Saline Lock vs I.V. Bag

[BURNSEMS]

Hello All, There is a Debate in our area about Saline Lock vs Starting a I.V. W/ 500 or 1000cc Fluids, Our Dept does not do Saline Locks due to Extended Transport Times, However a Paid Dept in another County only Starts Saline Locks or 250cc Bags on All med Patients, I am not Familure with them except in Hospitals, Whats the Good Vs Bad.

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Here today for a Safer Tomorrow

[Medic019]

We have to option to start either or both. I've found it personally better to put a heplock on the IV cath for all patients that need IV interventions. The reason is sorta two fold:

You can always hook a bag of fluid up to the heplock if the patient needs fluids. Also, when you get to the ER the staff there can just unhook the bag of fluid leaving the Heplock in place to undress the patient's - instead trying to snake IV Fluid & Tubing through shirt/jacket sleaves.

If you have to a move the patient long distances with an IV (how many times have you seen the IV get pulled becuz the tubing got caught on something ? Me, alot), you can unhook the fluids and re-establish the drip when you finish the moving.

I really like the advantages of the Heplock/Saline Locks. It does not add that much time to put one on the cath and the flexibility it offers are great...

Hope this helps...

Tad

[smokinmedic]

Hey, why not one of each. Especially with cardiac pts or anyone about to crash at a moments notice. It can't hurt.

[Boothby]

We have the option of doing both. I look at hanging fluid in the same way I look at giving meds. If they don't need it they don't get it. You really have to look at why you start the IV. If I am starting a precautionary IV as a route for drugs then they get a saline lock, If they need the fluid then they get a bag. The only time I hang fluid as a precaution is with trauma and OB pts. Most of your medical patients don't need fluids, at least not the type that we carry. This is especially true for anybody with pulmonary edema. If I am going to give someone Lasix to get the fluid off of them, then the last thing I want to do is give them more fluid. As far as the argument about long transport times, I'm not sure I understand. I have seen patients in hospitals go for days with saline locks without complications. One last thing. SmokinMedic suggested starting one of each and that it "can't hurt". Well I don't know about you but the last time I had an IV started on me it hurt like hell. Try to keep that in mind while your jamming needles in you patients.

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Larry Boothby
Firefighter/Paramedic
Truck 3 A-shift
Local 1784
Memphis.

[Trauma_Dog]

Again the I am going to make an argument for common sense. First there are many reasons why to hang fluid on a pt than most medics seems to overlook. First all urgent pts should have a bag hanging for reasons that need no explaination, but what about the the asthma or copd pt that is not normally what we call urgent, but needs a breathing treatment? I can make an argument that a large number of our pts are respiratory in nature and that most standing orders do or should call for agressive fluid therapy in these pts, the old dialate and hydrate attage. If we are not treating these pt with all of our tools then we are not doing all we can for them. I do agree there are times that we should start locks, dont misunderstand what I am saying. I just think that a blanket statement about what I am going to do before I am even responding and not in the pts best interest. The truth is there is no best way, there is only the way that is best for the pt.

Kjs
mchd ems

[Medic019]

Trauma, Your right that the patient's well being is your foremost priority. That is why I stated that utilizing a Saline/Heparin lock on all IV Cath's is in my opinion the best route to take. If you need to hang fluids on a patient, you plug it in through the Heplock - It does not take that much time and you can begin the IV, put a heplock on the IV cath, spike your fluids, and begin running your fluids through the heplock.

The ER up here in the snowbelt also follow that routine. That way after the patient is stabilized, all you have to do is unplug the fluids (whatever it maybe) and the patient has the heplock still in place.

Tad

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Firefighter/Paramedic in Northwest Pennsylvania... Stay Safe

[Terry McDonald]

I wish we could use saline locks. In MS it is IV fluids in the field or nothing. The argument i got is that MS medicare will not pay for an INT. They pay a token amount for a bag of fluids, tubing, and a cath., but nothing for a saline lock. Seems to me it would cost less money in the long run for the services to be able to use the INTs and eat the small cost than to keep losing money on the full cost of a fluid set up. To push any drug, you have to run fluid into the pt. When you have a pt. with severe edema that you can here from ten feet away when the pt. breathes, it is ridiculous to give the person any fluid just to push some Lasix. INTs definately have there place in the field.

[Weruj1]

bump ........

[latigo]

OK, my 2 cents. If I do decide to start an IV, I almost always start a saline lock. In my hospital we also will pull up a syringe of blood for labs and while I am hooking up the lock, my partner is filling the blood tubes. We do this for many of the same reasons stated earlier. But, it is also for the tubing. We carry straight tubing for the bag normally. If the Pt is admitted and getting fluids, they go on a pump, different tubing. If the Pt is then transferred out of the ER or floor, they will go to another facility, and another set of pump tubing. With an lock in, you unscrew one, wipe with alcohol, and screw on the new tubing. Easy as pie, and keep the # of sticks down.

[sparkymedic83]

I use both. I start the IV, hook up a saline lock, then attach fluids to the end of the saline lock if needed. Our Saline locks are the same size tubing as IV tubing, so there's really no restriction. They also have what are called "CLAVE" ports on the end of them. I like em.

-- J. Jones

[medic02019]

I work for a private service in massachusetts. We have been using Saline Locks along with the Saline Infusions. I guess it is all on how the patient presents to you. Does the patient's blood pressure seem stable if the patient looks stable enough Then go with the saline lock instead of going with the fluid route, because you can always connect a liter quickly if ou need it. So I would say Yea with the saline locks , And it is cost Effective As well.

[thebigcheese]

At my (new) service we aren't allowed to start saline-locks. We don't even carry the equipment for it on the truck. Our medical directors opinion is that if we start a line they must need fluids, which is rather...um, narrow minded. We're trying to get it changed, but for now if they really don't need fluids (ie. CHF, hypoglycemia, etc) we just run it at TKO or shut it off completely.

[latigo]

And a big reason we do locks. Quite often, when the Pt gets to the ER, we will want to put them in a gown. With a lock, this is easy, no threading bags and tubing thought shirt sleeves. It works well for us.

[parafire81]

While I agree that there are significant benefits to being able to establish a saline lock instead of an IV with fluid, alot of it boils down to straight economics.

A bag of fluid and tubing costs about $2 to stock

The cost for a saline lock is about $3.50 and the cost of the prefilled 3cc NS flush is about $4.

If you were in charge of ordering supplies for your agency, and had to stay within a budget, would you rather pay $2 for an IV start or $7.50? Also consider the cost increases to $9.50 if you end up having to upgrade the lock to a line.

[Plattsfire2]

If the patient needs fluids, they get a bag. But if I'm starting a precautionary lock, I'll wait until i'm pretty well out of stuff to do before I stick. I'd like to think I'm cutting down on infections from pre-hospital sticks, but I'm probably kidding myself. I like to keep "precautionary" invasive procedures at a minimum in the squad.

[swvafiremedic]

our regional protocol allows for both in different conditions. med only pts get a lock, fluid replacement in burns trauma and ob get a line or the medic can decide. my policy is to start the lock on any pt that gets a line ( except for trauma pts) then draw labs on pts with dyspnea,chest pain,or other problem that will need lab work. the reason for this is 3 fold, 1 the pt is stuck only once 2 the er is going to draw labs anyway and if they do it they will probably call the lab and this can take 10 minutes or better at times. in the modern drug world,drs. want to minimize door to drug times and if i can save them 10 or more minutes it transport then the pt will benefit.3 the hospital aprreciates the help when they may be short handed and this build reputation with the staff, when you need that order for drugs the dr and staff will most likely say hay he is very compentent and helps us out he wouldnt be asking if not needed so we will let him do it, again benefit to the pt. Also our policy states that iv therapy begin in transit except for long extrications,codes,hypoglycemi a,or pts who need imediate drug intevention. we have to limit attempts to 2 in the field and then tx is mandatory,also our policy limits to 60gtt or locks on pts with pulmunary edema,peds. The lock and lab is very quick and helps the pt also alows for removal of line if needed for whatever reason and is easy to handle, a lab kit with lock, vials, vacutainer,cath 18 &20 gauge, prep pad, line to lock adapter, prefilled flush, 2X2 gauze,and see through dressing can all be put into a small container, dumped onto the pts lap, and everything is right there at hand. Of course the hospitals do stock these for us so cost isnt an issue and you can always start a second line with just line or lock it off as well. i have never got anything but positive feedback from this type of treatment. also we hang ns as iv fluid on all pts however we can vary from protocol with ed dr's signature and i often hang lr on pts with dehydration only ie flu like symptoms etc.

[FyrGuy176]

Our medical Director has been talking about changing the protocols to include saline locks. Most of the hospitals we transport to use this method and it would standardize the procedure and add the convenience/easiness of changing fluid bags when one runs out.

[EMTZeek]

I work in an ED, and in my opinion I would love ONLY locks. I dont understand, other than cost why it would be any different. If you need to switch out bags, its much easier, if you need to get the patient undressed, its much easier. I'm usually the person who changes the normal IV star t to a saline lock anyway, so why not do it in the field?

[Dave1983]

Locks have no place in the field. If you need to give meds or fluid, hang a bag. If you dont need to give either, you dont need to stick the patient. Used to be we only stuck patients who needed it. But weve had the locks here for a while and now pretty much every patient gets one.

Nothing like turning a BLS patient into ALS by starting a lock just because you can. As for the "well the ER likes them", srew it. When was the last time an ER gave you anything other then crap for something you did or didnt do. If the ER wants a lock they can start it themselves.

[croaker260]

Originally posted by Dave1983
Locks have no place in the field. If you need to give meds or fluid, hang a bag. If you dont need to give either, you dont need to stick the patient. Used to be we only stuck patients who needed it. But weve had the locks here for a while and now pretty much every patient gets one.

Nothing like turning a BLS patient into ALS by starting a lock just because you can. As for the "well the ER likes them", srew it. When was the last time an ER gave you anything other then crap for something you did or didn’t do. If the ER wants a lock they can start it themselves.

Well, I disagree with the first paragraph, although I do agree with the sentiment of the second part if not the way its put. There are patients who I start a lock for a reasonable chance I will do something in route, such as administer an anti-emetic, or as part of the chest pain protocol...even if it has resolved with a little NTG, in the event it returns and I want to give some MS.

I myself use saline locks for a lot of patients, even those who I do several IV interventions to. I (personally) only hang a bag for patients who need fluid actively or major trauma.

Since we carry a LOT of 10 cc NACL flushes, that’s what I use with my locks when I give meds instead of hanging a full bag just top flush a lock with . Since all of our stuff is needleless leur lock connections, this is especially convenient.

For example, the little old lady with hip Fx, I will draw up my valium, my MS or Fentanyl, give my drugs followed by flushes...no problem.

Same for patients with nausea, etc.

I like this especially in cases where the patient may be combative, like SZ and OD's, as I wrap the saline lock in coban (vet wrap)except for the hub, makes it harder to pull out.

My chest pain patients are the same unless they need fluids for right sided MI's. Even my dual lumen caths get two saline locks.
I find that, since a lot of treatment is started on scene for STABLE Patients, not having a "line" to tangle up, get in the way, etc is more of a benefit than having a "bag" just in case". Over the years I have found this to be a lot easier than worrying about a patient, another responder, or the cat pulling out a line. Especially that, on average, most patients get less than 50 cc infused since we usually would "TKO" most infusions.


To the person that illustrated at their department how it is cheaper to hang a bag...in our system, our saline locks are long enough to double as ext sets (approx 6-8 inches), since we use long tubing anyway. So there is a real cost savings for us as we don’t have a separate "extension set".

AS A SIDE NOTE:
This is a very mundane topic open to personal preference. Truly, I can not think of a single patient in 15 years where having a saline lock in place (with or with out a bag...) attached made a true difference in patient outcome (although having some form of IV access did), it’s a personal pref and a scene dynamics issue.
I like the post that mentioned the "argument for common sense".

[Dave1983]

Originally posted by croaker260


Well, I disagree with the first paragraph, although I do agree with the sentiment of the second part if not the way its put. There are patients who I start a lock for a reasonable chance I will do something in route, such as administer an anti-emetic, or as part of the chest pain protocol...even if it has resolved with a little NTG, in the event it returns and I want to give some MS.

I myself use saline locks for a lot of patients, even those who I do several IV interventions to. I (personally) only hang a bag for patients who need fluid actively or major trauma.

Since we carry a LOT of 10 cc NACL flushes, that’s what I use with my locks when I give meds instead of hanging a full bag just top flush a lock with . Since all of our stuff is needleless leur lock connections, this is especially convenient.

For example, the little old lady with hip Fx, I will draw up my valium, my MS or Fentanyl, give my drugs followed by flushes...no problem.

Same for patients with nausea, etc.

I like this especially in cases where the patient may be combative, like SZ and OD's, as I wrap the saline lock in coban (vet wrap)except for the hub, makes it harder to pull out.

My chest pain patients are the same unless they need fluids for right sided MI's. Even my dual lumen caths get two saline locks.
I find that, since a lot of treatment is started on scene for STABLE Patients, not having a "line" to tangle up, get in the way, etc is more of a benefit than having a "bag" just in case". Over the years I have found this to be a lot easier than worrying about a patient, another responder, or the cat pulling out a line. Especially that, on average, most patients get less than 50 cc infused since we usually would "TKO" most infusions.


To the person that illustrated at their department how it is cheaper to hang a bag...in our system, our saline locks are long enough to double as ext sets (approx 6-8 inches), since we use long tubing anyway. So there is a real cost savings for us as we don’t have a separate "extension set".

AS A SIDE NOTE:
This is a very mundane topic open to personal preference. Truly, I can not think of a single patient in 15 years where having a saline lock in place (with or with out a bag...) attached made a true difference in patient outcome (although having some form of IV access did), it’s a personal pref and a scene dynamics issue.
I like the post that mentioned the "argument for common sense".


Yeah, my comments were a bit strong. But this really strikes a nerve with me. Im so tired of all the "over treating" of patients I see on a daily basis. Just because you have a whole rig full of equipmnent doesnt mean you have to use it on every patient.

I guess my view on these kinds of things is clouded by my 22 years of watching a good EMS system that relied on the medic to use their training and experience to determine a course of treatment turn into the poster child for "cookbook" medicine.;)

[Loco615]

Ok I have a few things to say about this. I think we are overthinking this. The IVL that the hosp use and we use are a smaller tubing in my area. So as most of us being firefighters understand the whole concept of diameter.

I have a few comments that my medical directors made. One being a older doc and the other younger.

For example, the little old lady with hip Fx, I will draw up my valium, my MS or Fentanyl, give my drugs followed by flushes...no problem.

We use MSO4 for our pain relief. Most of the time we give 10mg over a 5/3/2 stack. Now a old lady I would hang a bag. I am giving a medication that can have vascular effects I want that extra comfort. It has happened to me and I wasnt looking around to hook up that bag on a small IV tubing lock.

My chest pain patients are the same unless they need fluids for right sided MI's. Even my dual lumen caths get two saline locks.

Well you would be in trouble here. Both my medical directors and protocal say hang a bag. I believe ANY time you give a vascular dilator. You should hang a bag. Yes SL NTG doses are small compared to the NTG drips.

I think IVL have their place. Such as a seizure pt you are observing and think you will not give any meds to. Other pts that you will not do interventions also.

[deputychief1441]

We have the option, my opinion is that saline locks are usefull , however the adaptor we use to go from the fluid to the SL, is only the equiv. of an 18ga. cath. so starting of 16, 14's are useless. The only time that I personaly start an IV with no SL, is on Trauma for rapid infusion. This is also coming from a FF/Medic who mainly deals with trauma in the field and not a lot of t-port.

[ColdFireJT]

I'm all about the saline locks. I picked up the habit from the local ERs around here of starting a lock first and then adding a line to it if you need to administer fluids. I think the locks are a little more versatile because you always have that access point available to you and you can add or disconnect other lines more easily than just hooking a line up to the hub.

[RoryEl]

Saline locks certainly have a place in the context of pt treatment and incidentally have a lower rate of reimbursement. There are those pt's who obviously need fluids, those who need IV access because of treatment with vasoactive meds, and those who need emergent access due to disease process or medication administration. The latter are candidates for saline locks. Consider a pt with CHF. A saline lock is beneficial where as IV fluid (even TKO) is detrimental.

[kramelop]

While I agree that there are significant benefits to being able to establish a saline lock instead of an IV with fluid, alot of it boils down to straight economics.

A bag of fluid and tubing costs about $2 to stock

The cost for a saline lock is about $3.50 and the cost of the prefilled 3cc NS flush is about $4.

If you were in charge of ordering supplies for your agency, and had to stay within a budget, would you rather pay $2 for an IV start or $7.50? Also consider the cost increases to $9.50 if you end up having to upgrade the lock to a line.


:cool: Parafire I don't know where your supplies are coming from, but as of last year (2004) my cost for an IV set up was about $4.80 (cath, tegaderm, and the works). My cost last year for a lock...about $4.25 (cath, tegaderm, lock and 10 cc flush). I had to do a lot of shopping for my prices. As far as the whole IV vs. Lock issue thing, my patients get appropriate treatment. Cost, preference, and timing to the ED dont matter. Course it always helps that I call the shots in our little slice of EMS heaven. :cool:

[Code3Jeep]

every single iv i ever start is both... i always use a saline lock, and if needed a bag... so if needed its easy to undress the patient.

[mjacobs]

When this discussion comes up on our service (we don't do locks) I state one question. How many times that we start an IV does the pt. actually need or get fluids? Most times it is a "maintenance" line. Would be much easier to start a lock, especially using a hub lock. Put hub lock on syringe, start IV, put hub lock on IV, draw blood, remove syringe and flush saline. Alot less mess due to IV being open once during the process. I work PRN at another service where we use hub locks and that is the majority of our starts.

[mjacobs]

Wow, I just read Dave1983 comment. Sounds a little burnt out. First of all I don't treat a pt. to "help" the ER out, I do it for pt. care. If I know that when a pt. arrives in the ER they are going to need blood drawn (which is most pt's) I will go ahead and start the IV and draw blood. This is just good pt. care, it speeds up the treatment process for the pt. and that is better for the pt. not ER. As far as turning a run into ALS. What is the advantage there? If it's BLS I don't have to do paperwork I give it to my partner! If your response to that is the service can charge more. I could care less, I still get my pay check every 2 weeks. Sounds like an old medic I used to work with "why do we need pain control? Have you ever heard of anyone dying from being in pain?" Dude, take a vacation! By the way, no I'm not a rookie been doing this for 18 years.

[emtJon]

We have the option of doing either. If I am going to hang a bag, I put a lock on the end of it for the reasons already mentioned. Obviously, my decision is based on the pt's condition and the nature of the emergency. If it's more of a "routine" call and I'm just going be drawing bloods (as opposed to giving meds, etc.) I'll just put a lock in after I draw and let the ER do what they will with it when we arrive. More often than not, they may just have decided to draw bloods, so even the pt may not have "needed" the IV, I have access just in case, AND we made the ER's job a little simpler.

[RyanEMVFD]

Most everyone gets a lock for me. If I hang a bag, I hang a bag. It takes two seconds to hook up the bag to the lock. I never hook a line straight up to the IV hub unless I have a dial-a-flow on it.

[N2DFire]

WOAH - another "Thread from the Dead" (X 2 actually) :D
Kinda funny reading all the old post and seeing how some thing never change. Same old arguments from both sides of the subject.

Anyhow - Our system gives us the option of using a lock if we so desire. Our "Locks" are actually a 3" extension tubing.

I can't say what everyone else does but for me - since we also now have the option of drawing tubes for labs in the field - I'll pretty much stick a lock on every cath I stick. Then I don't have to worry about hooking & unhooking stuff to get labs, flushing, and putting a line on. I just hook a 20CC syringe to the lock - draw my sample then either use a 3CC prefilled flush or hook up the IV line and I'm good to go.

As far as doing things to make life easier for the E.R. ;
1) I guess we're fortunate that we have good working relationships with the ER's as a whole (there are the ocasional staff persons that can be a pain)

2) Almost all the Tech's and some of the Nurses from the area ER's also run EMS somewhere so that helps with the working relationships.

3) Last time I checked we (EMS - i.e. "field care") were supposed to be an extension of care from the ER to the field environment so the more we do (on both sides) to make that transition as seamles as possible, the better for the patient.

4) Our Agency OMD is also our (Protocol) regional OMD and he's a very active ER doc as well so He'll issue a butt chewin to whatever side of the ER door you work on if you don't play nice together :D

[NHBasic25]

Small studies, but seem relevant to the discussion.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10155526&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=9754500

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10155494&itool=iconabstr&query_hl=4&itool=pubmed_docsum

[Azurri111]

I don't agree that Saline locks have no place in EMS. I feels it's a closed minded statement. Have they saved a life? doubtful but they can have benefit - i.e. some pts I initiate IV's on are for hospital tx. No I can't always give them drugs I want to give them b/c we don't have them, but I can give the hospital access to administer meds quickly o/a at the receiveing facility. Especially when they are busy and have no time to do an IV. They always seem appreciative for this. Do I do them in everyone?... of course not - but from working in the ER you get to know tx plans and which pts will get IV rx not carried by EMS.

Another point I have noted is that some people use saline locks inappropriately. We have 2 types of the CLAVE type. A Macrobore and Microbore. As is stated one is lg tubing one is not. When you see sick trauma's / sepsis / hypovolemic pts come in with microbore it is frustrating. It reduces fluid delivery rate, and then you have to change the tubing. Something to think about when starting them. If you only use microbore.... will it inhibit rapid fluid admin?? If so avoid and go soley with the 10/15 gtts/ml sets. I always use the macrobore locks on combative trauma pts, so they still have lg tube access without all the extra tubing to pull off the bag / out of their skin.

[croaker260]

I remain somewhat shocked that this is even a hot topic. It seems to e there are bigger issues in EMS, and that this is solely Dependant on the medics style.

Sure, I may correct a student/new medic on a choice like this, but it is even then gentle, and constructive....and then I would move on to real topics of discussion.

[mitllesmertz1]

zzzzzzzzzzzzzzzzzzzzzzzzzzzzzz zzzzzzzzzzzzzzzzzzzzzzzzzzzzzz zzzzzzzzzzzzzzzzzzzzzzzzzzzzzz zzzzzzzzzz

[DrParasite]

awww, c'mon mitllesmertz1, you have an opinion on everything else, I was actually looking forward to what you thought about this topic.

[mitllesmertz1]

Well, I'd hate to leave you feeling needy...
Some random thoughts on the matter:
Locks are fine for alot (most?) of the pts transported, IMO.
I imagine it's a cost thing-which is cheaper?

I do like to minimize tripping/strangulation hazards on scene, though.

When all else fails, I like to think, "If I had the same pt at the ED, what would a DR order?"
Amazing how that makes it easier. They would rarely order a 1000ml bag hung "just in case". Usually it's, "Saline lock until we need something else. " Any chance that would work fine for us too?
The 30 seconds it takes to spike a bag won't kill a pt who's BP gets a little low following NTG. Put their head a little lower, check your own pulse, and relax.

Limiting fluid to CHF'ers is a great idea. I like medics that can even remember to shut down the drip after giving the Lasix, but let's not expect too much here.

All things being eqaul, I think you can "what if" every pt you have and hang a big bag of salt water. Maybe it looks more impressive swinging from the gurney as they roll into the ED?
So many out there will continue to overtreat their pts, using that favorite response- I do it for the pt's best interest!!!!

[fdmhbozz]

We put a lock on every IV we start. That is the way we are taught in Tech School, at clinicals, and on our OJT.

[potbellymedic]

We have an IV setup that we have designed at our service that includes a 20 gauge protectacath, 18 gauge protectacath, 3 ml LL syringe, 20 ml syringe IV prep kit, and extension. We always use this set and use the 3 ml syringe to draw blood into the line and use that for a glucometer reading or most of the time we will grab a 20 ml syringe and do a blood draw (rainbow). After that we use the 10 cc NS flush and flush the line or in cases where we need to give fluids, medications, or acute patient we will hook up a line. Most of my patients only get the lock. The leftovers are taken back to the station and resealed for next time.

[LordMedic]

we dont have locks in protocol but we put them on between cath and the bag anyway for ease of switching and transfers where the bag is in the way.

[emt161]

we dont have locks in protocol but we put them on between cath and the bag anyway

If you don't, the first thing that's going to happen at the hospital is your line will be pulled and a new one started. With a lock.