Chapter 7: IV medication Principles Flashcards
Peripheral venous catheters
Inserted into smaller veins away from the bodys central compartment. Common veins used for peripheral venous catheters are the cephalic vein in the arm and the saphenous vein near the ankle.
Phlebitis
Vein irritation
Venous thrombosis
Clots
Fluid extravasation
when the catheter becomes dislodged from the vein and the infusion contents enter surrounding tissue
Administering drugs into smaller veins can cause
Phlebitis, venous thrombosis, and fluid extravasation
Central lines are required in the administration of
Highly concentrated drugs (KCl >20mEq/100mL)
Long term antibiotics (example to treat osteomyelitis)
Toxic drugs that would cause severe phlebitis (eg chemotherapy, especially with vesicants)
Drugs with a pH or osmolality that is not close to blood pH or osmolality (parenteral nutrition)
Central Line Placement
The catheter tip must be located in a large vessel (superior vena cava, right atrium, or inferior vena cava).
Peripherally inserted central catheters (PICC)
Inserted by placing the line into a peripheral vein and advancing (pushing) the catheter through the vein until the tip ends in the superior vena cava. PICC lines are more simple to insert than central lines and can be inserted at the bedside and checked with a quick xray.
Vesicants
Drugs that will cause severe tissue damage if the catheter tip comes out of the vein, allowing the drug to seep into the surrounding tissues (extravasate). Vesicants are safer through a central line.
Vesicants examples
Vasopressors (dopamine, NE), anthracyclines (doxorubicin), vinca alkaloids (vincristine, vinblastine), digoxin, foscarnet, nafcillin, mannitol, mitomycin, and promethazine
Promethazine can cause
Severe tissue injury.
Some hospitals removed it from formulary due to risk.
Not to be given intra-arterial or SC; IM is preferred but still has risk.
Do NOT give to children <2yo, dilute the drug, limit the dose and concentration and be careful
Primary resources for incompatible drugs
Handbook on Injectable Drugs (commonly called Trissel’s), the King Guide to Parenteral Admixtures (King’s), and the drugs package insert
Chemical Incompatibility
Causes drug degradation or toxicity due to a hydrolysis, oxidation, or decomposition reaction.
Physical incompatibility
Occurs between a drug and one of the following:
The container
The diluent
Another drug
DEHP from the container
The majority of PVC containers use DEHP as a “plasticizer” to make the plastic bag more flexible. DEHP can leach from the container and into the solution. DEHP is toxic and can harm the liver and testes.
Container absoprtion/adsorption
Absorption occurs when drug moves into the PVC container
Adsorption occurs when the drug adheres to the container
Both reduce drug concentration
Alternate (Non-PVC) Containers
Drugs that have leaching or absorption/adsorption issues with PVC containers can be placed in polyolefin, polypropylene or glass containers
Insulin and PVC containers
Insulin adsorbs to PVC. Clinicians adjust the rate of insulin infusions to obtain blood glucose control, regardless of the type of IV container and tubing used. It might be useful to know that insulin does adsorb to PVC for testing purposes.
Drugs with leaching/adsorption/absorption issues with PVC containers
Leach Absorbs To Take In Nutrients
Lorazepam
Amiodarone
Tacrolimus
Taxanes (Paclitaxel-albimin bound can be placed into PVC)
Insulin
Nitroglycerin
Other: Carmustine, Cyclosporine, Ixabepilone, Sufentanil, Temsirolimus
Saline (no dextrose) diluent drugs
A DIAbetic Can’t Eat Pie
Ampicillin
Daptomycin
Infliximab
Ampicillin/Sulbactam
Caspofungin
Ertapenem
Phenytoin
Other: Abatacept, Azacitidine, Belimumab, Bevacizumab, Idarucizumab, Iron sucrose, sodium ferric gluconate complex, Natalizumab, trastuzumab
Dextrose (no saline) diluent drugs
Outrageous Bakers Avoid Salt
Oxaliplatin
Bactrim
Amphotericin B
Synercid (Quinupristin/Dalfopristin)
Others: Carfilzomib, Mycophenolate, Pentamidine
Y-site administration
Drugs mix together briefly in the common portion of the IV tubing. Drugs and solutions must be compatible.
Additive Compatibility
Needs to be confirmed when putting multiple drugs together in the same container or syringe. Additive compatibilities and Y site compatibilities are separate on Trissel’s
High-risk incompatibilities- Ceftriaxone and calcium
Ceftriaxone and Calcium
Risk of precipitates
Lactated ringers contains calcium and cannot be mixed with ceftriaxone
Avoid in all age groups
High risk incompatibilities- Calcium and phosphate
Can form deadly precipitate in IV fluids
High risk incompatibilities- Amphotericin B and sodium bicarbonate
Incompatible iwth the majority of IV drugs and any type of IV administration
Precipitates
Risk of precipitates–> Emboli–> Fatality
Calcium and ceftriaxone
Calcium and phosphate
Most drugs use what filter?
0.22 micron filter
Lipids use what filter?
1.2 microns
Parenteral nutrition uses what filter?
0.22 micron
What drugs must not be filtered?
Large molecules, including many liposomal formulations of chemotherapy drugs.
Must not be filtered due to size of the drug particle.
Common drugs with filter requirements
GAL PLAT
Golimumab
Amiodarone
Lorazepam- if by CIVI
Phenytoin- if by CIVI
Lipids- 1.2 microns
Amphotericin B- liposomal requries 5 micron filter
Taxanes, except docetaxel
Time in solution
The likelihood of a chemical reaction that would degrade the drug increases with time. This is important to consider with Pip/Tazo longer infusion times.
Do not refrigerate drugs
Dear Sweet Pharmacists, Freezing Makes Me Edgy
Dexmedetomidine
Sulfamethoxazole/Trimethoprim
Phenytoin-crystallizes
Furosemide- crystallizes
Metronidazole
Moxifloxacin
Enoxaparin
Others- Acetaminophen, Acyclovir (crystallizes), deferoxamine (precipitates), levetiracetam, pentamidine (cystallizes), valproate
Light exposure causes
Photo-degradation, which destroys some rugs, and in some cases, increases a drugs toxicity (nitroprusside)
Protect from light during administration drugs
Protect Every Necessary Med from Daylight
Phytonadione
Esoprostenol
Nitroprusside
Micafungin
Doxycycline
Do not shake/agitate
Agitation destroys some drugs, including hormones and other proteins. Drugs that are easily destroyed/damaged should not be shaken.
Protein/blood products- albumin, immune globulins, monoclonal antibodies, insulins
Products that foam- alteplase, etanercept, rasburicase, Synercid, or caspofungin. Only swirl when reconstituting, do not shake.
Vaccines that have been reconstituted
Emulsions such as propofol and injectable lipid emulsions.
Check solutions for color changes
In most cases, discoloration indicates oxidation or another type of decomposition
Anthracyclines (doxorubicin) color
Red
Discolors sweat and urine
Rifampin color
Red
Discolors body fluids and teeth
Mitoxantrone color
Blue
Discolors skin, eyes, urine
Methotrexate color
Yellow
Does not discolor secretions or skin
Multivitamins for infusion color
Yellow
Does not discolor secretions or skin
Tigecycline color
Yellow/Orange
Teeth discoloration if used during teeth development
IV iron, various color
Brown
Urine discoloration
Chlorpromazine color
Slight yellow
Do not use if darkens
Dascarbazine color
Do not use if pink
Dobutamine color
Oxidation turns the solution slightly pink, but potency is not lost
Dopamine color
Slight yellow
Do not use if darkens
Epinephrine color
Do not use if pink or brown
Isoproterenol color
Damaged by air, light, heat
Do not use if pink or darker
Morphine color
Do not use if dark colored
Nitroprusside color
Blue indicates nearly complete dissociation to cyanide.
Orange–> Brown-> Blue
Norepinephrine color
Normal color: yellow/orange
Do not use if brown or any discoloration
Tigecycline color
Do not use if green/black
