Electronic pumps VS mechanical flow regulators

I am now responding to questions received via email by posting it on my blog. It seems that this is the way I can make the best use of limited time and get the information out to lots of people. So this is the first message on the blog of the new year.

"We usually always use infusion pumps on all IV therapies. The only time we ever use mechanical flow regulator (e.g. Dial A Flow) and gravity drip tubings is in an emergency situation or perhaps when a hurricane was in the Gulf and we questioned whether a patient would lose electricity and couldn't use the electric pumps.
However, recently a few Home Health nurses are requesting that instead of sending out a stationary electric pump, to please send out Dial A Flow tubings. Most of these patients have PICC lines. In the past two weeks, I have had two patients come back to my infusion center for me to declot the PICC using CathFlo, because the Dial A Flow tubing was used and evidently not put high enough and dripped so slow that it stopped and caused the PICC to occlude. Another patient complained that the one hour infusion was taking three hours to infuse.
MY question:
Does the INS recommend or do YOU recommend the use of pumps when infusing via PICC lines? If so, do you have documentation that I could show the pharmacists and Home Health nurses? We mainly are infusing IV antibiotics."

Mechanical flow regulators have the exact same accuracy as a standard roller clamp on the gravity administration set. This is usually around +/- 10%, however it can be +/- 25%. This variation depends upon the height of the fluid container, the movement of the patient, and many other factors that produce resistance inside the catheter and vein. Many nurses think that the numbers on these flow regulators means that they do not have to count drops, but these numbers give a false impression of accuracy. The nurse or patient or family member will still need to count drops to ensure the correct rate. Accuracy of electronic infusion pumps is usually less than +/-5%.

I would direct you to the Infusion Nursing Standards of Practice #33 Flow Control Devices, page S34-35. The standard lists many factors that direct decisions about the type of flow control device and the type of vascular access device is one of those factors. While it does not specifically state that an electronic infusion pump is required for any central venous catheter, you have pointed out many good reasons for using a pump instead of an form of gravity control. These standards also states that each organization must establish protocols for the use of flow control devices.

My personal opinion is that these mechanical flow regulators may be beneficial in a few situations including infusion during an MRI when the pump can not be used, during transfer from one facility to another when the pump can not go with the patient, and during times when there is danger of loosing electrical power as you mentioned. These pumps do have battery backup and would allow enough time to switch to a mechanical flow regulator after the power has been lost. I would also consider the patient and caregivers. Can they count drops? Is there a problem with manual dexterity to manipulate the flow regulator? Is there a vision problem that would make this task more difficult? What accuracy do you need for the therapy being infused?

You mentioned the outcome of clotted catheters. Flow rate can certainly be a contributing factor, however there are many other factors that should be evaluated such as the flushing technique used, the needleless connector being used, catheter tip location, and the patient's clotting factors. So all factors should be considered.

I would also want to know why the home health nurses think that the mechanical flow regulators are superior to an infusion pump.

A large volume, pole-mounted infusion pump may not be the best alternative for patients that are ambulatory. You mentioned primarily infusing antibiotics. There are many safe ways to infuse antibiotics such as gravity flow with a standard roller clamp, elastomeric balloon pumps, electronic ambulatory pumps, or even IV push for some drugs. I don't think these flow regulators are the sole factor responsible for the catheter complications but I also do not think that they will solve your problems of clotted catheters. If you can learn more information about the reason for this request maybe we can come up with some other useful information.