How does underdosing occur?
It’s common practice to administer short term intermittent infusions for example, antibiotics, via a pump or gravity administration set. With a gravity system, when the infusion ends and the antibiotic container empties, air is pulled into the line until a state of equilibrium occurs between the fluid level in the line and the back pressure from the patient’s vein. This results in residual volume of antibiotic remaining trapped in the line of the tube1,2. Similarly, with infusion pump administration, once the programmed infused volume is complete, the infusion line remains filled with the antibiotic.
There is a common misconception that this is resolved by flushing the short extension line (needlefree extension) attached to the patient’s vascular access device post-infusion however, the residual volume trapped inside the line of the administration set, is far more significant than might appear and it can result in an under deliver of the antibiotic dose prescribed of between 20% (100ml infusion) and 40% (50ml infusion)2.
What are the implications of underdosing?
Line flushing guidance
In 2021, the National Infusion and Vascular Access Society issued line flushing guidance highlighting that administration methods must be improved to minimise the risk of underdosing and ‘to ensure that all of the prescribed medicine is administered’.
‘Ensure that all of the prescribed medicine is administered’5
Intrafix® SafeSet Flush - Enabling total prescribed dose delivery
Intrafix® SafeSet Flush combines a Caresite® needlefree injection port above the drip chamber with AirStop technology at the base of the drip chamber. The unique combination enables the administration set line to be flushed post-medication via attachment of a small volume syringe to the Caresite® needlefree injection port. This permits the residual volume of prescribed antibiotic only to be administered to the patient, reducing the risk of air embolism and fluid overload which could occur if using a flushing bag.
‘It was a very seamless transition, training involved in using these sets is very minimal, they are very easy to use’6
Andrew Barton, Nurse Consultant
Benefits
Benefits
Flushing the line prevents unnecessary wastage of antibiotics and exposure to vapours from administration sets discarded into waste streams containing residual volume of antibiotic
Scientific evidence & webinars
Advancements in IV Administration: The Issue of Underdosing
Mark Santillo – Former Chair of the NHS Pharmaceutical Quality Assurance Committee
Implementing IV Line Flushing Guidance in Critical Care
Kate Holland – Royal Bournemouth Hospital
Line Flushing – Changing the way we do things
Andrew Barton – Frimley Health NHS Foundation Trust
Clinical demonstration videos
Intrafix® SafeSet Flush - Gravity Administration Set for General Ward Use Facilitating a Post Medication Line Flush
Infusomat® SafeSet Flush - Volumetric Pump Administration Set for General Ward Use Facilitating a Post Medication Line Flush
Infusomat® SafeSet Flush - Volumetric Pump Administration Set for ITU/CC Facilitating a Post Medication Line Flush
Related documents and further reading
References
1Santillo, M (2022) IV Forum; Advancements in IV Administration,
https://www.youtube.com/watch?v=0WAupmxRDTY
2Cooper DM, Rassam T, Mellor A. Non-flushing of IV administration sets: an under-recognised under-dosing risk. Br J Nurs. 2018 Jul 26;27(14):S4-S12. doi: 10.12968/bjon.2018.27.14.S4. PMID: 30048183.
3Harding M, Stefka S, Bailey M, Morgan D, Anderson A. Best Practice for Delivering Small-Volume Intermittent Intravenous Infusions. J Infus Nurs. 2020 Jan/Feb;43(1):47-52. doi: 10.1097/NAN.0000000000000355. PMID: 31876774.
4Roseau JB, Pradines B, Paleiron N, Vedy S, Madamet M, Simon F, Javelle E. Failure of dihydroartemisinin plus piperaquine treatment of falciparum malaria by under-dosing in an overweight patient. Malar J. 2016 Sep 20;15:479. doi: 10.1186/s12936-016-1535-8. PMID: 27646822; PMCID: PMC5028982.
5National Infusion & Vascular Access Society, Intravenous Administration of Medicines to Adults: Guidance on ‘Line Flushing’, version 3, 2021
6Barton, A (2022) Line Flushing – Changing the way we do things, presented at Infection Prevention Society IV Forum Conference, https://www.youtube.com/watch?v=eEOeYVjru00
7Goodyear, C (2022) Poster presentation at the National Infusion and Vascular Access Society Conference, Antimicrobial Stewardship & Patient Safety Improvements: Introducing the NIVAS Line Flushing Guidance