Intravenous intermittent infusion is an infusion of a volume of fluid/medication over a set period of time at prescribed intervals and then stopped until the next dose is required. An intermittent IV medication may be called a piggyback medication, a secondary medication, or a mini bag medication (see Figure 7.16). Intravenous medications may be given in small volumes of sterile IV solution (25 to 250 ml) and infused over a desired amount of time (given for 30 minutes every 4 hours) or as a single dose. Many medications must be given slowly to prevent harm to the patient, and this method of administration reduces the risk of rapid infusion. A piggyback medication is given through an established IV line that is kept patent by a continuous IV solution or by flushing a short venous access device (saline lock). Always check the Parenteral Drug Therapy Manual PDTM to ensure the correct guidelines are followed for each specific medication given in IV solution. The PDTM provides guidelines on how to mix the IV medication, the amount and type of solution, and the rate of infusion (Perry et al., 2014). An intermittent medication may be administered by gravity or on an electronic infusion device (EID), also known as an infusion (IV) pump. Many piggyback IV medications must be on an IV pump, which requires programming and specialized training to prevent medication errors. The IV infusion pumps provide hard- and soft-dose limits and safety practice guidelines to aid in safe medication administration (Lynn, 2011). IV medications may also be given by gravity infusion, in which case the health care provider must calculate the infusion rate for drops per minute. The best practice for piggyback infusions is to use an IV infusion pump. Figure 7.16 Secondary medication (upper IV mini bag) set up with primary infusion set (lower IV bag)At times, a volume-controlled (intermittent infusion) set may be used to deliver medication for children, older adults, or critically ill patients where fluid volume is a concern. A volume-controlled intermittent set is a small device attached below the primary infusion to regulate the mini bag. The medication is added to a small amount of IV solution and administered through an IV line (Lynn, 2011). Intravenous medications are always prepared using the seven rights x 3 as per agency policy. Because of the many high-risk events associated with intravenous medications, additional guidelines are required. A PDTM or monograph provides this additional information, which includes the generic name, brand name, classification of the drug, and a chart defining which parenteral route may be utilized. Some medications may only be given via a piggyback method or large-volume IV solutions, and some medications may be given diluted over 1 to 2 minutes. In addition, information on indications, contraindications, dosage (age dependent), administration/dilution guidelines, adverse effects, clinical indications (e.g., specialized monitoring required, must be on an IV pump), and compatibility and incompatibility in relation to reconstitution and primary IV solution are specified (Alberta Health Services, 2009). The Institute for Safe Medication Practices (2014) has created a list of high-alert medications that bear the heightened risk of significant harm when they are used in error. Specific safeguards for these medications can be found in the PDTM. It is vital to understand which medications are considered high risk prior to administration. A link to the list of high-alert medications can be found under Suggested Online Resources at the end of this chapter. In addition to the seven rights x 3 for medication preparation, Table 7.10 summarizes what to review in the PDTM when preparing and administering an intravenous medication. The acronym RED CARS can be used as a reminder.
Special considerations when preparing IV intermittent medications:
Using sterile technique, prepare the intravenous medication as per agency policy, using the PDTM and the seven rights x 3. Many piggyback medications come prepared from the pharmacy and still require a complete check (SEVEN rights x 3) prior to administration. Checklist 63 lists the steps to administering an intermittent IV medication by gravity or an IV infusion pump.
Checklist 64 lists the steps to administer an intermittent IV medication using an existing secondary line, by gravity or an IV infusion pump.
Continuous Intravenous (Medication) InfusionA continuous intravenous infusion is the infusion of a parenteral drug over several hours (continuous drip) to days. It involves adding medication to sterile IV solution (100 to 1,000 ml bag), and then hanging the IV solution as a primary infusion. A continuous drip must be ordered by the physician and listed in the PDTM as a medication to be given by IV continuous infusion. Most IV continuous infusions are given for a short duration. Examples of continuous IV infusion medications include heparin, insulin R, and pantaprazole. Continuous intravenous infusions may come pre-made from the pharmacy, and are labelled with the patient name; IV solution; volume, amount, and concentration of medication; initials of the RN; and date and time prepared (Alberta Health Services, 2009). Always refer to the PDTM for guidelines on how to administer, regulate, and titrate continuous infusions. An electronic infusion device (EID) must be used to infuse continuous IV medications. Assessments and lab values must be monitored following the PDTM guidelines. A health care provider must assess the continuous medication for the dose, rate, and patency of the IV site, and assess the patient for therapeutic and adverse reactions to the medication. The Institute for Safe Medication Practices (ISMP) (2013) recommends that all high-alert medications be independently double-checked to detect potential harmful errors before they reach the patient. Independent double checks have been shown to detect up to 95% of errors (ISMP Canada, 2013).
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