Advertisement

Can variable practice habits and injection port dead-volume put patients at risk?

  • Michael T. Kuntz
  • Roman Dudaryk
  • Richard R. McNeer
Original Research
  • 15 Downloads

Abstract

Injection ports used to administer medications and draw blood samples have inherent dead-volume. This volume can potentially lead to inadvertent drug administration, contribute to erroneous laboratory values by dilution of blood samples, and increase the risk of vascular air embolism. We sought to characterize provider practice in management of intravenous (IV) and arterial lines and measure dead-volumes of various injection ports. A survey was circulated to anesthesiology physicians and nurses to determine practice habits when administering medications and drawing blood samples. Dead-volume of one and four-way injection ports was determined by injecting methylene blue to simulate medication administration or blood sample aspiration and using absorption spectroscopy to measure sample concentration. Among the 65 survey respondents, most (64.52%) increase mainstream flow rate to flush medication given by a 1-way injection port. When using 4-way stopcocks, 56.45% flush through the same injection site. To obtain a sample from an arterial line, 67.74% draw back blood and collect the sample from the same 4-way stopcock; 32.26% use a different stopcock. Mean (SD) dead-volume in microliters ranged from 0.1 (0.0) to 5.6 (1.0) in 1-way injection ports and from 54.1 (2.8) to 126.5 (8.3) in 4-way injection ports. The practices of our providers when giving medications and drawing blood samples are variable. The dead-volume associated with injection ports used at our institution may be clinically significant, increasing errors in medication delivery and laboratory analysis.

Keywords

Administration, intravenous Blood specimen collection Embolism, air Medication error Vascular access device 

Notes

Acknowledgements

The authors acknowledge Emre Dikici, PhD of the University of Miami Department of Biochemistry and Molecular Biology, Miami, FL, USA, for allowing use of his laboratory’s spectrophotometer for absorption measurements.

Funding

Equipment for this study was purchased using RM’s departmental discretionary funds.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Given the nature of the survey in this study, no formal Institutional Review Board approval was necessary. A waiver stating this was obtained. All procedures were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

References

  1. 1.
    Smart NG. The functional deadspace of needle-free injection ports. Anaesth Intensive Care. 1991;19(3):429–33.PubMedGoogle Scholar
  2. 2.
    Gould T, Roberts RJ. Therapeutic problems arising from the use of the intravenous route for drug administration. J Pediatr. 1979;95(3):465–71.CrossRefPubMedGoogle Scholar
  3. 3.
    Lovich MA, Doles J, Peterfreund RA. The impact of carrier flow rate and infusion set dead-volume on the dynamics of intravenous drug delivery. Anesth Analg. 2005;100(4):1048–55.CrossRefPubMedGoogle Scholar
  4. 4.
    Lovich MA, Kinnealley ME, Sims NM, Peterfreund RA. The delivery of drugs to patients by continuous intravenous infusion: modeling predicts potential dose fluctuations depending on flow rates and infusion system dead volume. Anesth Analg. 2006;102(4):1147–53.CrossRefPubMedGoogle Scholar
  5. 5.
    Bartels K, Moss DR, Peterfreund RA. An analysis of drug delivery dynamics via a pediatric central venous infusion system: quantification of delays in achieving intended doses. Anesth Analg. 2009;109(4):1156–61.  https://doi.org/10.1213/ane.0b013e3181b220c9.CrossRefPubMedGoogle Scholar
  6. 6.
    Cole DC, Baslanti TO, Gravenstein NL, Gravenstein N. Leaving more than your fingerprint on the intravenous line: a prospective study on propofol anesthesia and implications of stopcock contamination. Anesth Analg. 2015;120(4):861–7.  https://doi.org/10.1213/ANE.0b013e318292ed45.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Wald M, Kirchner L, Lawrenz K, Amann G. Fatal air embolism in an extremely low birth weight infant: can it be caused by intravenous injections during resuscitation? Intensive Care Med. 2003;29(4):630–3.  https://doi.org/10.1007/s00134-003-1681-7.CrossRefPubMedGoogle Scholar
  8. 8.
    Muffly MK, Chen MI, Claure RE, et al. Small-volume injections: evaluation of volume administration deviation from intended injection volumes. Anesth Analg. 2017;125(4):1192–9.  https://doi.org/10.1213/ANE.0000000000001976.CrossRefPubMedGoogle Scholar
  9. 9.
    Casella SJ, Mongilio MK, Plotnick LP, Hesterberg MP, Long CA. Accuracy and precision of low-dose insulin administration. Pediatrics. 1993;91(6):1155–7.PubMedGoogle Scholar
  10. 10.
    Reason J. Human error: models and management. BMJ. 2000;320(7237):768–70.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Stefanini M. Iatrogenic anemia (can it be prevented?). J Thromb Haemost. 2014;12(10):1591.  https://doi.org/10.1111/jth.12642.CrossRefPubMedGoogle Scholar
  12. 12.
    Steffen K, Doctor A, Hoerr J, et al (2017) Controlling phlebotomy volume diminishes PICU transfusion: implementation processes and impact. Pediatrics.  https://doi.org/10.1542/peds.2016-2480.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Fowler RA, Berenson M. Blood conservation in the intensive care unit. Crit Care Med. 2003;31(12 Suppl):715-20.  https://doi.org/10.1097/01.CCM.0000099350.50651.46.CrossRefGoogle Scholar
  14. 14.
    Brull SJ, Prielipp RC. Vascular air embolism: a silent hazard to patient safety. J Crit Care. 2017;42:255–63.CrossRefPubMedGoogle Scholar
  15. 15.
    Kumar D, Gadhinglajkar SV, Moorthy K, Bhandari D. Paradoxical air embolism to left anterior descending artery during induction of anesthesia in a patient with an atrial septal defect. A A Case Rep. 2014;2(6):66–9.  https://doi.org/10.1213/XAA.0000000000000007.CrossRefPubMedGoogle Scholar
  16. 16.
    Dube L, Soltner C, Daenen S, Lemariee J, Asfar P, Alquier P. Gas embolism: an exceptional complication of radial arterial catheterization. Acta Anaesthesiol Scand. 2004;48(9):1208–10.  https://doi.org/10.1111/j.1399-6576.2004.00476.x.CrossRefPubMedGoogle Scholar
  17. 17.
    Murphy GS, Szokol JW, Marymont JH, Avram MJ, Vender JS, Kubasiak J. Retrograde blood flow in the brachial and axillary arteries during routine radial arterial catheter flushing. Anesthesiology. 2006;105(3):492–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature B.V. 2018

Authors and Affiliations

  1. 1.Department of Anesthesiology, Jackson Memorial HospitalUniversity of MiamiMiamiUSA

Personalised recommendations