Numerous questions to the Committee on Technology are individually and quickly answered each quarter by knowledgeable committee members. Many of those responses would be of value to the general readership, but are not suitable for the Dear SIRS column. Therefore, we have created this simple column to address the needs of our readership.
Last year, the Executive Committee of the APSF considered whether or not it would be safe to re-use the syringe of medication within the syringe pump, if in fact the small-bore extension tubing was changed between patients. We did not know whether it would be possible for retrograde contamination to occur, if in fact the syringe was pressurized and the tubing was connected to a proximal intravenous port. Although there was variation in individual response, our opinion mostly, if not unanimously, opposed such practice. We knew that previous studies had demonstrated via Hemoccult® testing that invisible blood could migrate many inches retrograde up free-flowing IV tubing, at least. Does your committee have any opinion or facts in this matter?
Dear Executive Committee,
Your question generated numerous emphatic responses that are listed here:
I would never use IV sets or infusions from patient to patient regardless of extension tubing or type of pressurized pump.
I am strongly against the practice of using a syringe for more than one patient. There are the infectious disease issues, which include both the theoretical retrograde contamination with bacteria, viruses, and prions and also the issue of having the medication drawn out of a sterile vial and remaining in a syringe for longer periods than if it were freshly drawn. Additionally, there is also the concern that a drug labeling error (though less likely with propofol) could now affect more than one patient.
I would think that a “multiple use” practice would be a legal problem as well.
As a former hospital administrator, I can’t imagine such a practice being defensible. Therefore I would avoid it.
Reuse of a syringe with change of tubing between patients is totally unacceptable, although one type of tubing contains a one-way valve with a forward cracking pressure of approximately 100 mmHg and a reverse cracking pressure that is much, much higher. Nonetheless, reuse of syringes with a change of tubing between patients is totally unacceptable.
In my opinion, currently UN-controlled substances with potential for abuse might need internal control or at least internal audit capability. This is one more reason for not reusing a propofol syringe between patients, for example.
There is no possible justification for such practice, no matter how small the risk of cross-contamination.
I am in full agreement . . . absolutely no justification for re-using the syringe. Interestingly, I participate in providing anesthesia and medical leadership for surgical mission work (e.g., Guatemala) on a regular basis. We are always burdened with very limited resources, but would never support or condone such a practice.
I think providing opinion is helpful, but providing evidence is better. A short search of PubMed found several pertinent articles. A more detailed search would probably find more specific articles; however, the general consensus of these articles (from many countries and over many years) is that a tubing set should be used with only one patient. By extension, the suggested practice is wrong and very likely dangerous.
It seems that there is pretty uniform consensus against this. The professional societies should also be a resource, and here, for example, are relevant quotes from the AANA’s infection control manual (available online at
Administration of Drugs and Solutions
The potential for infection and transmission of microorganisms exists during the administration of drug therapy. Instructions for preparation, storage, and administration of all pharmaceutical agents provided by each manufacturer shall be read and followed. Drug administration by injection offers many opportunities for contamination. These include previously used needles, syringes, drug administration sets, intravenous tubing, and fluid containers.
#11. Do not reprocess for multiple use any intravenous fluids, tubing, or other intravascular infusions or connectors that are single-use disposable items. This includes transducers, tubing, and other items that make contact with the vascular system or other body compartments.
In our Clinical Engineering department we inspect syringe pumps for delivery accuracy. After multiple uses, we notice that the syringe integrity begins to degrade. This is manifested by the downstream occlusion pressure continuing to rise, secondary to increasing friction between plunger and barrel. We experienced some syringes causing false occlusion alarms during these tests. Such testing is performed using just water, and changing the fluid medium would undoubtedly have an impact. Many operators would not think the syringe is wearing out when it “looks” perfectly fine. You cannot determine the self-integrity of a multiple-used syringe unless you attach a pressure meter to it. Furthermore, fluid delivery rate can influence the friction; slower rates have more problems. These are just some technical things to consider if using a syringe multiple times.
Subsequent to the consideration of this question and the answers provided above, the highly publicized incident of actual cross-contamination in Nevada1 made national headline news, and in February 2008 the U.S. Department of Health and Human Services Centers for Disease Control and Prevention released a Fact Sheet, “A Patient Safety Threat-Syringe Reuse,” online at
http://www.cdc.gov/ncidod/dhqp/ PS_SyringeReuseFS.html, to patients who may have been exposed to multiple use vials/syringes/needles. That fact sheet, in addition to advising such patients, contains a link for health care providers:2
http://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html, regarding standard precautions for preventing transmission of infectious diseases, specifically including “Safe injection practices” under section IV.H. The precautions and practices state
Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient.
The following comment was opined after revelation of the Nevada event:
I think it is correct but insufficient to condemn such a practice without acknowledgement of the factors that could lead to syringe re-use. Addressing the symptoms without trying to cure the underlying “disease” would be but a short-term solution. Thus, we must investigate, understand, and eliminate the factors that predispose one to the practice of unsafe medicine: as clinicians, we face severe production pressure and take “shortcuts” in the process of safe preparation of medication; we may give in to the financial importance that others, or we ourselves, place on speed and efficiency; or we may sincerely believe that we are preventing waste, thereby reducing the cost of medicine. An understanding of this complex environment may help to eliminate the root cause of such behaviors, which could then facilitate safer practices.
- Wells A, Harasiim P. Exposure Feared: 40,000 LV clinic patients urged to be tested for viruses. Syringe reuse at Endoscopy Center of Southern Nevada “common practice.” Las Vegas Review-Journal. Feb. 28, 2008.
- Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings, June 2007.
The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of APSF. It is not the intention of APSF to provide specific medical or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information.