2 Aims and objectives Rationale for IV use Advantages and disadvantages of IV therapyRoles and ResponsibilitiesConsiderations for IV therapyPrescribingPreparingAdministeringMonitoringNational and Local PoliciesCalculations
3 The Five Rights of Medicine Administration Right patientRight medicineRight routeRight doseRight time……every time!
4 Why IV? Oral or other route of administration not suitable or availablee.g. vomiting, diarrhoea, malabsorption, resting gastro-intestinal tract, low muscle massWhere rapid effect or high/predictable concentrations essentialMedicine not effective via other routes e.g.gentamicin, benzylpenicillinFor NBM patients e.g. for TPNFor drugs that have no oral formulation e.g. Ceftazidime, Piperacillin, ReoproFor drugs that are not absorbed from GI tract e.g. Gentamicin, Vancomycin, HeparinFor drugs that are destroyed by stomach acid e.g. Benzylpenicillin, Insulin ( broken down straight away by gut)When IM injection is unsuitable e.g. elderly emaciated patients, severe shock, paediatricsWhen you want a rapid response in emergencies e.g. anaphylactic shock, cerebral oedema, p psychiatric emergencies, acute pain management, inducing anaesthesia, severe dehydration E.g. Amiodarone- loadingWhen predictable and/or high blood level are required e.g sepsis, theatre, anaesthetic induction( delivery of known quantity of drug over a known period of time)For drugs that have to be given by continuous infusion. Continuous infusion allows fine tuning and frequent adjustment to be made e.g insulin, morphine, drugs with short duration of action – inotropes. You can stop treatment and effects are quickly re erased.For drugs that have high first pass, which means that oral administration is relatively ineffective. Examples are Lignocaine, Adrenaline, Dopamine. IV administration gives direct access to blood stream and bypasses initial gut and liver metabolism.
5 ADVANTAGES Medicine gets into the circulation quickly Rapid effect achievedPredictable concentrations achieved i.e. 100% reaches systemic circulationSome medicines cannot be given by another route e.g. gentamicin and meropenem
6 DISADVANTAGES Risk of Infection Severity of side effects Multiple steps in preparationIncreased cost and nursing timeIncreased complications e.g. extravasation, emboli, anaphylaxis reactions
7 IV Therapy incidents/reports Published in The Times 18th May 2010Hospital is fined £100,000 over death of mother in drugs mix-upPatient died hours after her son was born when a nurse at the Great Western Hospital in Swindon, Wiltshire, wrongly attached an epidural anaesthetic Bupivacaine to her intravenous drip instead of a saline solution.NRLS incident reports24% of total medication incidents reported related to IV medications.93% of IV medication incidents reported to the NPSA were prescribing, administration or preparation errors.25 incidents of death reported to NPSA from IV medication incidents between Jan 2005 – June 2006.NPSA Patient Safety Alert 20 – Promoting Safer use of injectable medicinesHighlights actions to be taken by healthcare providers to ensure safe and effective IV medication use.All healthcare providers have to comply with guidance.NRLS – National Reporting and Learning System – (the body that collects information on medication errors and incidents around the UK and feeds into the NPSA)
8 Professional Responsibility Prescription is clear, unambiguous and legalMedicine is essential and appropriateDose, route and rate is appropriateMedicine is compatible with infusion fluidPatient is not allergic to prescribed medicationAppropriate monitoring requirements are inplace e.g. ECG machine for potassium infusionsPrescriber and AdministratorDoctors have responsibility for making the decision that a drug should be given by the IV route.They should ensure that the drug is essential (could an alternative be given?) Is the drug compatible with the prescribed infusion fluid.They must also ensure that the prescription is written correctly and clearly with all required information, Drug, Dose, Infusion fluid, Administration time and method (bolus, infusion)Both prescriber and administrator must ensure that appropriate monitoring equipment is available before medications is administered.Think about the patients’ condition electrolytes and diabetic status and give a drug in glucose if compatible and sodium levels are high.Also think about the concentration, some drugs can be over or under diluted and think about the flush.
9 Professional Responsibility Must have completed IV Medicines Training, be certified competent and be aware of own limitationsMust not administer a drug if doubtful about any aspect of IV medicine prescription / calculation / preparation / compatibility / administration / monitoringMust ensure that appropriate and current information sources are usedNurseIt is the responsibility of the nurse/midwife to ensure that he/she is deemed competent by the Trust/Hospital where employed.Staff member must also be confident of performing tasks once training is completed and singed off as competent.Each site/hospital will have local policies and member of staff needs to ensure that they are aware and follow policy.
10 Professional Responsibility Legal responsibilitySpecialist knowledgeAccess to specialist and up to date informationCan advise and provide support on any aspect of IV medicine use i.e. dose, calculations, method and rate of administration, diluents, stability and incompatibilitiesCan provide advice via ward pharmacist or on-call pharmacistPharmacistIn special circumstances e.g. fluid restriction, not enough lines etc. the pharmacist can advice.Need for IV therapy needs to be considered first e.g. ciprofloxacin has a great bioavailability when given orally.
11 Considerations for IV therapy Dose, Route and Rate Is the dose appropriate for the IV routeIs the route suitable for the medicine and required rate?Is the expected duration of treatment specified and/or appropriate?Properties of the medicine? e.g. osmolarity, pH, irritant, short half lifeIs the dose and frequency appropriate for the route?IV doses can be different from oral doses e.g. ciprofloxaxin, metronidazole, ranitidine, hydrocortisoneIs the route suitable for the medicine and required rate?IV Bolus e.g. amoxicillin, tramadol,IV intermittent infusion e.g. erythromycinIV continuous infusion e.g. heparin, insulinCentrally or peripherallyRequired rateCan increase risk of toxicity/adverse effects if administered at the incorrect rate.Too quickly – e.g. furosemide, vancomycin adverse effectsDurationOnce off prescription or to continue? Number of days?IV prescriptions valid for 24 hrs – need to represcribed on inpatient chartsPropertiespH – can precipitate if diluted to incorrect pHIrritant – extravasation, phlebitis,Short t1/2 – heparin, therefore continuous infusion
12 Considerations for IV therapy Concentration, Diluent and Vehicle Check that the concentration of the drug is within the recommended range for safety and efficacy and method of administration.e.g. erythromycin must be between 1-5mg/mlDiluent and VehicleNot always the same! !ALWAYS CHECK!e.g. clarithromycin must be reconstituted with water but diluted in sodium chloride 0.9%Often used interchangeably by most staff i.e. most refer to both as diluent.Concentration:Too concentrated or over dilutedToo concentrated: Vancomycin or caspofungin, tigecyclineToo dilute e.g.: Amiodarone, cyclizine,Concentration can be deciding factor on method of IV administration i.e.: bolus, central, peripheral, etcDiluent and vehicleDiluent – what fluid you use to reconstitute withVehicle – infusion fluid or what is used to further dilute with
13 Considerations for IV therapy Compatibility Incompatibility occurs after mixing parental drugs if one or all of them become less effective. Changes that occur include:Physical incompatibility e.g. precipitation, crystallisation, cracking e.g. TPNLargely determined by pH and formulationChemical incompatibility e.g. degradation, inactivation or a new compound formedChemical reaction between drugsNever add medicines to fluid unless compatibility assuredNever mix medicines together unless compatibility assuredAsk audience – how are parental drugs mixed?e.g.In the same bag of IV fluidsIn the same syringe, diluted for a subcutaneous infusionIn the same syringe neat for IM/IV injectionIn the same IV line or giving setIn the same venflon/ cannulaY site compatibility is different to compatibility in a bag/syringe
14 Considerations for IV therapy Compatibility Caspofungin is incompatible with diluents containing glucoseErythromycin must be diluted to 5mg/ml for peripheral usePhenytoin is given as undiluted bolus into a large vein or as an infusion diluted in NaCl 0.9%, can easily participate thus in- line filter is necessaryVitamin K flush with glucoseErythromycin for fluid restricted patients in ITU setting can be given as 50mg/ml via a central line 1g over 60 minutes (this is an UNLICENSED preparation/ method)
15 Preparation: Factors Affecting Stability EffectActionExampleLight rate of degradationEnsure appropriate storageTPN, Pabrinex®Temperature rate of degradation / microbial growthAciclovir, TPNpHAdd bufferPhenytoin (in glucose 5%)ConcentrationLess stable at changes in concentrationCheck volumeAmiodarone, AmphotericinAdsorptionDrug loss into plastic/glassAvoid or minimise contactInsulin, Nitrates e.g. GTNLightCauses photo degradation of some products.E.g. TPN, and most chemotherapy drugs are light sensitive and therefore must be covered whilst being infused.TempHeat provides energy for chemical reactions and some drugs will not be stable once reconstituted. E.g. Aciclovir must be discarded after 12hours.Drugs normally stored in the refrigerator may be stable at room temp for short time only. E.g. lorazepam.pHThe most likely reason for precipitation is the mixing in the infusion container/line of two medicines with very different pH values, especially if one is acidic and the other alkalineConcentrationOnce reconstituted the stability of some drugs varies at certain concentrations and therefore cannot be over diluted or too concentrated.AdsorptionSome drugs bind to certain plastics depending on available surface area, diluents, flow rate, temperature, time and pH.
16 Displacement Volumes and pH Volume of fluid displaced by a powder when reconstitutedImportant when part-vials are usedMainly only relevant to paediatricspHMost medicines are stable at a specific pHRate of degradation often pH dependente.g. amphotericin requires glucose pH>4.2Displacement value example:The displacement value of Augmentin® / Co- amoxiclav is 0.5ml/ 600mgThus when 100mg is needed 11.5 ml of WFI is added to the vial (giving a solution of 600mg in 12ml= 50mg/ml) and then 2 ml is used.pH example:IV Amiodarone pH is and therefore only stable in glucose 5% (pH )IV cyclizine pH is and is also only stable in glucose, can be diluted to 1:1 but this is unlicensed. IT MUST BE FLUSHED WITH GLUCOSEPhenytoin pH is 12 and therefore only stable in NaCl 0.9% ( use an inline filter)(Can also be given as a bolus in a central line)
17 LabellingWhen drugs are added to burettes, syringes or IV bags, the container must be clearly labelled with following:Drug addedDose addedDate and time of additionSignature of practitionerImportant that all products are correctly labelled for identification.Any additions made to IV fluid bags must be labelled using the IV additive labels and attached to the IV bag/syringe.Ensures that errors in administration are minimised.All IV doses administered must be recorded on the drug chart and fluid balance chart.
18 Rate of Administration Most IV bolus injections over at least 3-5 minutes95% of IV bolus injections given too fast!!!!!!!Ensure device is capable of accurate delivery and desired infusion rateSystemic damageFurosemide ototoxicityPhenytoin arrhythmiasRanitidine bradycardiaVancomycin red man syndromeLocal damagePainExtravasationPhlebitis
19 Phlebitis more likely with MonitoringExtravasationPhlebitis more likely withIrritantsHypertonic solutionsHighly acidic solutionsAlkaline solutionExtravasation of drugs i.e. leakage of drug outside the vein into the surrounding tissues can result in severe tissue damage and necrosis.Phlebitis - inflammation of the veinPhlebitis is more likely to occur the narrower the veinIrritants like: cytotoxics, erythromycinhypertonic solutions (glucose >10%)highly acidic solutions like ciprofloxacin, amiodaronealkaline solutions like aciclovir, sodium bicarbonate
20 Sources of Information IV Drug Monographs/ Medusa website(available on grapevine with log in detailsBNF/BNFCProduct Information LeafletMedicines InformationPharmacistOn-call PharmacistUniversity College London Hospitals Injectable Medicine Administration GuideMany different sources of information available to staff which they can refer to and will usually provide answer to any query they may have regarding the preparation of the drug required.Another source is the University College of London Injectable Medicines Administration Guide produced by the pharmacy department.
21 RememberIf in doubt, don’t administer! Most important consideration is the PATIENT They have to suffer the consequencesFinal reminder that if they are unsure of anything don’t administer the medication. Always investigate any irregularities and double check details. The most important person to remember is the patient. They are already unwell and if anything is wrong they have to suffer the consequences. They are innocent and rely on you to know what you are doing. Don’t put them at unnecessary risk.
23 Calculations 1:1000 means 1g in 1000ml How much adrenaline is there in 0.5ml if the strength you have is 1:10001:1000 = 1g in 1000ml1000mg in 1000ml1mg in 1ml0.5mg in 0.5ml
24 CalculationsA 6 year old boy (20kg) must receive a morphine infusion at a dose of 10mcg per kg per hour. The syringe is labelled 25mg in 50mls. What rate should infusion pump be set at?1. We need: 10mcg/kg/hourWe have: 25mg in 50mls2. The boy weighs 20kg we need to calculate the total dose for his weight :10 mcg x 20 kg/hour=200mcg/hour3. We need to give 200mcg/hour and the syringe is labelled in milligrams:1000mcg=1mg mcg/hour= 0.2mg/hour4. We have got syringe with 25mg in 50ml, we need to calculate in what volume is 0.2mg.25mg…………..50ml0.2mg …………..XmlX= x 50 =0.4ml255.The infusion pump should be set in 0.4ml/hour.
25 CalculationsDobutamine 250mg amp is diluted to a total of 50ml normal saline. A patient weighing 60kg must receive 5mcg/kg/min. How many mls per hour would you give the patient?We need: X mls/hour We have: 250mg in 50ml2. The patient is 60kg, we need to calculate the total dose for his weight:5mcg x 60 / min = 300mcg/min3. Our result needs to be per hour and the dose is per minute:300mcg / min x 60 = mcg/hour4. Dobutamine is available in mg and our dose is in mcg:1000mcg = 1mg mcg/hour = 18mg/hour5. Ampoules available are 50ml, we have to calculate the dose per 1ml250mg in 50ml? in 1ml = 5mg506. We have solution with 5mg in 1ml and need to give 18mg /hour. How many mls per hour do we give?5ml …………1ml18mg………….Xml X = = 3.6ml /hour57.We need to give to patient 3.6ml/per hour of our Dobutamine.