CPT2: IV administration Flashcards
What can IV administration be used for?
- Patients who are unconscious (sedated, coma)
- Patients who are ‘nil by mouth’ due to surgery or swallowing difficulties
- Patients who have reduced absorption from the GI tract
- Patients who are severely unwell and require intravenous antibiotics
- Patients who require medicines that are not absorbed form the GI tract (gentamicin, some chemotherapy)
When must the intravenous route only be used and why?
The intravenous route must be used only when other routes are deemed less suitable for the patient as it bypasses the innate immune barrier of the skin, which leads to a risk of infection.
Pharmacists in clinical settings are often involved with providing advice regarding intravenous medication administration. Here are some common questions asked:
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- The patient is nil-by-mouth, can any of their oral medications be given IV and if so are the doses prescribed still the same?
- What diluent do I use to reconstitute the drug and does it need to be diluted further?
- What rate should the IV drug be given at?
- Should the IV drug be given as an infusion or as a bolus?
- The patient is on multiple IV drugs and is fluid-restricted. Can any of the IV medications be given in a smaller volume?
- The patient has a central line and is on multiple IV drugs, can any of these be run together through the same line?
When is a peripheral venous catheter used?
Preferred when IV access is required for shorter periods of time, when direct access to central circulation is unnecessary, and when smaller gauge catheters suffice.
Advantages of a peripheral catheter?
Generally safer, easier to obtain and less painful than central access.
What options is there for centeral acess?
- Peripherally inserted central catheter (PICC)
- Tunnelled central venous catheter
- Subcutaneous port:
What is a peripherally inserted central catheter?
Typically inserted in a vein above the elbow and is threaded through the vein to rest above the right atrium of the heart
What is a tunnelled venous catheter?
Tunnels under the skin of the chest and enters a large vein near the collarbone and threads inside the vein to sit above the right atrium.
Sometimes referred to by their brand name eg. Hickman line.
What is a subcutaneous port?
A small, round titanium or plastic chamber with a self-sealing top usually made of silicone and a flexible tube.
Placed completely under the skin on the right or left side of the chest and the catheter threads under the skin from the portal into a large vein near the collarbone, then above the right atrium of the heart.
Sometimes called a ‘Port-a-Cath’
When are centeral venous catheters preferred to peripheral?
Central venous catheters are preferred in patients receiving sclerosing medications that can damage peripheral veins, or may cause injury if extravasated (eg. some chemotherapy).
May also be preferable in patients with severe volume depletion or in whom peripheral catheter placement has a low likelihood of success (eg. frequent use of IV illicit drugs).
What are formulations available?
Advantages and disadvantages of each?
What are complications that can arise from IV administration?
- Infiltration
- Haematoma
- Air embolism
- Phlebitis and Thrombo phlebitis
- What is infiltration?
- What is it usually caused by?
- What does infiltration manifest as?
- What is extravasation?
- Infusion of medications or fluids outside the intravascular space into the soft tissue surrounding the area.
- Usually caused by improper placement of the needle outside the vessel.
- Often noted as a swelling of the soft tissue around the site of insertion associated with a pale appearance and feels firm and cool upon touching.
- While a small amount of fluid may not cause an issue, infiltration of large amounts of fluid can cause serious complications.
- Extravasation occurs when there is accidental infiltration of a vesicant or chemotherapeutic drug which may cause tissue irritation and damage.
What is a haematoma?
When does this resolve and what is it manifested as?
- Leakage of blood from the blood vessels into surrounding soft tissues.
- Generally accompanied by pain and resolves within 2 weeks.
When does an air embolism occur?
What can this lead too?
How is it avoided?
- Occurs when a considerable amount of air enters the veins.
- Rare but has serious consequences - dependent on location. Impedes blood flow and if this occurs in the heart shock can develop.
- Prevented by ensuring there are no air bubbles in the intravenous tube before administration.
What is phlebitis and thrombo phlebitis?
What is management?
- Most common complication.
- Caused due to inflammation of the vein due to local trauma.
- Thrombophlebitis is a serious form of phlebitis, associated with the formation of a thrombus.
- Management involves elevation, warm compresses and NSAIDs. Anticoagulants and antibiotics are not usually required.
What is chemotherapy commonly given as?
Chemotherapy is most commonly delivered intravenously, as either a bolus injection, an infusion or a continuous infusion via a drip or a pump.
In chemotherapy what are the aims of the follow agents:
- Curative
- Adjuvant
- Neoadjuvant
- Pallatative
1. Curative:
- Chemotherapy is the definitive treatment for cure
2. Adjuvant:
- Given after definitive treatment such as surgery or radiotherapy
- Aims to eradicate micrometastases and improve cure rate
3. Neoadjuvant:
- Given prior to definitive treatment to facilitate the procedure and improve chance of cure
- May be given to shrink a large tumour to make it more operable
4. Palliative:
- Used to control symptoms and improve quality of life
- May prolong life, but not in every case
Advantages of intravenous chemotherpay?
Advantages:
- Good bioavailability
- Predictable plasma levels
- Not effected by swallowing difficulties and/or vomiting
Disadvantages of intravenous chemotherapy?
Disadvantages:
- Risks associated with injection
- Multiple drug administration can lead to issues with drug and fluid incompatibilities and IV access
- Inconvenient for the patient and time-consuming
- Associated cost
Intravenous chemotherapy is usually either bought in pre-prepared or made in hospital pharmacy aseptic units.
- Advantages of pre-prepared?
- Storage conditions?
Intravenous chemotherapy is usually either bought in pre-prepared or made in hospital pharmacy aseptic units.
Pre-prepared products, or ‘dose-banded’, are advantageous in that they reduce waste and waiting times for patients waiting to receive their chemotherapy. Historically, when patients received their chemotherapy, the dose would be based on their height and weight and calculated exactly, meaning that any chemotherapy agent left in the vial that is not required would be discarded. The dose banding system means that a number of doses are pre-prepared that closely match the vial size and the most appropriate dose for the patient’s height and weight can be selected.
Chemotherapy made on-site in hospital pharmacy aseptic units is available for those drugs which are not available ‘dose-banded’.
Chemotherapy is either stored at room temperature or in the fridge depending on the product, and all preparations have varying expiry dates. Chemotherapy is photosensitive so is stored with a light-protective cover over the bag to prevent degradation.
Before administration of intravenous chemotherpay what must be done?
What must be done?
Who can it be carried out by?
Chemotherapy must only be administered by a healthcare professional who has been specifically trained to administer cytotoxic agents.
A double layer of protective gloves must be worn by the person handling and administering the chemotherapy to protect them from the cytotoxic effects in case of any spillages.
Chemotherapy must always be checked by two healthcare professionals against the prescription prior to administration. The patient details, chemotherapy agent, diluent, expiry date and rate of administration must be checked.
What does extravasation manifest as?
What can it cause?
The leakage of drug into extravascular space during the injection/infusion process which can causes severe local tissue damage (necrosis) and may require plastic surgery if severe.
Most common symptoms are pain, burning and stinging at the site, although if there are any acute changes at the site extravasation should be suspected.
Who is TPN indicated for?
The fundamental indication for TPN is intestinal failure which may be short, medium or long-term. Causes of intestinal failure include:
- An inaccessible gut (eg. bowel obstruction, tumour)
- A malabsorptive or high-output state (eg. severe mucositis, graft vs. host disease, high-output stoma)
- A shortened or absent gut
- A dysmotility syndrome or post-operative ileus
The need for TPN is dependent on the duration of intestinal failure, but should be considered for anyone with intestinal failure persisting for more than a few days.
