Over the last few years, the design of IV stopcocks, manifolds and injection ports has evolved to help anesthesia providers deliver increasingly complex combinations of fast-acting drugs with greater accuracy and efficiency, and less risk of infection. Here are six concerns addressed by these improvements.

1. Needlesticks during drug injection. In the old days, anesthesia providers routinely used a spiked syringe to inject medication into an insertion port on an IV line. "We should be getting away from the needle insertion technique," says Daniel K. O'Neill, MD, assistant professor of anesthesiology at the New York University School of Medicine. Needleless systems are safer and required by law. The Needlestick Safety and Prevention Act of 2000 requires an anesthesia provider to use a needleless system for infusion of drugs or fluids once initial venous or arterial access has been established. Since the 1990s, manufacturers have been developing IV connector systems that let you inject medication or fluid without using a sharp needle.

Early systems required a blunt needle on a standard syringe. More recent systems have luers that don't require needles because the syringe can be attached directly to the stopcock, manifold or injection port. These systems work well when more than one drug will be used because the syringes can be attached in advance. "I prefer a manifold because I can hook up three different syringes," says Alan P. Marco, MD, MMM, chairman of the anesthesiology department at the University of Toledo in Ohio.

2. Too much dead space. One of the problems with needleless systems has been the dead space needed to accommodate the tip of the syringe. In this dead space, blood can accumulate and coagulate, causing a blockage in the IV line. The infused drug can accumulate there, too, which means that not all the medication reaches the patient if the anesthesia provider doesn't perform a positive pressure flush. Plus, if the connector isn't flushed, the patient later may receive too much medication because the next bolus will include the residual drug in the dead space. More recent connectors have a luer-activated system that automatically performs a positive pressure flush. Upon removal, the luer expels fluid from the system, which can help prevent blood from backing up into the chamber. This system also helps ensure proper dosage during anesthesia delivery.

3. Difficult aspiration. In an outpatient setting, the anesthesia provider rarely needs to aspirate fluids or air from the IV line. But when it is necessary, it can be difficult with an IV line constructed of one-way valves. Some manufacturers have introduced two-way stopcocks and manifolds that have check valves to prevent the drug from flowing back into the syringe, while at the same time allowing for aspiration.

4. Where'd I put that cap? Some stopcock and manifold sets come with removable caps on the injection ports. It sounds like a good idea: Make your injection, remove the syringe and then close the port with the cap for added infection prevention. The trouble is that rarely does the anesthesia provider replace the cap. Well, those little caps may be on their way out. A new generation of ports is now available without caps to conform to CDC and ASA infection control guidelines for prevention of nosocomial and occupationally acquired infections. In its Recommendations for Infection Control for the Practice Of Anesthesiology, the ASA suggests that "equipment that will enter or contact any body area that is normally sterile must be sterile at the time of use, and aseptic techniques must be employed to maintain sterility." These new ports with needle-free valves are swabbable to help prevent contamination. The CDC's Guidelines for the Prevention of Intravascular Catheter-related Infections recommend cleaning the injection ports with 70 percent alcohol or an iodophor before accessing the IV system. In these swabbable devices, the check valve is flush with the lip of the port so that it can be swabbed with alcohol. Some providers say they prefer this system to the conventional ports with a hollow gap where open contaminants can fall inside.

5. Which line is this? The U.S. Coast Guard has a good system for marking the shipping lanes: When you're returning to port or going up river, the red buoys should be on your right side. Red, right, returning, it's easy to remember. In anesthesia, there's no standardized system like this to indicate whether an IV line is going to a vein or an artery. But Dr. O'Neill would like to see a standardized system similar to the one that the sailors have: blue for veins and red for arteries. Some manufacturers have stopcocks with blue levers and others have red levers. When he uses an arterial line without a color-coded stopcock, Dr. O'Neill marks the stopcock with red tape in order to avoid confusion and errors. Color-coding is especially important for arterial lines. "Some drugs or air injected into the arterial lines can cause a vascular injury or stroke," says Dr. O'Neill.

6. The syringe keeps slipping out. Stopcocks and manifolds with lipless luers can cause a lot of worry. "You hope that friction keeps them together," says Michael Schneider, MD, an anesthesiologist in Huntington Beach, Calif., and assistant clinical professor of anesthesiology at the UCLA School of Medicine. If friction doesn't keep the components together, the weight of the loaded syringe could cause the syringe to fall on the floor. To be safe, many anesthesia providers tape the syringe to the stopcock or manifold. In recent years, stopcocks, injection ports and manifolds have been molded with a threaded or locking luer to hold the syringe in place. The result is more holding power and less stress.

Customize your IV delivery kit
If you've not given much thought to connectors for IV delivery before, now you can see that with just a little trialing it's possible to create a custom IV delivery kit that will help your facility comply with federal regulations, reduce safety risks and match your facility's style of anesthesia delivery.