≥ 92% of participants will know how to administer IV medications and fluids safely and correctly.
CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
≥ 92% of participants will know how to administer IV medications and fluids safely and correctly.
After completing this continuing education course, the participant will be able to:
Administration of intravenous (IV) medications is a standard therapy. The following will be discussed in this course:
With some medication categories, there are so many drugs that a complete discussion of each one is impractical. In those instances, the discussion will be limited to issues common to all the drugs of that class.
A 48-year-old female with a past medical history of breast cancer is treated with doxorubicin and cyclophosphamide. She has completed two days of treatment.
The nurse is administering a dose, and during the infusion, the patient says that the injection site “looks a little swollen.” The nurse notices what he considers mild swelling and some redness, but the patient is not having pain, and there is an immediate return of blood when he aspirates from the catheter.
The nurse knows that doxorubicin is a vesicant, and infiltration of this drug can cause extravasation and severe tissue damage. Per the healthcare facility’s protocol, he immediately stops the infusion, aspirates from the infusion catheter again, removes the catheter, and elevates the patient’s arm. The provider is contacted, and she recommends applying a cold compress for 20 minutes. A new IV catheter is inserted in the other arm, the doxorubicin and cyclophosphamide are infused, and the infusion is completed without a problem. The patient is instructed to apply a cold compress four times daily for one to two days. The provider decides that further treatment for this incident is not needed.
The next day’s infusion is completed without incident, and the infiltrated IV site looks fine.
However, when the patient comes the day after, the IV insertion site is now swollen, red, and painful. A small blister is immediately adjacent to the site, and some of the skin is blanched. After an examination, the provider makes the diagnosis of extravasation, and a plastic surgeon is consulted.
The primary issues of this case are:
Accessing a patient’s vascular space with an IV catheter is done for two primary purposes:
Accessing the vascular space with an IV catheter and IV drug/fluid administration are invasive procedures requiring sterile technique.
There are many specific reasons why IV fluid and/or drug administration is needed (Gomella & Haist, 2022; Tomlin, 2018).
IV fluids and medications can be administered through a peripheral or central line catheter (Manrique-Rodríguez et al., 2022). A central line catheter is an IV catheter placed in a large, non-peripheral vein like the subclavian or through a peripheral IV, and the tip of a central line catheter is (usually) in the vena cava.
Understanding basic concepts of body fluids, electrolytes, and fluid balance is necessary to administer IV fluids and medications competently and safely.
Body fluid is divided into body water and blood (Gomella & Haist, 2022; Tomlin, 2018). Total body water (TBW) differs depending on age, gender, and body composition (Gomella & Haist, 2022).
Body water is divided into intracellular and extracellular.
Body water contains many electrolytes. An electrolyte is a compound dissolved in water and has a negative or positive charge. We get electrolytes from the foods and fluids we consume. Important physiologic functions like cardiac and muscle contraction and the formation and transmission of nerve impulses depend on electrolytes like calcium, magnesium, potassium, and sodium. Homeostatic mechanisms tightly control the levels of these electrolytes. The vital body processes that use electrolytes cannot function normally if the blood level of an electrolyte is too low or too high.
Fluid balance depends on fluid intake and fluid loss.
Fluid loss comes from urine output, loss of fluid in feces, and insensible losses of water from the skin and breathing (Gomella & Haist, 2022). A high ambient temperature, physical activity, or fever can increase fluid loss. For example, every 1-degree increase in body temperature over 98.6°F increases insensible fluid loss by 2.5 mL/kg/day (Gomella & Haist, 2022).
A normal level of body fluid is essential. For example, a normal body fluid level is necessary to fill the vascular space, maintain blood pressure, and perfuse the brain, heart, and kidneys. Hypovolemia, a significant loss of blood volume, can occur when there is a loss of blood or body fluid and/or poor intake. A patient can become dehydrated when fluid loss exceeds fluid intake (Tomlin, 2018). Signs and symptoms of dehydration include decreased urine output, changes in the level of consciousness, dizziness, dry mucous membranes, hypotension, orthostatic hypotension, and tachycardia (Tomlin, 2018).
Electrolyte disorders can also be caused by poor intake and fluid loss. Persistent diarrhea and vomiting are common causes of electrolyte and fluid loss (Gomella & Haist, 2022).
IV fluids are given to correct fluid and/or electrolyte loss and to provide energy. Knowing the average fluid, electrolyte, and energy needs help to understand why specific IV solutions are prescribed. It is important to remember that the fluid requirement listed here is the maintenance IV fluid amount. Maintenance IV fluid is the amount that provides a patient with water, electrolytes, and energy when that patient cannot take oral fluids and food (Sterns, 2021). Maintenance fluid is different from replacement fluid; replacement fluid therapy corrects a problem, and maintenance fluid therapy prevents problems.
Standard IV fluids are colloids or crystalloids; colloids will be described but not discussed, as most IV fluid administration involves crystalloids.
Colloids are products like albumin that generate a high osmotic pressure that helps keep fluid in the intravascular space (Gomella & Haist, 2022).
Crystalloids are IV fluids like 5% dextrose in water and 0.9% normal saline that have a compound (dextrose, saline) dissolved in the fluid. The crystalloids are all used as a source of fluid and can also be a source of energy and electrolytes. Table 1 lists some of the commonly used crystalloids. The primary differences between crystalloid solutions are:
5% dextrose in water
50 grams glucose/1000 mL, no electrolytes, 170 calories/liter
|0.9% sodium chloride||154 mEq/L of sodium, 154 mEq/L of chloride|
|5% dextrose and 0.45% NaCl, aka D5 ½ normal saline||50 grams of glucose/L, 77 mEq/L of sodium and chloride, 170 calories/liter|
|Lactated Ringers||130 mEq/L of sodium, 110 mEq/L of chloride, 4 mEq/L of potassium, 3 mEq/L magnesium, 27 mEq/L of HCO3|
|3% normal saline||513 mEq/L sodium, 513 mEq/L of chloride|
Crystalloid IV solutions have different compositions, which is important regarding the electrolytes and energy each provides. The composition of a crystalloid can also affect where the body fluid is and the electrolyte composition of a body fluid, which is due to a process called osmosis.
The ECF and the ICF each have specific concentrations of electrolytes. These concentrations are maintained by active processes and by the passive process of osmosis. Osmosis is the movement of molecules (in this case, electrolytes) from a less concentrated solution to a more concentrated one to maintain normal balance. For example, suppose the concentration of sodium in the ECF and/or the ICF is not at the correct level. In that case, sodium will passively move in one direction to regain and maintain the proper concentrations. The electrolytes and the glucose in a crystalloid each have a specific osmotic value. For example, 0.9% normal saline has an osmotic value of 308 mOsmol/liter, and 0.45% normal saline has an osmotic value of 154 mOsmol/liter. Depending on what is in the crystalloid, they are one of these three types:
IV fluids are prescribed based on the patient's needs, the clinical condition that needs to be treated, and any pre-existing medical conditions like renal impairment that affect fluid balance. The most common uses of IV fluids are to provide fluids, energy, and electrolytes to patients who cannot take oral intake, administer IV medications, and correct volume depletion or acid-base disorders (Gomella & Haist, 2022).
After the IV fluid and rate of administration have been chosen, nurses are responsible for observing and monitoring the patient for adverse effects and the response to IV therapy.
Nurses must know and be able to identify the complications of IV medication administration.
Common complications of IV medication administration are infiltration, occlusion, phlebitis, infection, thrombus, and extravasation (Goel et al., 2020; Marsh et al., 2021).
Infiltration occurs when the IV catheter dislodges from the vein, and IV fluid infuses into the surrounding tissue. Signs and symptoms of infiltration include swelling in/around the area. Infiltration usually does not cause significant pain, but infiltration of certain medications, like chemotherapy drugs, can cause severe tissue damage (Brock & Cruz-Carreras, 2020; Masood et al., 2022).
Occlusion is simply a blockage somewhere in the IV system.
Phlebitis is an inflammation of the blood vessel. Common signs of phlebitis are pain, redness, and swelling at the catheter site.
Infection is also characterized by pain, redness, and swelling at the catheter site. Inserting a peripheral IV catheter is a simple procedure, but it is invasive, so there is a risk of infection.
A thrombus is a blood clot, and like infection and phlebitis, there can be pain, redness, and swelling at the catheter site.
Extravasation is the same as an infiltration; the IV catheter has dislodged from the vein, and IV fluid is moving into the tissue. The difference between them is the type of IV fluid and the consequences (Hadaway, 2007).
Extravasation causes irritation, pain, and swelling. It can also cause compartment syndrome, severe tissue damage, and tissue necrosis (Chinn & Colella, 2017; Brock & Cruz-Carreras, 2020; Masood et al., 2022). Extravasation can cause delayed complications and may take 14 to 55 days to be resolved (Ehmke, 2021; Pluschnig et al., 2015).
Extravasation can happen with peripheral and central IV lines (Ehmke, 2021). Every healthcare facility should have a policy/procedure for managing extravasation. Specific treatments include fasciotomy for compartment syndrome, hyaluronidase, supportive treatments like the application of cold or heat, aspirating fluid from the IV line, splinting, and elevation of the affected limb (Mandlik et al., 2019; Thomas et al., 2022). However, currently, there is little evidence for the effectiveness of any extravasation treatment, and the appropriate protocol for preventing damage has not been identified (Cho et al., 2019).
Air embolism is a rare complication of IV medication administration.
Monitoring for complications: The IV catheter site should be inspected at least once a shift or at the frequency the healthcare facility/organization recommends (Webster et al., 2019). If the medication is not infusing correctly, or the patient has signs/symptoms of an air embolism or extravasation, a supervisor should be notified immediately.
Every healthcare facility/organization has policies and procedures for preventing and treating complications like changing the catheter at specific intervals or, if there are signs of complications like occlusion or extravasation, stopping the infusion and removing the IV catheter. Every situation is different, and nurses should know what to do if a complication occurs so that the right actions/treatments can be done without hesitation.
Monitoring: Observe for adverse effects, check the clinical response to the dose, adjust this if needed, and measure drug levels when necessary.
Intravenous medications are associated with the highest medication error frequencies and more serious consequences to the patient than any other administration route (Kuitunen et al., 2021). The error rate is not surprising; administering IV medications is a multi-step, complicated task. Some of the important issues of IV medication administration are:
Administering supplementary magnesium to correct hypomagnesemia and supplementary potassium to treat hypokalemia is a common procedure, and in some cases, they need to be given IV.
Potassium is the primary intracellular electrolyte, essential for muscle contraction, the transmission of nerve impulses, and other physiologic functions.
IV potassium is typically given if the patient cannot take oral potassium, if oral potassium supplementation has not been successful, or if the patient has symptomatic hypokalemia (Lewis III, 2022a). If the serum potassium is > 3.0 mEq/L oral supplementation is recommended (Lewis, 2022). The IV route is preferred at lower potassium concentrations or in urgent situations.
Potassium chloride is the form that is commonly used for IV administration; the information provided here applies to that form of potassium.
During the infusion, the patient should be monitored for signs and symptoms of hyperkalemia (serum potassium > 5.5 mEq/L), including arrhythmias, bradycardia, hypotension, ECG changes, and ascending paralysis (Mount, 2018; Sur & Mohiuddin, 2022).
Magnesium is an essential electrolyte involved in the functioning of cells, muscle contraction, nerve conduction, and other physiological processes. Hypomagnesemia, defined as serum magnesium < 1.8 mg/dL, is very common, especially in hospitalized patients (Cheungpasitporn et al., 2020; Lewis III, 2022b).
Signs and symptoms of hypomagnesemia include anorexia, arrhythmias, nausea, vomiting, tremors, weakness, hypocalcemia, and hypokalemia (Papadakis & McPhee, 2023b; Lewis III, 2022b).
Hypomagnesemia is caused by decreased absorption or intake, such as with alcohol use disorder, diarrhea, thyroid disease, or increased excretion by the kidneys because of a diuretic or other drugs (Papadakis & McPhee, 2023b).
IV magnesium is given to treat hypomagnesemia, treat arrhythmias caused by hypomagnesemia, and prevent seizures in patients with preeclampsia/eclampsia. IV magnesium sulfate is preferred to an oral preparation if the serum magnesium is < 1.25 mg/dL (Lewis III 2022b).
Administration: The dose and infusion rate depend on the serum magnesium level and the patient’s clinical condition (Coralic, 2022). There are differing dose and infusion time recommendations.
For an asymptomatic or mildly symptomatic patient, 1 to 2 grams mixed with 5% dextrose or 0.9% normal saline can be infused in over 5 to 60 minutes (Papadakis & McPhee, 2023b). If the patient is significantly symptomatic and/or has Torsades de Pointes (TDP), 1 to 2 grams diluted with 10 mL of 5% dextrose can be infused in over 15 minutes (Papadakis & McPhee, 2023b).
Adverse effects of IV magnesium include bradycardia, hypotension, hypothermia, flushing, flaccid paralysis, respiratory paralysis, and sweating (Coralic, 2022).
Antibiotics are a diverse group of medications used to fight bacterial infections.
The two basic classes of antibiotics are:
Antibiotics work in many ways, but their primary mechanism of action is to disrupt vital functions and processes like cell wall synthesis that bacteria need to multiply and survive (MacDougall, 2023). Depending on the drug, this can slow bacterial growth (bacteriostatic) or kill the bacteria (bacteriocide).
There are three primary ways that antibiotics are used (MacDougall, 2023):
Antibiotics are categorized by chemical and pharmacologic properties. Antibiotics in the same category are likely effective against the same types of bacteria (Falagas & Bliziotis, 2017).
Categories of antibiotics, with examples of specific drugs, are listed in Table 2 (Calhoun et al., 2022; Falagas & Bliziotis, 2017).
IV antibiotics should be administered using sterile technique, safe injection practices, and the basic principles of safe medication administration: The right drug, right dose, right route, right time, and to the right patient. An IV antibiotic must be infused at the correct speed.
Common adverse reactions for each of the antibiotic classes are listed below.
Given the wide range of antibiotics and the clinical conditions they treat, no single monitoring parameter could/would be used for all. Specific drugs require specific monitoring, and several examples are provided.
For aminoglycosides, measuring blood levels to determine an appropriate dose and prevent complications is frequently recommended, and patients should be monitored for hearing impairments.
Macrolide antibiotics put patients at risk for QT prolongation and TDP, so an assessment of a patient’s cardiac status should be performed. Drug-drug interactions that may cause QT prolongation and/or TDP should be evaluated, and a 12-lead ECG should be done before starting and during treatment with a macrolide (Al-Jazairi & Alotaibi, 2020).
For lincosamides, observe the patient for persistent and/or severe GI distress, as this may be a sign of C. difficile infection.
Recognizing the signs and symptoms of an allergic reaction and knowing what to do if an allergic reaction occurs is essential.
Penicillin allergy is one of the most common drug allergies, but most allergic reactions to penicillin are mild (Castells et al., 2019). Serious allergic reactions that can be fatal - an anaphylactic reaction - occur, but fortunately, these are rare (Castells et al., 2019; Har & Solensky, 2017). Also, cross-reactivity can occur. For example, approximately 2% of patients allergic to penicillin are also allergic to cephalosporins (Shenoy et al., 2019).
Allergic reactions can occur within minutes of administering a drug (Hong & Boyce, 2022). If the patient is or may be having an allergic reaction, stop the infusion immediately and notify a supervisor or a physician.
Anticoagulants treat or prevent thrombi and pulmonary embolisms (PE). The goal of anticoagulation therapy is to promote anticoagulation while minimizing hemorrhagic issues.
The most used anticoagulants are:
These drugs prevent clots and emboli by affecting the clotting process, each in different ways. Heparin is given IV and subcutaneously (SC); the others are given orally or SC. The low-molecular-weight heparins can be given IV, but only for a patient that is having an acute myocardial infarction.
Heparin prevents and treats venous thromboembolism (VTE) and PE by interrupting the clotting process, specifically by irreversibly inactivating thrombin, factor Xa, and other clotting factors (Katzung et al., Chapter 34, 2021g). The onset of anticoagulation caused by heparin is immediate (Katzung et al., Chapter 34, 2021g). In most cases, an oral anticoagulant will be given until the therapeutic effect of the drug is established, e.g., two days for warfarin. Then the IV heparin infusion will be stopped.
The Institute for Safe Medication Practices (ISMP) considers anticoagulants to be high-alert medications that can cause significant harm if given incorrectly. The Joint Commission requires healthcare facilities to have approved protocols and evidence-based guidelines for using anticoagulants (ISMP, 2018; UpToDate, 2022e). Anticoagulants, including heparin, can cause serious harm if given incorrectly, and medication errors involving heparin, such as incorrect doses, are common (El-Bosily et al., 2022).
Administering IV heparin safely requires nurses to:
Anticonvulsants available as an IV preparation are listed in Table 3.
|Generic Name||Brand Name|
There are a few adverse effects that are common to all IV anticonvulsants, such as central nervous system (CNS) depression. Administration issues and adverse effects of individual anticonvulsants are described next; administration issues and adverse effects common to all the anticonvulsants will be discussed later.
Lacosamide: Lacosamide should be infused over 30 to 60 minutes, but if needed, a 15-minute infusion duration is acceptable (UCB Pharmaceuticals, 2022b). A diluted preparation of lacosamide should not be stored at room temperature for > 4 hours. Common adverse effects are dizziness, headache, nausea, and somnolence (UCB Pharmaceuticals, 2022b). IV lacosamide can cause bradycardia, ECG changes, and arrhythmias. If the patient has a cardiac condition, an ECG should be done before starting therapy and when the maintenance dose has been established (UCB Pharmaceuticals, 2022b).
Levetiracetam: Levetiracetam should be infused in over 15 minutes (UCB Pharmaceuticals, 2022a). A diluted solution of levetiracetam should be stored at room temperature and be used within 4 hours (UCB Pharmaceuticals, 2022a). Common adverse effects of levetiracetam include asthenia (lack of energy, weakness), hypertension, behavioral abnormalities such as aggression, psychotic signs/symptoms, and abnormal blood counts (UCB Pharmaceuticals, 2022a).
Phenobarbital: IV phenobarbital can cause hypotension and respiratory depression (Doshi et al., 2019; Pugin et al., 2014; Hocker et al., 2018).
Phenytoin: Hypotension, arrhythmias, and other adverse cardiac effects can happen if IV phenytoin is given faster than the recommended infusion rate (Guldiken et al., 2014; Smollin, 2018; UpToDate, 2022h). Use a slower infusion rate that is less than the maximum 50 mg/minute for elderly patients or those who have a cardiac condition, and closely monitor their blood pressure and heart rate (Guldiken et al., 2014; UpToDate, 2022h). Neurological adverse effects of phenytoin include mild CNS depression, fatigue, and nystagmus (Farrokh et al., 2018). If the serum level is abnormally high, ataxia, incoordination, slurred speech, and seizures can occur (Farrokh et al., 2018; Smollin, 2018). A diluted solution should be used within 4 hours.
Valproic acid: IV valproic should be infused over 60 minutes. The prescribing information for valproic acid has a black box warning: “Hepatic failure resulting in fatalities has occurred in patients receiving valproate. These incidents usually occur during the first six months of treatment. Serious or fatal hepatotoxicity may be preceded by nonspecific symptoms such as malaise, weakness, lethargy, facial edema, anorexia, and vomiting.” (UpToDate, 2022g). A black box warning means that a drug can cause a severe adverse effect, and nurses should be aware of this adverse effect (Livertox, 2020b). A high serum ammonia level is one of the causes of liver damage from valproic acid, and ammonia levels should be periodically measured (Livertox, 2020b). Drowsiness and thrombocytopenia are common adverse effects of valproic acid (Buoli et al., 2018; Duman et al., 2019).
Administration issues and adverse effects of anticonvulsants include:
Hypertension is a common disease that can cause serious complications like kidney damage, myocardial infarction, and stroke (Hall et al., 2022).
Antihypertensive medications treat elevations of systolic blood pressure, diastolic blood pressure, or both. Categories of the antihypertensives and available IV preparations are listed in Table 4. The only IV centrally acting alpha2 antagonist, dexmedetomidine, is not used to treat hypertension. IV nitroglycerin can be used to treat hypertension; it is discussed in the section on antianginals.
|Angiotensin-converting enzyme (ACE) inhibitors|
|Calcium channel blockers|
|Centrally acting alpha1 antagonists|
The ACE inhibitors lower blood pressure by decreasing vasoconstriction.
IV enalapril is used when the patient cannot take oral enalapril and can be used to treat hypertensive emergencies (Pfizer Pharmaceuticals, 2021; Whelton et al., 2018). Hypertensive emergencies will be explained in the section on beta-blockers.
IV enalapril can be delivered undiluted as an IV push dose, infused over at least 5 minutes, or mixed with up to 50 mL of an appropriate diluent and infused over 5 minutes (Pfizer Pharmaceuticals, 2021).
Adverse effects: Adverse effects of IV enalapril are uncommon but include headache, hypotension, and nausea (Pfizer Pharmaceuticals, 2021). Cough is not mentioned in the prescribing information as an adverse effect of IV enalapril, but a cough is a very common adverse effect of ACE inhibitors (Pfizer Pharmaceuticals, 2021); Wilkerson & Winters, 2022).
The beta-blockers lower blood pressure by decreasing the force of myocardial contraction and/or by vasodilation.
The available IV preparations of the beta-blockers are esmolol, labetalol, metoprolol, propranolol, and sotalol. Oral beta-blockers are used to treat chronic hypertension. IV beta-blockers, specifically esmolol and labetalol, are used to treat a hypertensive emergency or severe asymptomatic hypertension, aka hypertensive urgency (Stanistreet et al., 2018). A hypertensive emergency is elevated blood pressure (> 220 mmHg systolic, 120 mm Hg diastolic), and a serious complication like an MI or pulmonary edema is possible (Sutters, 2023). A patient who is having a hypertensive emergency should be admitted to intensive care (Peixoto, 2019).
Esmolol: Using IV esmolol to treat hypertensive urgency or emergency is an off-label use of the drug, but it is commonly used for these conditions (Sutters, 2023; Whelton et al., 2018).
Labetalol: Labetalol is approved for treating hypertensive emergencies and is commonly used for this (Peixoto, 2019).
The calcium channel blockers lower blood pressure by decreasing the force of myocardial contraction and by vasodilation. The IV calcium channel blockers are clevidipine, diltiazem, nicardipine, and verapamil; clevidipine and nicardipine are the only two used to treat hypertension or hypertensive emergencies (Whelton et al., 2018; Peixoto, 2019).
Clevidipine: Clevidipine is a first-line drug for treating hypertensive emergencies (Watson et al., 2018). Clevidipine lowers blood pressure by causing peripheral vasodilation.
Nicardipine: Nicardipine is one of the preferred drugs for treating hypertensive emergencies (Peixoto, 2019; Whelton et al., 2018). Nicardipine lowers blood pressure by causing peripheral vasodilation and reducing systemic vascular resistance (Baxter Healthcare Corporation, 2004).
Phentolamine: Phentolamine is the only drug of this category that has an IV preparation, and phentolamine can be used to treat hypertensive crises and hypertension caused by specific situations, including certain drug overdoses, drug-drug interactions, and the diagnosis of pheochromocytoma (Brathwaite & Rief, 2019; Whelton et al., 2018). Pheochromocytoma is a rare tumor of the adrenal glands that produce excess amounts of catecholamines like norepinephrine. Phentolamine lowers blood pressure by causing vasodilation. Phentolamine is available as a generic drug and the brand name preparation OraVerse®.
Hydralazine: Hydralazine lowers blood pressure by dilating the arteries and decreasing systemic vascular resistance. Hydralazine has often been used to treat hypertension and hypertensive emergencies. However, the response to the drug is considered unreliable, and it has a long duration of action of 1 to 4 hours (Peixoto, 2019; Braithwaite & Reif, 2019; Whelton et al., 2018). Hydralazine is not the first choice for severe hypertension or hypertensive emergencies (Peixoto, 2019).
Nitroprusside: Nitroprusside (brand name Nipride® RTU) lowers blood pressure by dilating peripheral arteries and veins (Excela Pharma Sciences, 2017b). Nitroprusside is used to immediately decrease blood pressure, control hypotension during surgery, and treat acute heart failure (Excela Pharma Sciences, 2017b).
The loop diuretics include bumetanide, ethacrynic acid, furosemide, and torsemide. These are all available as IV preparations. Ethacrynic acid is more likely to cause ototoxicity and is only used if a patient cannot take one of the other loop diuretics (Jackson, 2023).
Loop diuretics are not the first choice for treating hypertension, but IV loop diuretics can be used to treat acute, severe hypertension, hypertensive emergencies, acute heart failure, and pulmonary edema (Felker et al., 2020; Kiefer et al., 2023; Whelton et al., 2018; Papadakis & McPhee, 2023a). In these situations, IV boluses or a continuous infusion can be used (Felker et al., 2020).
Adverse effects of loop diuretics are electrolyte disorders, especially hyponatremia and hypokalemia (this increases the risk of cardiac arrhythmias), hypotension because of excess diuresis, and ototoxicity (Jackson, 2023; Papadakis & McPhee, 2023a). Ototoxicity, deafness, hearing impairment, and tinnitus can occur when the IV infusion rate of a loop diuretic is too fast (Jackson, 2023).
The loop diuretics and the sulfonamide antibiotics are structurally similar. There is a very small risk of an allergic reaction to a loop diuretic if one of these drugs is given to a patient allergic to sulfonamide antibiotics (Chow & Khan, 2022).
The thiazide and thiazide-like diuretics include chlorthalidone, chlorothiazide, hydrochlorothiazide, indapamide, methyclothiazide, and metolazone. Thiazide and thiazide-like diuretics are a first-line treatment for hypertension, but only chlorothiazide is available as an IV preparation, and it is not used to treat hypertension or hypertensive urgency/emergencies (Papadakis & McPhee, 2023a).
The potassium-sparing diuretics include amiloride, eplerenone, spironolactone, and triamterene. These drugs treat chronic hypertension and are available only as oral preparations.
NSAIDs are used as analgesics, antipyretics, and anti-inflammatories, and they are available as over-the-counter drugs like aspirin and naproxen and as prescription drugs (Shagroni et al., 2021).
The primary way that NSAIDs reduce inflammation is by inhibiting cyclooxygenase (COX-1 and COX-2) enzymes (Shagroni et al., 2021). The COX-1 and COX-2 enzymes help synthesize prostaglandin production, and prostaglandin is a lipid compound that controls the inflammatory process.
Older NSAIDs like ibuprofen inhibit COX-1 and COX-2 (Shagroni et al., 2021). The inhibition can affect platelet function and cause GI bleeding. Some of the newer NSAIDs, like celecoxib, are selective COX inhibitors. They only inhibit COX-2 and do not affect platelet function, so the risk of GI bleeding is reduced (Shagroni et al., 2021).
Ibuprofen and meloxicam are available as IV preparations. There are two IV ibuprofen preparations, Caldolor® and Neoprofen®. Neoprofen is used to treat clinically significant patent ductus arteriosus (PDA) in premature infants who are no more than 32 weeks gestational age when usual medical management (fluid restriction, diuretics, respiratory support, etc.) is ineffective (Recordati Rare Diseases Inc., n.d.).
Caldolor is a COX-1 and COX-2 inhibitor, and it is used to treat mild to moderate pain; it is used with opioids to treat moderate to severe pain; and to reduce fever (Cumberland Pharmaceuticals Inc., n.d.).
Anjeso is a COX-1 and COX-2 inhibitor, and it is used alone or with non-NSAID analgesics to treat moderate to severe pain (Baudax Bio., 2021).
Anjeso has a delayed onset of 2 to 3 hours in most patients; using Anjeso is not recommended if the patient needs rapid relief (Baudax Bio, 2021).
Acetaminophen (brand name Tylenol®) is a non-opioid analgesic. The mechanism of action of acetaminophen is not well understood. Acetaminophen is used to treat mild pain and reduce fever.
IV acetaminophen (brand name Ofirmev®) treats mild to moderate pain in children two years and older. For adults, it is used to treat moderate to severe pain in combination with an opioid analgesic. It is used for treating fever in patients over two years of age (Mallinckrodt Hospital Products, 2018).
Antineoplastics are used to treat cancer, and there are > 200 drugs that are/can be categorized as antineoplastics (Kim-Katz, 2022). Discussing all of them would be very lengthy; this module will cover the primary categories of antineoplastics (Katzung et al., Chapter 54, 2021i). Other sources categorize antineoplastics differently.
Antineoplastics include alkylating agents, antibiotics, antimetabolites, natural products, and miscellaneous agents.
Antivirals are used to treat and manage viral infections, including coronavirus disease (COVID-19), cytomegalovirus, herpes simplex, herpes zoster, human immunodeficiency virus (HIV), and influenza. There are several classes of antivirals, and each antiviral disrupts a different stage of the viral life cycle. The exact mechanism of action is different for each drug.
IV antivirals include:
Acyclovir is an antiviral that inhibits DNA synthesis and replication. IV acyclovir has labeled uses and is a first-line treatment for the following conditions (Kubota et al., 2019; Patil et al., 2022; Stahl & Mailles, 2019):
Foscarnet (Foscavir®) treats herpes simplex infection that has not responded to acyclovir (Clinigen Healthcare Ltd., 2020; Patil et al., 2022).
Cytomegalovirus (CMV) is a common virus that can cause retinitis. Retinitis is an infection of the retina. CMV retinitis can cause retinal detachment and vision loss, and it is a well-known complication of HIV infections (Ude et al., 2022).
Foscarnet is a second-line treatment for CMV retinitis; it’s used when the patient does not respond to ganciclovir or valganciclovir or if the patient cannot take ganciclovir (Ude et al., 2022; UpToDate, 2022c). The patient is given induction treatment for 14 to 21 days and maintenance therapy for ≥ 3 to 6 months until specific clinical endpoints are reached (UpToDate, 2022c). Aside from that, the administration recommendations, warnings, adverse effects, and monitoring are the same as for treating herpes simplex.
Ganciclovir inhibits DNA synthesis. It is the first-line treatment for CMV retinitis and has a labeled use as a prophylactic for transplant patients at risk for CMV disease (Ude et al., 2022). Ganciclovir is a generic drug; there is no brand name preparation.
The dose and the duration of therapy of prophylactic ganciclovir are different than for CMV retinitis. Aside from that, the administration recommendations, warnings, adverse effects, and monitoring are the same as for treating CMV retinitis.
Antipsychotics treat schizophrenia, bipolar disorder, and other psychiatric illnesses. Some older antipsychotics have anti-emetic effects (Katzung et al., Chapter 29, 2021e). Antipsychotics are also commonly administered for off-label uses.
Antipsychotics are divided into two classes: The original, first-generation antipsychotics, also known as typical antipsychotics, and second-generation, also known as atypical antipsychotics. The terms typical and atypical refer to the adverse effect profile. The first-generation antipsychotics caused movement disorders that were common or “typical” for these drugs. The second-generation antipsychotics, initially, were thought to be far less likely to cause movement disorders, so they were called atypical. Also, a distinction was made between them because they had slightly different mechanisms of action.
Typical antipsychotics like haloperidol are commonly referred to by their discontinued brand name form (haloperidol = Haldol), but these drugs are now all generic.
Three antipsychotics are available as IV preparations: chlorpromazine, droperidol, and haloperidol. The atypical antipsychotic olanzapine is often given IV to treat agitated patients, but this is an off-label use (Wang et al., 2022a).
IV chlorpromazine is approved for treating prolonged, intractable hiccups, and IV droperidol is approved for use as an antiemetic. Other uses of IV chlorpromazine, droperidol, and haloperidol, while not uncommon, are unlabeled uses.
Typical antipsychotics include chlorpromazine (Thorazine®), droperidol (Inapsine®), fluphenazine (Modecate®), haloperidol (Haldol®), perphenazine, and thioridazine (Mellaril®).
Atypical antipsychotics include aripiprazole (Abilify®), lurasidone (Latuda®), olanzapine (Zyprexa®), quetiapine (Seroquel®), and risperidone (Risperdal®).
Antiarrhythmic medications treat heart rate and/or rhythm disturbances, also known as arrhythmias. Arrhythmias are caused by abnormal cardiac impulse conductions, such as a heart block, or an abnormal cardiac impulse formation, such as atrial or ventricular fibrillation (Katzung et al., Chapter 14, 2021c).
Table 5 lists a basic classification system for antiarrhythmics. There are more drugs in each class; the ones listed in Table 5 are the available IV preparations. The beta-blockers, calcium channel blockers, and digoxin are discussed in other sections of this course.
|Class 1: Sodium channel blockers|
|Class 2: Beta-blockers|
Esmolol, metoprolol, and propranolol
|Class 3: Potassium channel blockers||Amiodarone, bretylium, ibutilide, sotalol|
|Class 4: Calcium channel blockers||Diltiazem and verapamil|
|Class 5: Miscellaneous antiarrhythmics||Adenosine and digoxin|
Adverse effects include hypotension, seizures, and TDP (Katzung et al., Chapter 14, 2021c).
Adenosine treats paroxysmal supraventricular tachycardia (PSVT); PSVT is characterized by a heartbeat > 100, sudden onset and a short duration (30 seconds), and signs and symptoms like dizziness, palpitations, and shortness of breath. Adenosine is the first-line choice for treating PSVT (Katzung et al., Chapter 14, 2021c; Hospira Inc., 2020).
Cardiac glycosides are drugs used to treat atrial fibrillation, heart failure, and supraventricular arrhythmias.
The primary therapeutic mechanisms of action of digoxin are decreasing heart rate and increasing the force of myocardial contraction (Alobaida & Alrumayh, 2021; Katzung et al., Chapter 13, 2021b).
Atrial fibrillation is the most common arrhythmia in adults (Alobaida & Alrumayh, 2021). Atrial fibrillation is characterized by a rapid heart rate (> 100 beats/minute and often higher), an irregularly irregular heart rate, and decreased cardiac output (Mitchell, 2022). Atrial fibrillation is a significant cause of stroke and heart failure, and controlling heart rate is a primary treatment for atrial fibrillation (Alobaida & Alrumayh, 2021). Pharmacologic rate control is done with a beta-blocker, a calcium channel blocker, or digoxin; digoxin is the last choice (Alobaida M & Alrumayh, 2021).
Digoxin-specific antibodies, or Fab fragments, are the antidote for digoxin toxicity. Digoxin-specific antibodies bind digoxin, and the Fab fragment-digoxin complex is excreted by the kidneys (Ma, 2022). Digoxin-specific antibodies are given if the patient has an elevated digoxin level, a serious arrhythmia, is hemodynamically unstable, and/or has a serum potassium > 5 mEq/mL (Ma, 2022).
The dose is measured in vials based on the steady-state serum digoxin level or the amount of digoxin ingested (Ma, 2022); the formula is provided here with an example. Example: The steady-state digoxin level (12-16 hours after the last dose) is 2.8 ng/mL, and the patient weighs 80 kg. 2.8 x 80 = 224, 224 ÷ 100 = 2.24 vials. After dilution, the vials of digoxin-specific antibodies should be infused over 30 minutes (Ma, 2022).
Adverse effects include exacerbation of heart failure, increased heart rate after the effect of digoxin has been neutralized, and hypokalemia (Ma, 2022).
Oral and IV beta-blockers, calcium channel blockers, and nitrates can be used to treat angina. The beta-blockers and calcium channel blockers were previously discussed; this section will discuss IV nitroglycerin.
Angina is caused by myocardial ischemia, and IV nitroglycerin has a labeled use as a treatment for acute angina. Nitroglycerin relieves angina by decreasing myocardial oxygen demand and increasing oxygen supply to the heart, primarily by causing vasodilation (Katzung et al., Chapter 12, 2021a).
Corticosteroids are naturally occurring hormones. Pharmaceutical corticosteroids are synthetic corticosteroids divided into two categories: glucocorticoids and mineralocorticoids (Katzung et al., Chapter 39, 2021h).
The glucocorticoids affect the metabolism of carbohydrates, fats, and proteins and help control and mediate the immune response and inflammation (Katzung et al., Chapter 39, 2021h).
IV glucocorticoids are used, on-label and off-label, for a wide variety of conditions, including (but not limited to) acute respiratory distress syndrome (ARDS), adrenal crisis, COVID-19, allergic reactions, exacerbations of asthma, chronic obstructive pulmonary disease (COPD), multiple sclerosis, sepsis, systemic lupus erythematosus, and rheumatic arthritis (Shah et al., 2022). These are immune-driven pathologies and/or characterized by inflammation, so glucocorticoids can be a helpful treatment. There are many glucocorticoids, and they are used to treat many conditions; a full discussion would be very lengthy. Administration issues, warnings, and adverse effects common to all IV glucocorticoids will be covered.
Diabetic patients are treated with insulin, oral medications, or both. Insulin is primarily given SC, but it can be given as an IV bolus or infusion, and it is the only diabetic medication that can be given IV. IV insulin is used to treat diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), and it is used to treat patients who have taken an overdose of a calcium channel blocker (Masharani, 2022; Benowitz & Wagner, 2022). Although these are off-label uses, IV insulin is standard care for these conditions.
Insulin lowers blood sugar by activating transport molecules that move glucose into the cells. Insulin also increases the glycogen stored in the liver (Katzung et al., Chapter 54, 2021i).
The most common adverse effect of insulin is hypoglycemia.
DKA is a complication of type 1 diabetes and occasionally type 2; it is a medical emergency (Masharani, 2022). Diabetic ketoacidosis is characterized by a blood glucose level > 250 mg/dL and metabolic acidosis, CNS depression, dehydration, electrolyte abnormalities, hypotension, nausea, and vomiting. Without proper treatment, the patient can die (Masharani, 2022).
The primary treatments for DKA are lowering blood glucose with insulin, IV fluid resuscitation, correcting acidosis, and correcting electrolyte abnormalities (Masharani, 2022). Treating DKA is very complicated, and there are different protocols:
HHS is an uncommon diabetic complication with a mortality rate of> 10 times that of DKA (Masharani, 2022). It can cause severe complications like MI and stroke (Masharani, 2022).
HHS is characterized by a blood glucose level > 600 mg/dL (and sometimes much higher), very high serum osmolality, a normal pH, lethargy, dehydration, polyuria, and polydipsia (Masharani, 2022). The hyperosmolar hyperglycemic state tends to occur in older adults (Masharani, 2022).
Treatment of HHS is essentially the same as that of DKA.
Calcium channel blocker overdose is characterized by bradycardia, hypotension, and hyperglycemia and is a life-threatening emergency (Benowitz & Wagner, 2022).
An IV infusion of regular insulin and an IV infusion of 10% dextrose in water is an effective treatment for calcium channel blocker overdose (Benowitz & Wagner, 2022). A calcium channel blocker overdose inhibits insulin release, so glucose cannot move into the myocardium, and the heart is deprived of an energy source (Benowitz & Wagner, 2022). The 10% dextrose provides energy, and the insulin provides a way to deliver the dextrose to the myocardium (Stassinos, 2022). Myocardial contractility is improved, and hypotension can be reversed. There are no standard dosing protocols for this as it is an off-label use. However, insulin-dextrose is commonly used to treat calcium channel blocker overdose, and a typical regimen is described below (Stassinos, 2022).
Opioids and opiates are natural, synthetic, and semi-synthetic compounds used as analgesics, antitussives (cough relief), antidiarrheals, as an adjunct to anesthesia, and to treat opioid use disorder or addiction (Katzung et al., Chapter 31, 2021f). The analgesic effect of opioids makes them suitable for a wide range of uses, such as postoperative pain, pain caused by a non-ST segment elevation myocardial infarction, sickle cell disease, and breakthrough pain in patients with chronic pain.
Opioids and opiates bind to opioid receptors in the brain and the CNS, and the therapeutic and adverse effects are caused by drug-receptor binding (Katzung et al., Chapter 31, 2021f). Opioids that can be given IV include buprenorphine, butorphanol, codeine, fentanyl, hydromorphone, meperidine, morphine, and nalbuphine. Discussing the clinical indications for use, the administration and monitoring issues, and the adverse effects of each drug would be very lengthy. Also, the adverse effects of all opioids and warnings are essentially the same.
The narcotic antagonist's naloxone and nalmefene are used to reverse sedation and respiratory depression caused by opioids and opiates. Nalmefene was only recently (2022) available again in the United States. Naloxone (Narcan®) is widely used, and nalmefene will not be discussed.
Medication errors account for over 98,000 deaths annually, a large part of healthcare costs (Pham et al., 2012). The Institute of Medicine revealed the seriousness of these errors and found that most were preventable (Kohn et al., 1999; Radley et al., 2013).
IV medications “are associated with the highest medication error frequencies and more serious consequences to the patient than any other administration route” (Kuitunen et al., 2021). Administering IV medications is an ongoing, multi-step, complicated task. IV medications are a common source of medication errors, and many of the classes of medications discussed in this module have been identified by the ISMP (2018) as high-alert medications.
Example: The ISMP considers anticoagulants to be high-alert medications, drugs that can cause significant harm if they are given incorrectly (ISMP, 2018), and the Joint Commission requires healthcare facilities to have approved protocols and evidence-based guidelines for the use of anticoagulants (UpToDate, 2022h).
The ISMP has published a list of high-alert medications in acute care settings. Examples of these drugs discussed in this course are listed in Table 6.
|Adrenergic agonists (Epinephrine, phenylephrine, norepinephrine)|
|Adrenergic antagonists (propranolol, metoprolol, labetalol)|
|Antiarrhythmics (lidocaine, amiodarone)|
|Dextrose, hypertonic, 20% or greater|
|Moderate sedation agents, IV (lorazepam, midazolam)|
IV medication therapy is a common form of therapy. It is often used for NPO patients who cannot tolerate other forms of administration and electrolyte imbalances. There are many complications of IV therapy, including infiltration and extravasation, that can severely affect the patient. Many medications can be administered via IV, but some are considered high-risk and require extra monitoring and laboratory testing. As medication errors are common, monitoring works to reduce these occurrences.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.