Each facility has a policy defining what medication can be given IV. This policy should define administration by area of practice and administration methods. Follow that policy.
Aseptic technique is required for all IV injections and mixing of medications or fluids.
Aseptic technique includes (ISMP, 2015):
- Hand hygiene prior to 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 prior to accessing the medication or solution
- Infection of the IV access port, needleless connector, or other vascular access device (VAD) prior to 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
A needleless system of infuse medications is the best practice. If infusing a large volume of blood, do not use a needeless system. Instead, attach the tubing directly to the hub.
When infusing or pushing multiple medications, be sure to flush 10cc of NS through the IV before and after each medication. This practice will clear the IV line.
IV piggybacks usually run over 1 hour. More 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 are using a gravity drip.
IV Push, or bolus, is the administration of medication from a syringe directly into an IV. This can be injected into the tubing or into a saline lock. The indications for use are (Nettina, 2019):
- When a rapid concentration of medication in the bloodstream is needed (CPR)
- When a quicker response to the medication is needed (furosemide, digoxin)
- To administer a loading dose for a planned continuous infusion (heparin, pain medication)
- Patient comfort to avoid intramuscular injections
- Avoid incompatibility issues when several medications are mixed in one bag
- When the patient is unable to take the medication orally, or IM
- Cost effective when you do not need a continuous infusion
Consult the pharmacy, policy, or manufacturer’s insert if you do not know how quickly a medication push should be given. Most medication is given slowly. Push is rarely in less than 1 minute and may be as long as 30 minutes. A push that is too rapid can cause serious adverse effects.
The best practice recommended by the Institute of Safe Medication Practices include (ISMP, 2015):
- Use IV push or flush in a ready to administer form, rather than drawing up a 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 product) to prepare IV flush syringes or to dilute or reconstitute medications for one or more patients in clinical care areas.
- Have 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 medication 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, prior to the preparation of 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 type of 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 in accordance with approved institutional guidelines.
- Unless its use would result in a clinically significant delay and potential patient harm, use barcode scanning or similar technology immediately prior to the administration of 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.
Do not administer IV fluids and medications that have particulate matter or discoloration. Some medications will be colored fluid. If in doubt, double-check. This cannot be checked for the few drugs that come in a dark bag because of the medication is light sensitivity.
Some medications require dilution, particularly medications that are irritating to the vein. If you are withdrawing the medication from a glass ampule, use a filter needle or straw unless contraindicated.
Alert: 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 pushing more than one medicine.
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.
Patient education includes 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. This most commonly occurs with the replacement of large blood volume, the patient is known to have cold agglutinins, and during cardiopulmonary bypass (Nettina, 2019).
Power injectors are used in radiology to deliver a specific amount of contrast media in 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).