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Mats Stromberg
Syringe size revisited

Dear list friends,
I am currenly writing the national PICC guidelines for the allied Swedish county councils. It will be available through the Internet and many hospitals will use it to base their own guidelines on. My problem at the moment is that me and the peer reviewer just cannot agree on what to say about syringe size.

My current suggestion is:
”The smaller the syringe, the easier it is to generate a too high pressure within the catheter system. It is therefore appropriate to use 10 ml or larger syringes for the flushing of central venous access devices. Never flush or inject forcibly against an increased resistance, as it is possible to damage a catheter also with a larger syringe.
For the administration of drugs in smaller volumes, a smaller syringe can be used provided that patency first has been established using a 10 ml or larger syringe. If increased resistance is met, see the chapter “Thromboses, occlusions and catheter damage”.”

The peer reviewer says that I cannot say that it is ever OK to use a syringe smaller than 10 ml. If I will not say that a smaller syringe never can be used, she wants me to at least just omit the fact that they actually can be used. I want to abolish the notions that using a large syringe is a safe harbour and that if you need to administer smaller volumes you should transfer the med to a larger syringe first (or place a PIV in i patient with a perfectly good CVAD).

Am I making sense here? Are there any refs that could back me up? What is your view. Lynn? What do the rest of you say?

Mats

Wendy Erickson RN
I agree with you.  What our

I agree with you.  What our policy says is if you are forced to use a smaller syringe because it is prefilled or due to small volume measurement requiring a TB or insulin syringe, you must inject gently and slowly.

I feel that the risk of contamination and needle pokes greatly increase as you attempt to transfer something from a smaller syringe to a larger one.  With most lines being polyurethane and therefore much stronger than silicone, I would much prefer to use the smaller syringe and inject gently than to risk contamination.  I would not say that you have to start a PIV - that makes no sense, as far as I am concerned.

Wendy Erickson RN
Eau Claire WI

Mats Stromberg
Help!

I have now added that injection with smaller than 10 ml syringe should be done gently and stopped immediately if incresed resistance is felt. My peer reviewer still refuses to accept that the guidelines in any way say that smaller than 10 ml syringes can ever be used. People will still use 5 ml syringes for CVADs (which she acknowledges) and my point is that it is better to say how it should be done rather than just not saying anything.

Is there a ref that could help me? What do you say, Lynn?

Mats

lynncrni
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Yes, I think there are references but I can not immediately recall them. In my opinion, the use of a smaller syringe that will accurately measure the medication dose is far safer than trying to transfer the small dose to a larger syringe. I would never transfer a dose from one syringe to another for the sole purpose of using a larger syringe on a catheter. A small syringe will not produce catheter damage if the catheter is open and patent, assessed by the initial flush with 10 mL of saline. This allows you to rule out resistance which is what produces the catheter damage. Resistance + force applied to the syringe plunger = catheter damage. Eliminate the presence of resistance and there will be no need for forceful injections and no catheter damage. You may want to review the following old articles, although I do not think they specifically state that it is acceptable to use a small syringe. The only size syringe that I would not use is a 1 mL size.Lynn

1.    Hadaway LC. Major thrombotic and nonthrombotic complications: Loss of patency. Journal of Intravenous Nursing. 1998;21(5S):S143-S160.
2.    Macklin D. What's physics go to do with it? Journal of Vascular Access Devices. 1999;4(2):7-13.

 

 

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Mats Stromberg
Thanks Lynn and I found an article.

It is really good to know that you agree with me. Thanks for answering!

Also, I found an article: It is a survey done on 20 paediatric surgery departments. 11/20 used 5 ml and one used 2 ml syringes for CVADs (15/20 used PICCs). They conclude that a "Practitioners should ascertain the patency of the catheter with the recommended syringe (10 ml) before administering prescribed medication with a smaller volume syringe." I can send the article to you Lynn (or any one else); just let me now. The article is: Douglas D et al 2009: Central venous access devices: review of practice. Paediatric Nursing 21(5)19-21.

Mats

lynncrni
Yes, please send to me. I

Yes, please send to me. I have trouble ordering articles from that journal as I just tried to obtain a couple this week. I would appreciate it. Thanks, Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

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