American College of Critical Care Medicine (ACCM) guidelines recommend early and rapid fluid resuscitation as a key element of care in pediatric septic shock.1 Adherence to fluid delivery guidelines has been shown to reduce mortality, organ dysfunction, and length of stay and to be a key driver of other components of sepsis bundles.2–4 Unfortunately, fluid targets recommended in the Society of Critical Care Medicine/Pediatric Advanced Life Support guidelines and hospital sepsis protocols often are not achieved as a result of technical barriers to fluid delivery, including slow infusion rate and cumbersome methods.2 , 5 , 6
A common method of rapid fluid delivery in children is the push-pull technique (PPT), in which a syringe and a 3-way stopcock are used repeatedly to deliver 10-mL to 60-mL doses of fluid, until the desired resuscitation volume is achieved.6–8 The PPT assembly is not purchased prepackaged; rather, it is assembled by a nurse using off-the-shelf components readily available in the hospital. The PPT offers a higher infusion rate than traditional alternatives such as an infusion pump or pressure bag, and in certain situations it can enable users to meet fluid resuscitation guidelines. Disadvantages of the PPT include complexity of set-up, the potential for user fatigue, difficulty tracking larger fluid volumes, and user errors, such as inadvertently withdrawing blood from the patient.8 Another disadvantage is the risk of syringe contamination because the plunger is repeatedly exposed to the provider's hands and surrounding environment. Several studies have documented that bacteria are readily transferred from contaminated gloves into the fluid being infused.9–11 Because the risk of contamination appears to be directly correlated with the number of strokes of the syringe plunger, PPT may be particularly likely to increase the risk of hospital-acquired infection. No study has rigorously documented how often users contact the syringe plunger while performing PPT.
LifeFlow (410 Medical, Inc; Durham, NC) is a manually operated device designed to deliver measured fluid boluses more rapidly and efficiently by using repeated and automatic filling of a 10-mL syringe enclosed within a single-use handle. While LifeFlow accomplishes faster flow compared with PPT or other common techniques, it also offers the advantage of fully protecting the sterile syringe plunger during use, potentially eliminating the nosocomial infection risk associated with repeated use of standard syringes.12
This study was conducted to compare aseptic technique compliance with 2 methods of rapid fluid resuscitation (PPT and LifeFlow) in a simulated pediatric patient with septic shock. Although there are several different techniques available for the infusion of fluids, LifeFlow was selected as the comparator for PPT because it is the only alternative fluid resuscitation technique that potentially offers a higher infusion rate and decreased contamination risk. The authors hypothesized that there would be fewer aseptic technique violations when using LifeFlow compared with PPT.
Aseptic Technique Simulation
Because this single-center study was considered a quality improvement initiative, it was determined to be exempt from review by the local institutional review board. Study participants were pediatric critical care nurses with 8 to 36 years of experience who were asked to complete a standardized fluid resuscitation procedure at the Center for Innovative Learning at WakeMed in Raleigh, North Carolina. Nurses were asked to deliver a rapid infusion of 500 mL of saline using each of 2 methods: 1) PPT with a 20-mL syringe, and 2) the LifeFlow rapid infusion device. Participants were familiar with both methods before the study, and no additional training or instruction was provided. Fluid was infused through a 22-gauge catheter into the simulated 25-kg patient.
The PPT setup consisted of a 76-inch administration set (Baxter; Deerfield, IL), connected to a 4-way stopcock (B. Braun; Melsungen, Germany) with a 20-mL syringe (BD; Franklin Lakes, NJ) and 7-inch extension tubing (ICU Medical; San Clemente, CA). When the PPT system was assembled (Figure 1A), a bag of sterile saline was spiked and the distal end was connected to a 22-gauge catheter placed in the simulated patient. The LifeFlow Rapid Infusion System setup included a sterile administration set and handle (Figure 1B). The LifeFlow device was assembled according to the manufacturer's instructions.
All participants gave written consent and were informed that fluid resuscitation methods were being observed and video recorded. Nurses were specifically instructed to use aseptic technique for each given method; gloves and alcohol wipes were provided. Participants were asked to infuse the fluid as quickly as possible using the 2 methods and were not aware that observers would be assessing their compliance with proper aseptic technique.
Two independent observers with training in aseptic technique observed the simulation for each method and separately recorded the number of aseptic technique violations observed for each participant. Four categories of aseptic technique violations were tabulated: 1) failure to properly clean the needleless connector with an alcohol wipe before connecting the administration set (alcohol wipes); 2) contamination of the sterile administration set by contacting a nonsterile surface (tubing); 3) hand contact with the sterile portion of the syringe plunger (plunger contact); and 4) any other violation of aseptic technique (other). If observers differed in the number of recorded aseptic violations, the numbers were averaged. The Fisher exact test was used to compare the number of users with aseptic technique violations by group, and the Mann-Whitney U test was used to compare the median number of aseptic technique violations by group. Statistical significance was set at α< .05.
Benchtop Demonstration of Syringe Contamination
After completing the simulation, a second benchtop experiment was conducted to visualize the effects of potential aseptic technique violations during PPT syringe use. Photographs were taken under ultraviolet (UV) light during various stages of the 500-mL bolus (Figure 2). All images were taken through a UV filter to visualize only the fluorescent and not the UV light. Wearing clean gloves, an investigator applied a small drop of water with fluorescein (fluorescein sodium salt; GTI Laboratories Supplies, Houston, TX) to the tip of the gloved index finger a single time (Figure 2A). The investigator then placed the index finger on a rib of the syringe plunger, as observed in the simulation (Figure 2B). After placing the droplet, the 20-mL syringe was cycled 25 times to simulate a single 500-mL bolus. The syringe was filled with water and then emptied immediately before the start of the test, so that small water droplets remained within the sterile portion of the syringe barrel. This was done to allow visualization of the fluorescein, if it were to travel across the plunger.
Aseptic Technique Simulation
During the PPT trials, there were on average 23 aseptic violations (median of 25) per study participant (n = 4) during the 500-mL infusion. All recorded violations for PPT were hand contact with the sterile portion of the plunger (plunger contact) (Table 1). Although it was not specifically quantified, it appeared that most of the contact occurred as the plunger was being retracted to refill the syringe.
In contrast, only 1 aseptic violation was observed by a single participant during the 500-mL infusion using LifeFlow. This violation resulted from failure to disinfect the tubing connection with an alcohol wipe before connecting to the catheter (tubing).
Evaluating only syringe plunger contamination, every user (n = 4) had repeated plunger violations using PPT; there were no instances of syringe contamination with the same users when they used LifeFlow (P = .029). The median number of violations for each user of LifeFlow was 0 versus 25 with PPT (P = .029) (Table 2).
Benchtop Demonstration of Syringe Contamination
In the benchtop experiment that followed the simulation, fluorescein was observed to pass across the plunger in enough quantity to be visible in water droplets on the inside of the syringe (Figures 2C and 2D). This benchtop experiment visually demonstrates that small particles of contamination can pass across the plunger during fluid delivery, as has been demonstrated in previous studies.9
All participants using PPT in the study inadvertently and repeatedly violated aseptic technique by contacting the sterile portion of the syringe plunger (see Figure 3 for areas of a syringe that should remain sterile and areas for potential contamination), highlighting the significant potential infection risk related to this frequently used practice. Interestingly, in several often-cited articles focusing on PPT as an optimal approach for fluid resuscitation, the same plunger rib contact violation observed repeatedly in this study can be seen in published images describing the technique.6–8 , 13 Additionally, in how-to videos readily available on YouTube, this method of aseptic violation can be seen in at least 2 demonstration videos with combined views of 5000.14 , 15
The Centers for Disease Control and Prevention estimate that 250 000 catheter-related infections occur annually.16 Catheter-associated infections account for approximately 10% of all hospital-acquired infections, resulting in significant morbidity and a mortality rate as high as 25%.17 , 18 Given the known risk of introducing bacteria into a sterile syringe through contamination of the plunger, this study demonstrates that the PPT technique can represent a significant potential source of introducing infection. Although providers typically wear gloves while infusing fluid by means of PPT, the gloves are nonsterile, and previous studies have shown that contamination exists on more than 80% of gloves before they are removed from the box.19 , 20
Additional contamination may occur during fluid administration as providers contact the patient, bedsheets, monitors, and other items in the room while wearing gloves. This may be of particular concern for the patients who are at high risk for septic shock, including immunocompromised patients and those with chronic illnesses and/or indwelling catheters. Recent studies have shown that the use of manufacturer-prefilled syringes for flushing implantable vascular access devices reduces the risk of syringe contamination and bloodstream infection.21 , 22 The use of a protected syringe, such as the LifeFlow system, would likely result in a similar infection reduction by preventing additional nonsterile contact with the plunger of the syringe.
Compared with PPT, LifeFlow is more effective at maintaining aseptic technique during rapid resuscitation, which has important implications for the treatment of pediatric sepsis. Additional studies investigating syringe contamination and the risk of infection for PPT are warranted.
1. Davis AL, Carcillo JA, Aneja RK, et al American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Crit Care Med. 2017;45(6):1061–1093.
2. Paul R, Neuman MI, Monuteaux MC, Melendez E. Adherence to PALS sepsis
guidelines and hospital length of stay. Pediatrics. 2012;130(2):e273–e280.
3. Balamuth F, Weiss SL, Fitzgerald JC, et al Protocolized treatment is associated with decreased organ dysfunction in pediatric severe sepsis
. Pediatr Crit Care Med. 2016;17(9):817–822.
4. Lane RD, Funai T, Reeder R, Larsen GY. High reliability pediatric septic shock quality improvement
initiative and decreasing mortality. Pediatrics. 2016;138(4):e20154153.
5. Davison D, Basu RK, Goldstein SL, Chawla LS. Fluid management in adults and children: core curriculum 2014. Am J Kidney Dis. 2014;63(4):700–712.
6. Stoner MJ, Goodman DG, Cohen DM, Fernandez SA, Hall MW. Rapid fluid resuscitation
in pediatrics: testing the American College of Critical Care Medicine guideline. Ann Emerg Med. 2007;50(5):601–607.
7. Cole ET, Harvey G, Foster G, Thabane L, Parker MJ. Study protocol for a randomised controlled trial comparing the efficiency of two provider-endorsed manual paediatric fluid resuscitation
techniques. BMJ Open. 2013;3(3):e02754. doi:10.1136/bmjopen-2013-002754.
8. Cole ET, Harvey G, Urbanski S, Foster G, Thabane L, Parker MJ. Rapid paediatric fluid resuscitation
: a randomised controlled trial comparing the efficiency of two provider-endorsed manual paediatric fluid resuscitation
techniques in a simulated setting. BMJ Open. 2014;4(7):e005028. doi:10.1136/bmjopen-2014-005028.
9. Oliver LC, Kendorf D, Wolfhard U, Nast-Kolb D, Nazif Yazici M, Esche H. Modified syringe design prevents plunger-related contamination—results of contamination and flow-rate tests. J Hosp Infect. 2003;53(2):140–143.
10. Blogg CE, Ramas MA, Jarvis JD. Infection hazard from syringes
. Br J Anaesth. 1974;46(4):260–262.
13. Parker MJ, Lee FMH, Mbuagbaw L, Thabane L. Evaluating the test re-test reliability and inter-subject variability of health care provider manual fluid resuscitation
performance. BMC Res Notes. 2014;7:724. doi:10.1186/1756-0500-7-724.
16. O'Grady NP, Alexander M, Burns LA, et al; Healthcare Infection Control
Practices Advisory Committee. Summary of recommendations: guideline for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):1087–1099.
17. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006;81(9):1159–1171.
18. Magill SS, Edwards JR, Bamberg W, et al Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13):1198–1208. doi:10.1056/NEJMoa1306801.
19. Hughes KA, Cornwall J, Theis JC, Brooks HJ. Bacterial contamination of unused, disposable non-sterile gloves on a hospital orthopaedic ward. Australas Med J. 2013;6(6):331–338.
20. Assadian O, Leaper DJ, Kramer A, Ousey KJ. Can the design of glove dispensing boxes influence glove contamination? J Hosp Infect. 2016;94(3):259–262.
21. Keogh S, Marsh N, Higgins N, Davies K, Rickard C. A time and motion study of peripheral venous catheter flushing practice using manually prepared and prefilled flush syringes
. J Infus Nurs. 2014;37(2):96–101.
22. Bertoglio S, Rezzo R, Merlo FD, et al Pre-filled normal saline syringes
to reduce totally implantable venous access device-associated bloodstream infection: a single institution pilot study. J Hosp Infect. 2013;84(1):85–88.