Each facility has a policy defining what medications can be given IV. The policy should define administration by area of practice and administration methods. It is essential to follow those policies to help reduce medication errors.
Policies should also note information on aseptic techniques. An aseptic technique is required for all IV injections and mixing medications or fluids. An aseptic technique includes (ISMP, 2015):
- Hand hygiene before and after preparation and administration of the medication or solution
- Disinfection of the medication access diaphragm on a vial or the neck of an ampule before accessing the medication or solution
- Disinfection of the IV access port, needleless connector, or other vascular access devices (VAD) before administration of the medication or solution
- The use of personal protective equipment (PPE) if contact and exposure to blood or bodily fluids are possible when administering the medication or solution
Policies should also note guidelines for various administration methods. A needleless system of infusing medications is the best practice. Do not use a needleless system if infusing a large volume of blood. Instead, attach the tubing directly to the hub.
When infusing or pushing multiple medications, flush 10cc of normal saline (NS) through the IV before and after each medication; it will clear the IV line.
An IV piggyback is a solution or medication attached to a primary infusion line or intermittent VAD to deliver medication over a specified period of time (Lee et al., 2021). IV piggybacks usually run over 1 hour. More modern or current pumps have the exact infusion time and rate pre-programmed by medication. Remember to hang the piggyback higher than the main infusion bag if you use a gravity drip.
IV push, or bolus, is the administration of medication from a syringe directly into an IV. The IV push can be injected into the tubing or a saline lock. The indications for use are (Nettina, 2019):
- When a rapid concentration of medication in the bloodstream is needed, such as in CPR
- When a quicker response to the medication is necessary, such as with furosemide or digoxin
- To administer a loading dose for a planned continuous infusion, as with heparin or pain medication
- For patient comfort and to avoid intramuscular injections
- To avoid incompatibility issues when several medications are mixed in one bag
- When the patient is unable to take the medication orally or via the IM route
- It is cost-effective when you do not need a continuous infusion
Consult the pharmacy, institutional policy, or manufacturer's insert if you do not know how quickly a medication push should be given. Most medication is given slowly. Pushes are usually between 30 seconds and a minute but may be as long as 5 minutes. A push that is too rapid can cause serious adverse effects.
The best practice recommended by the ISMP include the following:
- Use an IV push medication or flush in a ready-to-administer form rather than drawing up medication in a syringe.
- When administering IV push medications through an existing IV infusion line, use a needleless connector that is proximal (closest) to the patient unless contraindicated in current evidence-based literature or if the proximal site is inaccessible for use, such as during a sterile procedure.
- Never use IV solutions in containers intended for infusion, including mini bags, as common source containers (multiple-dose products) to prepare IV flush syringes or to dilute or reconstitute medications for one or more patients in clinical care areas.
- Have the pharmacy prepare more than one medication in a single syringe for IV push using their sterile compounding center. If the clinician needs to prepare and administer more than one syringe of medicine or solution to a single patient at the bedside (ISMP, 2015):
- Prepare each medication or solution separately and immediately administer it before preparing the next syringe or
- If preparing several IV push medications at a time for sequential IV push administration, label each syringe as it is being prepared before preparing any subsequent syringes.
- If preparing one or more medications or solutions away from the patient's bedside, immediately label each syringe, one at a time, before preparing the next medication or solution.
- Never pre-label empty syringes in anticipation of use.
- Immediately discard any unattended, unlabeled syringes containing any solution.
- Bring only one patient's labeled syringe(s) to the bedside for administration.
- Only dilute IV push medications when recommended by the manufacturer, supported by evidence in peer-reviewed biomedical literature, or following approved institutional guidelines.
- Unless its use would result in a clinically significant delay and potential patient harm, use barcode scanning or similar technology immediately before administering IV push medications to confirm patient identification and the correct medication.
- Assess central line patency using, at a minimum, a 10 mL diameter-sized syringe filled with preservative-free 0.9% sodium chloride. Once patency has been confirmed, IV push administration of the medication can be given in a syringe appropriately sized to measure and administer the required dose (ISMP, 2015).
Do not administer IV fluids and medications that have particulate matter or discoloration. Some medications may come as a colored fluid. If in doubt, double-check. Some drugs come in a dark bag because the medication is light-sensitive, limiting its ability to be double-checked.
Some medications require dilution, particularly medications that are irritating to the vein. If you withdraw the medication from a glass ampule, use a filter needle or straw unless contraindicated.
Eliminate air from the tubing set and injecting device to avoid air emboli. Before injecting anything into an IV, check the patency. Flush the IV tubing or saline lock with NS before and after a push. Check medication compatibility if you insert the push into an ongoing IV infusion or push more than one medication.
Monitor the patient's reaction during and after the push. Major adverse effects include (Nettina, 2019):
- Respiratory distress
Minor adverse effects include (Nettina, 2019):
If there is an adverse effect, stop the medication and notify the provider. Take emergency action if needed. Document in detail and generate an adverse event report.
Monitor the IV site for infiltration or extravasation.
Provide patient education regarding the medication or fluid to be infused and for the patient to report any burning, pain at the IV site, and symptoms of adverse effects.
Blood and fluid warmers are ordered to avoid hypothermia and require strict adherence to institutional guidelines of administration (Nettina, 2019).
Power injectors are used in radiology to deliver a specific amount of contrast media at a specific time. Contrast material is to be considered a vesicant solution. Check your patient after return from contrast injection for infiltration and extravasation (Nettina, 2019).