I have recently joined an outpatient cancer treatment facility as Clinical Coordinator. The current practice of oncology nurses is the use of preservative-free normal saline for flushing VADs. My previous experience in this type of setting has involved the use of bacteriostatic normal saline for flushing (except, of course, for patients with sensitivity to benzyl alcohol). In an outpatient setting, the volume of patients treated dictated preparation of normal saline flushes well in advance. Preparation and use of preservative-free normal saline over several days raises concern about sterility. In reviewing the Intravenous Nursing Standards of Practice, I found that the use of preservative-free and/or bacteriostatic normal saline is not differentiated. Does INS address this issue?
Your inquiry about the use of preservative-free 0.9% sodium chloride, prepared ‘early' as flushing material for your oncology patients, raises several issues. First, the use of sodium chloride with benzyl alcohol. Obviously, multi-dose vials need to have preservative as a preventative measure against the development of bacteria within the medium. Unfortunately, not everyone uses correct aseptic technique when accessing vials in order to aspirate the contents for injection into a patient. So the risk of contamination of the vial's contents is very possible. The FDA also issued an alert in the early 80's on the untoward effects benzyl alcohol in the neonate and pediatric populations; as a result, the accepted maximum amount of preserved sodium chloride injected daily should not be greater than 30 ml in any (adult) person.
You are correct in your concern over the possibility of contaminated flushes stored longer than 24 hours, especially if they are preservative-free (nonbacteriostatic). Intravenous Nursing Standards of Practice (revised 1998), Number 40, Intravenous Medication Administration, states, "a solution/medication container must be infused or discarded within 24 hours…" Have you investigated pre-filled syringes with 0.9% sodium chloride with the correct syringe size? Or infusing 0.9% sodium chloride as a ‘carrier' fluid in order to flush your infusion systems, thus averting the use of bacteriostatic 0.9% saline? What if your pharmacy prepared flush syringes for you under laminar hood?
Second, you need to reconsider the practice of ‘setting up' syringes too far in advance of the patient's treatment. Should the patient develop an infection which could be traced to contaminated syringes, litigation will swallow up the alleged time saved in re-filling syringes, as well as leave the patient receiving extensive medical treatment and fighting for survival.