On a regular basis, I get questions from readers and from Twitter colleagues. Here are some of the Q’s and my A’s which I thought I’d blog about it in the spirit of sharing and learning.

1. Vancomycin

Q: We give Vancomycin IV on a regular basis through an IV site in the arm at our hospital. I came across an article where it states that this drug is recommended to be given through a central line. I didn’t know this and wondered why we continue to give this through an arm vein.

A: Vancomycin has been around since the 1950’s and continues to be a popular medication prescribed for patients with gram positive infections. This antibiotic has been associated with thrombophlebitis and infusion related events related to the concentration and rate of administration. What we know about this drug is that the pH is less than 4  in most admixtures and is classified as acidic. The Infusion Nurses Society Standards of Practice recommends that medications with a pH below 5 or above 9 are not appropriate for infusion using a peripheral access device such as a peripheral IV or midline.  Using a central venous access device (e.g. PICC) to administer this drug will allow for better hemodilution and avoid vein irritation.

Another point to remember, if this medication infiltrates/extravasates in a peripheral IV, it can cause phlebitis, thrombosis and tissue damage , sloughing or necrosis because of the low pH.  The calculated osmolarity of various admixtures is within the 300 range so this is not much of a concern (INS recommended  central line for >600 mosmol). Many clinicians are more concerned with the dilution and rate of administration, which has little effect in reducing vein irritation  since there is no  significant change in pH of the final admixture. Many have overlooked the fact that if you have to restart a peripheral IV q 12hrs when it’s time to administer the next Vanco dose, then there is a problem and consider what is best for the patient – a central venous access. Thank you for your interesting question.

2. Infusions and MRI suites

Q: What is the procedure in your facility for IV infusion during an MRI procedure especially on patients with critical drips? I’m not sure the best solution is running long extension tubing outside of the room to the pump. Other than a waste of meds……is there any other reason against using multiple extension sets?

A: Great question and one that is still an issue in many hospitals. I work in an outpatient infusion center so our patients needing MRIs get the procedure without an infusion or after the infusion is completed. However, I do know from talking to many colleagues in the critical care areas that the practice of using a long tubing you described is still going on and we all know the potential problems that can create, including not only a waste of medication but also, under dosing especially if the tubing is kinked without anyone noticing, etc. Using multiple extension sets doesn’t eliminate any of these potential problems and increases the potential of  contamination.

According to a nurse colleague, (@chriscavrn – thanks!) there are syringe pumps approved for use in the MRI suites, which can be an alternative but cumbersome and increases the risk of contamination. There are currently two MRI safe pumps available on the market, one is non-magnetic, and operates similar to many floor infusion pumps, has programmed software for dosage safety, and a bypass tubing that can easily attach to the current tubing the hospital is using.   The other has to be attached to a pole bracket for safety, and is a small pump, like a homecare pump, and require the medication to be respiked with the tubing for that pump.  That pump, the MedRad Continuum had a recall of its tubing in November (I think) 2012, and is still on recall status according to the website, and they are not shipping tubing at all.   So, currently the only option for truly safe infusion in the MRI is the MRidium pump, made by IRadimed, Inc. Thanks for your question and hope this helps.

3. Wearing mask during port access procedure

Q: Do nurses at your institution wear a mask during a port access procedure?

A:  Yes, at the infusion center where I work as required by our institution policy. Many others do not because there is lack of research in this particular practice. The INS Standards of Practice states: Aseptic technique, including the use of sterile gloves, should be used when accessing an implanted port. The use of a mask during access is recommended; however, it remains an unresolved issue due to lack of research. Hope this helps and thank you for your question.

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References:

1. Infusion Nurses Society Standards of Practice 2011.

2. Hadaway L; Chamalls S. Vancomycin: new Perspective on an Old Drug.2003  JIN:26:5 pp 278-284.