Steps

Rationale/Points of Emphasis

1 Record the child’s weight in kilograms (kg) in an easily accessible location on the medical record before administration of cardiovascular medications and daily thereafter.

Most cardiovascular drug dosages are administered in milligrams per kilogram per minute (mg/kg/minute) or micrograms per kilogram per hour (µg/kg/hour). Quick access to body weight (kg) reduces delay in dosage calculation.

caREminder

In collaboration with the healthcare prescriber/pharmacist, dosages should be recalculated daily to reflect changes in body weight. Rapid fluctuations in weight can occur in critically ill children as a result of alterations in fluid status.

2 Perform hand hygiene.

Reduces transmission of microorganisms.

3 Ensure central venous line access.

Central venous access ensures drug delivery and bioavailability to the systemic circulation.

3a Administer infusions of cardiovascular drugs that support heart rate, blood pressure, or cardiac output through a central vein.

Central venous administration provides rapid steady drug delivery.

3b Infusions of vasoconstricting drugs should only be administered through a central vein.

Potent vasoconstricting effects of these drugs can cause tissue ischemia and necrosis if interstitial infusion (infiltration) occurs; central line administration reduces this risk.

3c Administer highly acidic or alkaline drugs through a central vein.

Extreme deviations in drug pH are not adequately diluted in a peripheral vein and could produce vessel erosion; central line administration reduces this risk.

4 Obtain an electronic infusion device or utilize “smart pumps” with built-in software to monitor medication administration.

An electronic infusion device is used to ensure safe, accurate delivery and titration of cardioactive or vasoactive medications. “Smart pump” software technology can reduce medication errors by creating safety guardrails for medication administration.

The pump must provide a constant continuous flow rate, not intermittent boluses of fluid.

5 Verify infusion orders. Orders must include:
5a Concentration—amount of drug per volume of solution
5b Type of IV solution that the drug is to be added to
5c Dosage to be delivered, calculated in

Orders for drug dosages, concentration, and IV solutions or admixtures are verified for accuracy and correct dosing, preparation, and administration instructions. Consult with the clinical pharmacist when necessary with questions regarding individual considerations and drug preparation or administration to ensure safe delivery.

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  Units of delivery (e.g., µg/kg/minute) and

  
  
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  Corresponding infusion rate in milliliters per hour (mL/hour)

6 Verify orders for titration.

Orders for titration are based on desired effect or therapeutic end point. Orders should specify the goal of therapy and clinical parameters for drug titration (e.g., to keep blood pressure greater than 90 mm Hg).

6a Orders must include starting dosage to be delivered, calculated in

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  Units of delivery (e.g., µg/kg/minute) and

  
  
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  Corresponding infusion rate in mL/hour

Dosages are titrated within a prescribed dosage range that includes starting dosage and maximum dosage. Generally, the drug is started at the lowest dose and is then titrated upward to achieve the desired effect.

6b Orders must include maximum dosage drug can be titrated up to, calculated in

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  Units of delivery (e.g., µg/kg/minute) and

  
  
• 
  

  Corresponding infusion rate in mL/hour

Orders must clearly specify the clinical parameters for dose titration. Parameters may include heart rate, rhythm, blood pressure, indicators of tissue perfusion, and measures of preload, afterload, and contractility.

7 Calculate dosage (see Chapter 6 for calculation procedures):

7a For IVP administration, determine duration of administration (e.g., IVP over 3-5 minute). Refer to pharmaceutical manufacturer’s instructions and institutional protocols for appropriate administration time.

Central venous IVP injection times must be strictly followed to prevent untoward reactions.

7b For continuous infusion administration, determine number of mL/hour to deliver desired dose. Preestablished infusion rate tables can be consulted and placed at the bedside for easy reference when titrating dosages.

Reference to pre-established infusion rate tables (available from pharmaceutical manufacturers, pharmacology textbooks, and as software programs) for individual drugs reduces delay in initial dose/rate calculation and in recalculation of rates when titrating dosages.

8 Before administration, verify:

8a Compatibility with other drugs or IV solutions.

Admixture specifications and compatibility requirements must be strictly followed for safe preparation and administration.

8b Time requirement for solution change (e.g., every 24 hours).

Many medications become less stable after 24 hours.

8c Requirements for protection from heat or light.

Some medications must be protected from heat or light to prevent degradation.

8d Integrity of IV solution (check expiration date; inspect for turbidity, discoloration, or particulate matter). Expired or potentially contaminated solutions must be discarded and reported to pharmacy.

8e Other specific requirements for administration or drug monitoring.

caREminder

Refer to pharmaceutical manufacturer’s instructions, institutional standards and protocols, and compatibility charts for specific preparation and administration requirements.

9 Verify all dosage calculations with another nurse or pharmacist before the initiation of therapy or drug titration.

Cochecking reduces the risk for dosage errors.

10 Ensure that the bottle/bag is clearly labeled with drug name. Include date/time hung, and specify date/time to be changed.

Clear labeling reduces the risk of errors. Changing solutions when specified maintains drug effectiveness and reduces the potential for bacterial growth.

11 Flag tubing with name of drug.

Tubes/tubing can become intertwined when multiple IV lines are in place. Clear labeling of each tubing reduces the risk for infusion errors.

12 Ensure that all central line connections are securely connected with locking devices (e.g., Luer-Lock connectors).

Secure connection of all central line tubing ensures drug delivery to the intended location and reduces the risk for air embolization, hemorrhage, and bacterial contamination.

caREminder

Routinely check all IV lines for secure connections throughout the course of therapy.

13 Use only central venous ports intended for drug administration. Appropriate sites include the introducer line or other central venous ports labeled for infusion access. Intracardiac catheters with PAP or LAP ports are intended for hemodynamic monitoring only and are not to be used for drug administration.

Hemodynamic monitoring cannot be interrupted. An inadvertent bolus injection of medication could be administered if a monitoring line is flushed. Most intracardiac catheters for hemodynamic monitoring have central venous infusion port access specifically intended for IV solution or medication administration. Refer to manufacturer’s instructions for medication port access specifications.

14 Verify the medication with the electronic medication record or take the medication record and syringe with bottle/bag of medication and any other IV equipment needed to the child to administer. Verify the child’s identity by comparing name on medication (if verified electronically) or on medication record with the child’s identification band and any other patient identifier required by the institution.

Ensures proper identification of the child utilizing two different patient identifiers (see Chapter 82 ).

15 Administer medication at ordered dosage/rate. Closely monitor the child for expected response, adverse effects, or untoward reactions (refer to Procedure for Assessment and Monitoring of the Child Receiving Intravenous Cardiovascular Medications). Notify the healthcare prescriber when unexpected responses occur.

Knowledge of expected responses and adverse effects is essential to evaluate the drug’s effectiveness and provide safe care.

16 Titrate dosage per order to achieve desired therapeutic response. Closely monitor the child for responses to dosage change with titration (refer to Procedure for Assessment and Monitoring of the Child Receiving Intravenous Cardiovascular Medications). Notify the healthcare prescriber if the desired therapeutic response does not occur within the ordered titration dosage range.

Titration requires frequent close monitoring of clinical parameters to evaluate drug effectiveness and achieve the desired goals of therapy.

17 Continuously monitor the child’s clinical status throughout the course of therapy (refer to Procedure for Assessment and Monitoring of the Child Receiving Intravenous Cardiovascular Medications).

Clinical changes in the child may require dosage readjustment or weaning during the course of therapy. Discontinuation of a drug may be necessary if unexpected or adverse reactions occur or when a therapeutic response is not achieved.