Intravenous Medication Principles Flashcards
What are common routes for parenteral drug administration?
Intravenous (IV), intramuscular, subcutaneous or transdermal administration
When is the intrathecal route typically used?
The intrathecal route is often used by anesthesiologists and for some chemotherapy, but when contraindicated, intrathecal administration can be fatal
When is the IV route required in hospitalized patients?
The IV route is required in hospitalized patients who are NPO (unable to take anything by mouth) and with gastrointestinal conditions when the gut needs to be bypassed. Drugs with poor oral bioavailability are often given IV. In a critical situation where fast (stat) onset is required, IV administration is a must
What is a catheter?
A catheter is a piece of plastic tubing that goes into a part of the body to put fluids in or take htem out
What is a venous catheter?
A catheter inserted into a vein is called a venous catheter and is used for fluid and drug delivery. A venous catheter is called a line, and the patient is said to have IV access
*Lines come in two primary types: peripheral and central
What does percutaneous and peripheral mean?
Percutaneous means through the skin and peripheral refers to locations away from the body’s central compartment, including the arms and legs
How can most IV drugs be delivered through?
Most IV drugs can be delivered through percutaneous, peripheral venous catheters that are inserted into smaller veins
What are common veins used for peripheral venous catheters?
The cephalic vein in the arm and the saphenous vein near the ankle
What are some limitations with administering drugs into smaller veins?
Administering drugs into smaller veins can cause phlebitis (vein irritation), venous thrombosis (clots) and interstitial extravasation (when the catheter becomes dislodged from the vein and the infusion contents enter the surrounding tissue
What is a central line?
A central line empties into a larger vein and the contents are quickly diluted
When are central lines required?
- Highly concentrated drugs
- Long-term antibiotics
- Toxic drugs that would cause severe phlebitis
- Drugs with a pH or osmolality that is not close to blood pH or osmolality
*Central lines are sometimes used for patients with poor peripheral venous access
What are the benefits of a central line?
- Central lines provide secure, long-term vascular access
- Additional benefits with a central line include the ability to administer higher volumes and use faster infusion rates
What is the criteria to be considered a central venous catheter?
The catheter tip must be located in a large vessel. The catheter can reach one of these locations by being inserted into a proximal central vein or a peripheral vein. A line inserted in a proximal central vein can be placed in the internal jugular vein, subclavian vein or femoral vein
How are peripherally inserted central catheters (PICC) lines inserted?
PICC are 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 (where the infusion contents will be released). A PICC line can be inserted at the bedside, and a quick x-ray will confirm that the tip has reached the right location
What is a vesicant?
A vesicant is a drug that will cause severe tissue damage if the catheter tip comes out of the vein, allowing the drug to seep into the surrounding tissues
Why are vesicants preferentially administered through a central line?
Vesicants are preferentially administered through a central line because the line is less likely to become dislodged from the vein
What are some examples of vesicants?
Vesicants include vasopressors, anthracyclines, vinca alkaloids, digoxin, foscarnet, nafcillin, mannitol, mitomycin and promethazine
What are some resources that can be used by pharmacists to check compatibility of medications?
The Handbook on Injectable Drugs or the King Guide to Parenteral Admixtures are the primary compatibility and stability resources, along with the drug’s package insert. Some drug information databases, including Micromedex, Clinical Pharmacology and Lexicomp, use the IV compatibility information from Trissel’s
When does chemical incompatibility occur?
Chemical incompatibility causes drug degradation or toxicity due to a hydrolysis, oxidation or decomposition reaction
When do physical incompatibilities occur?
Physical incompatibilities occur between a drug and one of the following: the container, the diluent, another drug
What is the danger of DEHP from the container?
The majority of polyvinyl chloride (PVC) containers use diethylhexyl phthalate (DEHP) as a “plasticizer” to make the plastic bag more flexibile. DEHP can leach from the container and into the solution. DEHP is toxic and can harm the liver and testes
When does container absorption/adsorption occur?
Absorption occurs when drug moves into the PVC container and adsorption occurs when drug adheres (or “sticks”) to the container; either will reduce the drug’s concentration
Where can drugs that have leaching or absorption/adsorption issues with PVC containers?
Placed in polyolefin, polypropylene or glass containers
What does insulin adsorb?
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
What are some key drugs that have sorption or leaching issues with PVC?
Lorazepam, Amiodarone, Tacrolimus, Taxanes, Insulin, Nitroglycerin
Which key drugs are only compatible with saline (no dextrose)?
Ampicillin, Daptomycin, Infliximab, Ampicillin/Sulbactam, Caspofungin, Ertapenem, Phenytoin
Which key drugs are only compatible with dextrose (no saline)?
Oxaliplatin, Bactrim, Amphotericin, Synercid
What is a strategy to minimize the number of inserted peripheral and central lines?
Infusion bags are often jointed together in a Y-site and run together in the same line during administration
What is a Y-site?
A Y-site describes the shape that forms when the lines are joined prior to entering the patient. Often, the large container is the patient’s fluids and the smaller IV piggybacks contain the drugs. Since the drugs mix together briefly in the common portion of the IV tubing, it is important the the drugs and solutions are compatible with Y-site administration
Why must additive compatibility be confirmed when putting multiple drugs together in the same container?
There are more compatibility issues with mixing drugs in the same container because the drugs are together for a longer period of time.
What is a dangerous example of incompatibility that should be avoided?
Ceftriaxone cannot be mixed with any calcium-containing solutions due to the risk of precipitates. Lactated Ringers, a common IV fluid, contains calcium and cannot be mixed with Ceftriaxone, including Y-site administration. This combination must be avoided in all age groups; neonates have the highest risk for lethal effects
What are some other high-risk incompatibilities?
- Calcium and phosphate can form a deadly precipitate in intravenous fluids
- Amphotericin B and sodium bicarbonate are incompatible with the majority of IV drugs with any type of IV administration
- Zosyn forms a precipitate when it mixes with acyclovir, amphotericin B and many other IV drugs
- Heparin is incompatible when administered with many drugs, including those often given concurrently in a patient requiring heparin (e.g. nitroglycerin, alteplase and hydromorphone)
- All of the IV quinolones are incompatible with Y-site infusion of many drug
When are in-line filters used?
In-line filters (attached to the IV tubing) are used with drugs that have a risk of particulates, precipitates, crystals, contaminants or entrapped air in the final solution
What filter is necessary for a majority of drugs?
The majority of drugs in which filters are necessary use a 0.22 micron filter
What is a common filter size for lipids?
Another common filter size is 1.2 microns, which is used for lipids
What kind of filters needed if compounding IV medications packaged in glass ampuiles?
If compounding IV medications packaged in glass ampules, filter needles or filter straws are used to prevent particulates from entering the IV bag and a filter may be required in the line
What are some key drugs that have filter requirements?
Golimumab, Amiodarone, Lorazepam, Phenytoin, Lipids, Amphotericin B, Taxanes (except docetaxel)
What does it mean when a drug is stable?
A drug that is stable will be stable only at a given concentration, for a certain time, at a certain temperature and with a certain degree of light exposure
What is the relationship between chemical reaction that would degrade the drug?
The likelihood of a chemical reaction that would degrade the drug increases with time
What is the relationship between temperature and chemical reactions that break down proteins?
Higher temperatures speed up chemical reactions and break down proteins
*Majority of IV drugs are refrigerated in order to permit longer stability
What are some key medications that should be kept at room temperature?
Dexmedetomidine (Precedex), Bactrim, Phenytoin, Furosemide, Metronidazole, Moxifloxacin, Enoxaparin
What is a potential complication that can be caused by light exposure?
Light exposure causes photo-degradation, which destroys some drugs, and in some cases, increases a drug’s toxicity
What are some strategies to prevent light exposure?
- Some medications are supplied in amber (light-protected) vials, and others are stored in the original packaging
- Can dispense medications that are so light sensitive with a light-protective tubing
What are some key drugs that require light protection during administration?
Phytonadione, Epoprostenol, Nitroprusside, Micafungin, Doxycycline
What are some examples of medications that can be destroyed with shaking?
Hormones, albumin, alteplase, immune globulins, insulins, monoclonal antibodies, rasburicase and some vaccines
What are some medications that can be swirled but not shaken?
Quinupristin/Dalfoprostin (Synercid) and etanercept (Enbrel) form a foam and should only be swirled when reconstituting. Do not shake; wait for the foam to dissolve
What are some examples of medications that solutions should be checked for color changes?
Chlorpromazine, Dacarbazine, Dobutamine, Dopamine, Epinephrine, Isoproterenol, Morphine, Nitroprusside, Norepinephrine, Tigecycline
What color should indicate that Chlorpromazine should not be used and what are some notes about it?
- Darker than slight yellow
- Slight yellow: potency retained, okay to use
What color should indicate that Dacarbazine should not be used?
Pink
What are some notes about Dobutamine?
Oxidation turns the solution slightly pink, but potency is not lost
What color should indicate that Dopamine should not be used and what are some notes about it?
- Darker than slight yellow
- Slight yellow: potency retained, okay to use
What color should indicate that Epinephrine should not be used?
Pink, then brown
What color should indicate that Isoproterenol should not be used and what are some notes about it?
- Pink or darker
- Damaged by air, light, heat
What color should indicate that Morphine should not be used?
Dark
What color should indicate that Nitroprusside should not be used and what are some notes about it?
- Orange –> brown –> blue
- Blue indicates nearly complete dissociation to cyanide
What color should indicate that Norepinephrine should not be used and what are some notes about it?
- Brown or any discoloration
- Normal color: yellow/orange
What color should indicate that Tigecycline should not be used?
Green/black
What is the color of the IV fluid of anthracyclines?
Red
What skin and secretions can be discolored by anthracyclines?
Sweat and urine
What is the color of the IV fluid of Rifampin?
Red
What are some skin and secretions discolored by Rifampin?
Body fluids and teeth
What is the color of the IV fluid of Mitoxantrone?
Blue
What are some skin and secretions discolored by Mitoxantrone?
Skin, eyes, urine
What is the color of the IV fluid of Methotrexate?
Yellow
What is the color of the IV fluid of Multivitamins for Infusion?
Yellow
What is the color of the IV fluid of Tigecycline?
Yellow/orangeq
What skin and secretions can be discolored by Tigecycline?
Teeth
What is the color of the IV fluid of IV iron?
Brown
What can be discolored by IV iron?
Urine
