Intravenous infusion (gravity)

Intravenous therapy is now an integral part of the majority of nurses’ professional practice (RCN 2010). The nurse’s role has progressed considerably from being able to add drugs to infusion bags (DHSS 1976) to now assessing patients and inserting the appropriate vascular access device (VAD) prior to drug administration (Gabriel 2005).

Any nurse administering intravenous drugs must be competent in all aspects of intravenous therapy and act in accordance with The Code (NMC 2015), that is, to maintain knowledge and skills (Hyde 2008, RCN 2010). Training and assessment should comprise both theoretical and practical components and include legal and professional issues, fluid balance, pharmacology, drug administration, local and systemic complications, infection control issues, use of equipment and risk management (Hyde 2008, RCN 2010).

The nurse’s responsibilities in relation to intravenous drug administration include the following.

Knowing the therapeutic use of the drug or solution, its normal dosage, side-effects, precautions and contraindications.
Preparing the drug aseptically and safely, checking the container and drug for faults, using the correct diluent and only preparing it immediately prior to administration.
Identifying the patient and checking allergy status.
Checking the prescription chart.
Checking and maintaining patency of the VAD.
Inspecting the site of the VAD and managing/reporting complications where appropriate.
Controlling the flow rate of infusion and/or speed of injection.
Monitoring the condition of the patient and reporting changes.
Making clear and immediate records of all drugs administered (Finlay 2008, NMC 2010b, NMC 2015, RCN 2010).
Evidence-based approaches

Methods of administering intravenous drugs

There are three methods of administering intravenous drugs: continuous infusion, intermittent infusion and direct intermittent injection.

Continuous infusion

Continuous infusion may be defined as the intravenous delivery of a medication or fluid at a constant rate over a prescribed time period, ranging from several hours to several days to achieve a controlled therapeutic response (Turner and Hankins 2010). The greater dilution also helps to reduce venous irritation (Weinstein and Plumer 2007, Whittington 2008).

A continuous infusion may be used when:

the drugs to be administered must be highly diluted
maintenance of steady blood levels of the drug is required (Turner and Hankins 2010).

Pre-prepared infusion fluids with additives such as those containing potassium chloride should be used whenever possible. This reduces the risk of extrinsic contamination, which can occur during the mixing of drugs (Weinstein and Plumer 2007). Only one addition should be made to each bottle or bag of fluid after the compatibility has been ascertained. More additions can increase the risk of incompatibility occurring, for example precipitation (Weinstein and Plumer 2007, Whittington 2008). The additive and fluid must be mixed well to prevent a layering effect which can occur with some drugs (Whittington 2008). The danger is that a bolus injection of the drug may be delivered. To safeguard against this, any additions should be made to the infusion fluid and the container inverted a number of times to ensure mixing of the drug, before the fluid is hung on the infusion stand (NPSA 2007d). The infusion container should be labelled clearly after the addition has been made. Constant monitoring of the infusion fluid mixture (Weinstein and Plumer 2007, Whittington 2008) for cloudiness or presence of particles should occur, as well as checking the patient’s condition and intravenous site for patency, extravasation or infiltration (Downie et al. 2003).

Intermittent infusion

Intermittent infusion is the administration of a small-volume infusion, that is, 25–250 mL, over a period of between 15 minutes and 2 hours (Turner and Hankins 2010). This may be given as a specific dose at one time or at repeated intervals during 24 hours (Pickstone 1999).

An intermittent infusion may be used when:

a peak plasma level is required therapeutically
the pharmacology of the drug dictates this specific dilution
the drug will not remain stable for the time required to administer a more dilute volume
the patient is on a restricted intake of fluids (Whittington 2008).

Delivery of the drug by intermittent infusion can be piggy-backed (via a needle-free injection port), if the primary infusion is of a compatible fluid; this may utilize a system such as a ‘Y’ set or a burette set with a chamber capacity of 100 or 150 mL (Turner and Hankins 2010). This is when the drug can be added to the burette and infused while the primary infusion is switched off. A small-volume infusion may also be connected to a cannula specifically to keep the vein open and maintain patency.

All the points considered when preparing for a continuous infusion should be taken into account here, for example pre-prepared fluids, single additions of drugs, adequate mixing, labelling and monitoring.

Direct intermittent injection

Direct intermittent injection (also known as intravenous push or bolus) involves the injection of a drug from a syringe into the injection port of the administration set or directly into a VAD (Chernecky et al. 2002, Turner and Hankins 2010). Most are administered over a time span anywhere from 3 to 10 minutes depending upon the drug (Weinstein and Plumer 2007, Whittington 2008).

A direct injection may be used when:

a maximum concentration of the drug is required to vital organs. This is a ‘bolus’ injection which is given rapidly over seconds, as in an emergency, for example adrenaline
the drug cannot be further diluted for pharmacological or therapeutic reasons or does not require dilution. This is given as a controlled ‘push’ injection over a few minutes
a peak blood level is required and cannot be achieved by small-volume infusion (Turner and Hankins 2010).
Rapid administration could result in toxic levels and an anaphylactic-type reaction. Manufacturer’s recommendations of rates of administration (i.e. millilitres or milligrams per minute) should be adhered to. In the absence of such recommendations, administration should proceed slowly, over 5–10 minutes (Dougherty 2002).
Delivery of the drug by direct injection may be via the cannula through a resealable needle-less injection cap, extension set or via the injection site of an administration set.
If a peripheral device is in situ, the bandage and dressing must be removed to inspect the insertion of the cannula, unless a transparent dressing is in place (Finlay 2008).
Patency of the vein must be confirmed prior to administration and the vein’s ability to accept an extra flow of fluid or irritant chemical must also be checked (Dougherty 2008).

Administration into the injection site of a fast-running drip may be advised if the infusion in progress is compatible in order to dilute the drug further and reduce local chemical irritation (Dougherty 2002). Alternatively, a stop–start procedure may be employed if there is doubt about venous patency. This allows the nurse to constantly check the patency of the vein and detect early signs of extravasation. If the infusion fluid is incompatible with the drug, the administration set may be switched off and a compatible solution may be used as a flush (NPSA 2007d)

If a number of drugs are being administered, 0.9% sodium chloride must be used to flush in between each drug to prevent interactions. In addition, 0.9% sodium chloride should be used at the end of the administration to ensure that all the drug has been delivered. The device should then be flushed to ensure patency is maintained (Dougherty 2008).

The following principles are to be applied throughout preparation and administration.

Asepsis and reducing the risk of infection

Microbes on the hands of healthcare personnel contribute to healthcare-associated infection (Weinstein and Plumer 2007). Therefore aseptic technique must be adhered to throughout all intravenous procedures. The nurse must employ good hand-washing and drying techniques using a bactericidal soap or bactericidal alcohol handrub. If asepsis is not maintained, local infection, septic phlebitis or septicaemia may result (Hart 2008, Loveday et al. 2014, RCN 2010).

The insertion site should be inspected at least once a day for complications such as infiltration, phlebitis or any indication of infection, for example redness at the insertion site or pyrexia (RCN 2010). These problems may necessitate the removal of the device and/or further investigation (Finlay 2008).

It is desirable that a closed system of infusion is maintained wherever possible, with as few connections as is necessary for its purpose (Finlay 2008, Hart 2008). This reduces the risk of bacterial contamination. Any extra connections within the administration system increase the risk of infection. Three-way taps have been shown to encourage the growth of micro-organisms. They are difficult to clean due to their design, as micro-organisms can become lodged and are then able to multiply in the warm, moist environment (Finlay 2008, Hart 2008). This reservoir of micro-organisms may then be released into the circulation.

The injection sites on administration sets or injection caps should be cleaned using a 2% chlorhexidine alcohol-based antiseptic, allowing time for it to dry (Loveday et al. 2014). Connections should be cleaned before changing administration sets and manipulations kept to a minimum. Administration sets should be changed according to use (intermittent/continuous therapy), type of device and type of solution, and the set must be labelled with the date and time of change (NPSA 2007d, RCN 2010).

To ensure safe delivery of intravenous fluids and medication:

replace all tubing when the vascular device is replaced (Loveday et al. 2014)
replace solution administration sets and stopcocks used for continuous infusions every 96 hours unless clinically indicated, for example, if drug stability data indicate otherwise (Loveday et al. 2014, RCN 2010). A Cochrane review of 13 randomized controlled trials found no evidence that changing intravenous administration sets more often than every 96 hours reduces the incidence of bloodstream infection (Loveday et al. 2014)
replace solution administration sets used for lipid emulsions and parenteral nutrition at the end of the infusion or within 24 hours of initiating the infusion (Loveday et al. 2014, RCN 2010)
replace blood administration sets at least every 12 hours and after every second unit of blood (Loveday et al. 2014, McClelland 2007, RCN 2010)
all solution sets used for intermittent infusions, for example antibiotics, should be discarded immediately after use and not allowed to hang for reuse (RCN 2010)
if administering more than one infusion via a multilumen extension set or multiple ports, be aware of the risk of back-tracking of medication and consider using sets with one-way, non-return or antireflux valves (MHRA 2010a).
Inspection of fluids, drugs, equipment and their packaging must be undertaken to detect any points where contamination may have occurred during manufacture and/or transport. This intrinsic contamination may be detected as cloudiness, discoloration or the presence of particles (BNF 2014, RCN 2010, Weinstein and Plumer 2007). Infusion bags should not be left hanging for longer than 24 hours. In the case of blood and blood products, this is reduced to 5 hours (McClelland 2007, RCN 2010).

Safety

All details of the prescription and all calculations must be checked carefully in accordance with hospital policy in order to ensure safe preparation and administration of the drug(s).

The nurse must also check the compatibility of the drug with the diluent or infusion fluid. The nurse should be aware of the types of incompatibilities and the factors which could influence them. These include pH, concentration, time, temperature, light and the brand of the drug. If insufficient information is available, a reference book (e.g. British National Formulary) or the product data sheet must be consulted (NPSA 2007d, Whittington 2008). If the nurse is unsure about any aspect of the preparation and/or administration of a drug, they should not proceed and should consult with a senior member of staff (NMC 2010a). Constant monitoring of both the mixture and the patient is important. The preferred method and rate of intravenous administration must be determined.

Drugs should never be added to the following: blood; blood products, that is plasma or platelet concentrate (see Chapter 7: Nutrition, fluid balance and blood transfusion); mannitol solutions; sodium bicarbonate solution; and so on. Only specially prepared additives should be used with fat emulsions or amino acid preparations (Downie et al. 2003).

Accurate labelling of additives and records of administration are essential (NPSA 2007d, RCN 2010).

Any protective clothing which is advised should be worn, and vinyl gloves should be used to reduce the risk of latex allergy (Hart 2008). Healthcare professionals who use gloves frequently or for long periods face a high risk of allergy from latex products. All healthcare facilities should develop policies and procedures that determine measures to protect staff and patients from latex exposure and outline a treatment plan for latex reactions (RCN 2010).

Preventing needlestick injuries should be key in any health and safety programme and organizations should introduce safety devices and needle-free systems wherever possible (EU Directive 2010). Basic rules of safety include not resheathing needles, disposal of needles immediately after use into a recognized sharps bin and convenient location of sharps bins in all areas where needles and sharps are used (Hart 2008, MHRA 2004, RCN 2010).

Comfort

Both the physical and psychological comfort of the patient must be considered. Comprehensive explanation of the practical aspects of the procedure together with information about the effects of treatment will contribute to reducing anxiety and will need to be tailored to each patient’s individual needs.

Legal and professional issues

At least one patient will experience a potentially serious intravenous (IV) drug error every day in an ‘average’ hospital. IV drug errors have been estimated to be a third of all drug errors. ‘Fifteen million infusions are performed in the NHS every year and 700 unsafe incidents are reported each year with 19% attributed to user error’ (NPSA 2004, p.1). Between 2005 and 2010, the MHRA investigated 1085 reports involving infusion pumps (MHRA 2011). In 69% of incidents no cause was established. However, of the remaining incidents, 21% were attributed to user error (e.g. misloading of the administration set or syringe, setting the wrong rate, confusing pump type) and 11% to device-related issues (e.g. poor maintenance, cleaning) (MHRA 2011). Syringe pumps have given rise to the most significant problems in terms of patient mortality and morbidity (Fox 2000, MHRA 2010b, NPSA 2003).

The high frequency of human error has highlighted the need for more formalized, validated, competency-based training and assessment (MHRA 2010b, NPSA 2003, 2004, Pickstone 2000, Quinn 2000). Nurses must be familiar with the device they are using and not attempt to operate any device that they have not been fully trained to use (MHRA 2011, Murray and Glenister 2001, NPSA 2003). As a minimum, the training should cover the device, drugs and solutions, and the practical procedures related to setting up the device and problem solving (MHRA 2010b, MHRA 2011, MHRA 2014). Staff should also be made aware of the mechanisms for reporting faults with devices and procedures for adverse incident reporting within their trust and to the MHRA (MHRA 2006b, MHRA 2011).

A useful checklist (Box 12.18) has been produced by the Medical Devices Agency for staff to follow prior to using a medical device to ensure safe practice (MHRA 2010b, MHRA 2014).

The nurse must have knowledge of the solutions, their effects, rate of administration, factors that affect flow of infusion, as well as the complications which could occur when flow is not controlled (Weinstein and Plumer 2007). The nurse should have an understanding of which groups require accurate flow control in order to prevent complications and how to select the most appropriate device for accuracy of delivery to best meet the patient’s flow control needs (according to age, condition, setting and prescribed therapy) (Weinstein and Plumer 2007).

The identification of risks is crucial, for example complex calculations, prescription errors (Dougherty 2002, Weinstein and Plumer 2007) and the risks associated with infusions, such as neonatal risk infusions, high-risk infusions, low-risk infusions and ambulatory infusions (MHRA 2010b, Quinn 2000). The early detection of errors and infusion-related complications, for example over- and underinfusion (Box 12.20), is imperative in order to instigate the appropriate interventions in response to an error or to manage any complications, as serious errors or complications can result in patient death (Dougherty 2002, NPSA 2003, Quinn 2008). Overinfusion accounts for about half of the reported errors involving infusion pumps, with 80% due to user error rather than a fault with the device (MHRA 2014). The use of infusion devices, both mechanical and electronic, has increased the level of safety in intravenous therapy. However, it is recommended that a clearly defined structure for management of infusion systems must exist within a hospital (Department of Health, Social Services and Public Safety 2006, MHRA 2010b, MHRA 2011, NHS Litigation Authority 2013, NPSA 2004).

Activity

Using this learning package along with research and literature local and nationally

Record what a vascular access device (VAD) is?
Record how you would assess this VAD in practice and how and where you would document your findings
If you can find any assessments for doing this bring them to the session to use in the practical session

Additional reading to support learning

PLease click on the following links to provide knoweldge and understanding on assessment, administration and setting up for intravenous infusions

RCN guidance on infusion therapy

BNF: Guidance on infusions

NICE guidance

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