Chapter 23

Principles of drug administration

Intravenous drug administration

Learning outcomes

Having read this chapter, the reader should be able to:

• list the indications for using the intravenous route

• discuss the possible disadvantages of using the intravenous route

• describe each of the different ways that drugs can be administered intravenously

• demonstrate giving an intravenous drug as a bolus and by intermittent infusion

• discuss the role and responsibilities of the midwife when undertaking intravenous drug administration.

Midwives are required to administer intravenous (I.V.) drugs to women, and sometimes babies, and should be trained and assessed as competent in this procedure, with regular updating to maintain this competency (NMC 2012). Intravenous drugs can be given as a small ‘bolus’ or ‘push’, as a large-volume infusion, or via a volume-controlled or patient-controlled infusion device. While antibiotics are the most common I.V. drugs administered, opioids, paracetamol, and uterotonics are examples of other drugs that may be given. This chapter considers the administration of I.V. medication for women as a ‘bolus/push’ or an intermittent infusion and concludes with a discussion on the use of continuous I.V. administration using a syringe-driver and patient-controlled analgesia. Administration of I.V. drugs to the neonate is not discussed. This chapter should be read in conjunction with Chapters 10, 18, 47 and 48.

Indications for I.V. use

• When rapid absorption and effect is required.

• When constant therapeutic blood levels of a drug are required.

• When drugs are contraindicated by other routes, e.g. oral, intramuscular (I.M.).

• Where peripheral perfusion is poor, reducing the effect of drugs administered by injection.

Disadvantages of the I.V. route

• It requires a patent peripheral I.V. cannula which may cause pain in the short-term.

• It is an invasive procedure increasing the risk of infection.

• The rapid absorption of the drug increases the risk for a reaction to the drug to occur.

• There is increased potential for medication errors, e.g. drug and physiochemical incompatibility, particularly if multiple drug infusions are required at the same time and the drugs are able to mix (Bertsche et al 2008, Nemec et al 2008).

• There is increased potential for bacterial or particulate contamination if drugs are being diluted or added to other fluids (Bertsche et al 2008).

Safety concerns

Aceves et al (2013) caution that despite all the improvements in I.V. medication administrations, particularly with advancing technology, there still remains a high-risk for error compared with other forms of drug administration. Shane (2009) suggests that 61% of serious and life-threatening drug errors are related to the administration of I.V. drugs with 73% of I.V. boluses being given too quickly. Cousins et al (2005) found this centred around four areas:

1. Unlabelled prepared drugs that were left for short periods were being administered to the wrong patient.

2. The wrong diluent was used resulting in the powder not dissolving or being inactivated.

3. The drug being given too quickly when administered as a bolus, which can cause phlebitis but may also result in an adverse event for the patient.

4. Loss of patency of the cannula and, more concerning, not adhering to the principles of an Aseptic Non Touch Technique (see Chapter 10 and discussed below).

The Institute for Safe Medication Practice (ISMP) (2015) advise discarding any unattended unlabelled syringes containing any type of solution and recommend that the syringe is always labelled once the drug is drawn up, unless this is done by the patient’s bedside and administered immediately. They also recommend using, wherever possible, medication in a ready-to-administer form (ISMP 2015). However, this is often not possible and it is important to follow the manufacturer’s instructions on which diluent to use (usually water or normal saline 0.9%). Powder must be diluted. If the powder is not dissolving it should be discarded and another dose of the drug and diluent mixed.

To promote safe medication management, the ‘nine rights’ should be checked in relation to the drug, the diluent, and the flush (see p. 145) by two midwives, one of whom must be the administrator of the drug (NMC 2008). Both midwives should ensure they independently check the medical infusion device is set to the correct programme for delivery of the medication (if used).

The cannulation site should be assessed before the drug is drawn up, with signs of infiltration and extravasation looked for (see Chapter 47). The cannula should be confirmed as being patent before administering the bolus as Hall (2015) cautions that accidental injection of drugs into the tissues rather than the vein can result in pain, sloughing of the tissues and abscess formation. If there is any doubt, the cannula should be flushed and if not patent, the cannula should be removed and a new one sited elsewhere if there is still a need for I.V. medication.

Flush

The site should be flushed with 2–5 mL of normal saline before and after the administration of drugs; if more than one drug is given, the cannula should be flushed between drugs to avoid drug incompatibilities (Ansell & Dougherty 2011).

Aseptic Non Touch Technique (ANTT)

It is important to use an ANTT approach to reduce the very real risk of infection occurring (see Chapter 10). An ANTT should be used when reconstituting the drug and when handling the syringe and cannula/needleless port (Key-Parts). The use of gloves will also protect the midwife’s hands from contact with the drug constituents whilst the drug is being drawn up.

Bolus/Push administration (direct intermittent injection)

An I.V. bolus introduces a concentrated dose of a drug through a needless port (often via an extension set) directly into the circulation, usually with a small amount of fluid (Hall 2015). This is useful when there is concern about fluid overload, but the high concentration can also cause a chemical phlebitis, particularly if administered quickly (Scales 2008). The bolus is administered as a ‘push’ as the midwife will physically push the drug through the woman’s cannula. Hall (2015) considers this to be the most dangerous way to administer drugs as they will be absorbed quickly with no time to correct errors. It is important the midwife is aware of the manufacturer’s recommendations for the speed of administration or where these are not available, the local approved guideline should be followed. deWit & O’Neill (2014) caution that no intravenous drug should be administered in less than 60 seconds and Ansell & Dougherty (2011) suggest most drugs would be administered between 3 and 10 minutes but if there are no recommendations regarding the rate of administration, they suggest proceeding slowly over 5–10 minutes. Further advice can be sought from the hospital pharmacist if any doubt exists. It is particularly helpful to give the drug slowly if there is a possibility of an anaphylactic reaction occurring, as this usually happens quickly and it enables the midwife to stop administering the drug (see Chapter 18).

PROCEDURE: ‘push’ administration

• Check that the cannula is patent and has an injection port, preferably a needleless one, attached (and an extension set if used).

• Undertake the thorough checking procedures, as for any medication administration (see Chapter 18).

• Decontaminate hands, clean a plastic tray with the locally approved cleanser to establish a General Aseptic Field, wash and dry hands.

• Gather equipment:

■ the medicine administration chart

■ the drug, including correct solution if it is to be diluted

■ appropriately sized sterile syringes, sterile syringe caps/covers and filter needles

■ non-sterile gloves (ensure the woman does not have a latex allergy)

■ pre-prepared 10-mL sodium chloride 0.9% flush or 10-mL sodium chloride 0.9% ampoule/vial with 10-mL syringe for flushing (or locally approved flushing solution)

■ cleaned plastic tray

■ approved skin cleanser, often 70% alcohol/2% chlorhexidine wipe

■ portable sharps box.

• Wash and dry hands and put on non-sterile gloves.

• Open the plunger end of the syringe packaging, ‘prepare’ the syringe by ensuring that the plunger moves within the barrel. Connect the filter needle firmly, using an ANTT (Key-Parts are the syringe tip and needle hub). Place the connected syringe and sheathed needle onto the tray.

• If a diluent is used:

■ open the diluent by snapping off the top

■ unsheath the needle and insert into the diluent, keeping the end of the needle within the solution to reduce the aspiration of air bubbles

■ draw up the required amount of diluent (Key-Parts are the diluent and needle) by either keeping the ampoule/vial upright on a flat surface or inverting the ampoule/vial and keeping the needle central (McKenna & Lim 2014)

■ place on tray

■ open the drug by snapping off the top, having first ensured all the powder/liquid is at the bottom of the ampoule/vial and insert the needle into the ampoule/vial (Key-Parts are the needle and the ampoule/vial top)

■ gently mix the drug and diluent to ensure the drug dissolves

■ withdraw the volume required (Key-Part is the needle).

• If there is no diluent:

■ open the drug by snapping off the top, having first ensured all the liquid is at the bottom of the ampoule/vial. If a vial is used with a rubber bung, the bung should be cleaned with the approved cleanser for 20 seconds, up and down, side to side, creating friction then left to dry for at least 30 seconds

■ unsheath the needle and insert into the ampoule/vial to withdraw the required amount of drug (Key-Parts are the needle and drug). If the ampoule has a rubber bung McKenna & Lim (2014) recommend air is drawn into the syringe equal to the volume of the drug required, the needle is inserted centrally, and the air injected taking care not to inject into the solution. Keep the needle in the solution to prevent air from being aspirated into the syringe.

• When the required volume of drug is drawn up, invert the syringe and examine it for air. If necessary tap the syringe gently to encourage the air up to the top of the syringe; push the plunger to exclude the air from the syringe, ensuring none of the solution is lost and the dosage in the syringe is correct.

• Remove the needle from the syringe without touching the end of the syringe and place in the sharps box.

• Cover the end of the syringe with a sterile cap/cover without touching the Key-Parts and place on the plastic tray.

• Label the syringe.

• Draw up a flush if required, using the ANTT described above, label and place on the plastic tray.

• Remove gloves and wash and dry hands.

• Take the medicine administration chart, sharps box, approved skin cleanser and tray to the woman.

• With both checkers present, confirm her identity by asking her to state her name and date of birth and checking her identity label with the medication administration chart.

• Decontaminate hands and apply non-sterile gloves.

• Scrub the tip of the I.V. port (Key-Site) with the approved cleanser for 20 seconds, up and down, side to side, creating friction and using different parts of the wipe. Then clean away from the tip using a non touch technique. Leave to dry for at least 30 seconds.

• If present, check the infusion for its smooth running then stop it.

• If using a flush, remove the cap/cover from the syringe containing the flush.

• Attach the syringe to the needleless port and inject half of the flush observing around the cannula site for swelling, then disconnect the syringe, recover with a sterile cap/cover using a non touch technique, and replace onto the tray.

• Remove the cap/cover from the syringe containing the drug.

• Attach the syringe and inject the first 1 mL of the drug according to the manufacturer’s recommendations, observing the woman’s condition throughout (Hayes & Williamson 1998).

■ if an infusion is present, it can be restarted and if no problems are noticed, stop the infusion, and continue to administer the rest of the drug at the correct rate

■ if the infusion fluid is incompatible with the medication, Ansell & Dougherty (2011) recommend stopping the infusion and flushing the line before and after the medication administration and then restarting the infusion