was still in his IV line from surgery...and was pushed into his bloodstream when the line was flushed post-op.

In another case, an ICU patient was weaned off norepinephrine, but some was left in his line. Later the line was used to give another med, and the norepinephrine was unknowingly pushed in...leading to arrhythmias.

Use these examples as reminders to ensure safe flushing strategies.

Continue to ask about IV lines and meds at patient handoff.

Inspect IV lines before giving meds. If the line is cloudy...or becomes cloudy while pushing a med...stop and change the tubing.

Keep in mind to flush IV lines before giving meds to rule out line occlusions...and prevent incompatibilities. For example, IV phenytoin (Dilantin) can precipitate if there’s dextrose in the line.

We also know to flush after an IV push med or intermittent infusion. But other scenarios aren’t as clear cut.

For example, flush after pushing meds at a Y-site...even when primary fluids are running. This keeps the med from lingering in the Y-site. Plus fluids running at low rates may delay the med from fully reaching the patient.

Flush at the same rate you give the med. Flushing too quickly may push what’s left of the med in too fast. For example, rapid IV labetalol administration is linked to cardiac arrest.

Verify your flush volume is enough to push all the med through the line. Follow your hospital policy. But generally expect to use at least 5 mL for most peripheral lines...and 10 mL for midlines or central lines.

But be aware of exceptions, such as longer tubing. Also consider using 20 mL after viscous solutions...blood, contrast, nutrition, etc...to prevent these from sticking to the inside of the IV catheter.

And run at least 50 mL of normal saline behind an alteplase infusion to ensure the full alteplase dose reaches the patient.

Lean toward using “push-pause” flushing...pausing briefly after each 1 mL. This turbulence may help remove deposits that lead to occlusions.

See our chart, Best Practices for Flushing IVs, for more strategies...and get our IV Push: Dos and Don’ts commentary.

Key References
  • J Infus Nurs 2016;39(Suppl 1):S1-S159
  • Nurs Res Pract 2015;2015:98568
  • www.ismp.org/guidelines/iv-push
  • ISMP Medication Safety Alert! Action Agenda 2018 (Jul-Sep);AA1-AA4
Nurse’s Letter. Apr 2019, No. 350425

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