7.6 Intermittent IV Medication Administration (Secondary Medication) and Continuous IV Infusions - Clinical Procedures for Safer Patient Care (2023)

Intermittent intravenous infusion is an infusion of a volume of fluid/drug over a specified period of time at prescribed intervals and then stopped until the next dose is required. Intermittent intravenous medications may be called overlap medications, secondary medications, or minibag medications (see Figure 7.16). Intravenous drugs can be administered in small amounts of sterile IV solution (25 to 250 mL) and infused over a desired period of time (every 4 hours for 30 minutes) or in a single dose. Many medications must be administered slowly to avoid patient harm, and this method of administration reduces the risk of a rapid infusion. Overlapping medication is administered through an established IV line that is held open by continuous IV fluid or irrigation from a short venous access device (saline solution). Always check theparenteral pharmacotherapy manualPDTM to ensure the correct guidelines are followed for each specific drug administered as an IV solution. The PDTM provides guidelines for intravenous drug mixing, amount and type of solution, and infusion rate (Perry et al., 2014).

An intermittent medication can be given by gravity or in an electronic infusion device (EID), also known as an infusion (IV) pump. Many overlapping IV medications must be in an IV pump, which requires special programming and training to avoid medication errors. IV infusion pumps provide strict and soft dose limits and safety practice guidelines to support safe medication administration (Lynn, 2011). Intravenous drugs can also be administered by gravity infusion, in which case the physician must calculate the infusion rate in drops per minute. Best practice for overlapping infusions is to use an IV infusion pump.

A volume controlled set (intermittent infusion) can sometimes be used to administer medication to children, the elderly, or critically ill patients in whom fluid volume is a concern. FORvolume controlled flashing setit is a small device that is placed under the primary infusion to regulate the mini bag. The drug is added to a small amount of IV solution and administered through an IV line (Lynn, 2011).

IV medications are always prepared with the seven rights x 3 according to agency guidelines. Additional guidelines are needed because of the many high-risk events associated with intravenous medications. A PDTM or monograph provides this additional information, including the generic name, trade name, drug classification, and a table defining which parenteral route can be used. Some medications can only be administered by the piggyback method or large volume intravenous solutions, and some medications can be administered diluted over 1-2 minutes. In addition, information on indications, contraindications, dosage (age-dependent), dosing/dilution schemes, side effects, clinical indications (e.g., special monitoring required, must be performed on an IV pump), and compatibility and incompatibility related to reconstitution and primary intravenous solution specifications (Alberta Health Services, 2009).

The Institute for Safe Medication Practices (2014) created a list of high-risk medications that pose a greater risk of significant harm if used incorrectly. Consult the PDTM for specific safety precautions for these drugs. It is important to understand which medications are considered to be at risk before administering them. For a link to the High Risk Drugs List, seeSuggested online resourcesat the end of this chapter. In addition to the seven x 3 rights for drug preparation, Table 7.10 summarizes what must be verified in the PDTM in the preparation and administration of an intravenous drug. As a reminder, the acronym RED CARS may be used.

Special considerations when preparing I.V. Intermittent medications:

• Most intravenous drugs have indications and contraindications, such as: For example, "use with caution in patients allergic to penicillin" or "do not use in patients with low potassium levels" or "watch for side effects in patients with hepatic or renal failure" . Clinical indications may include "must be on a cardiac monitor" or "must only be administered in a specialized area such as ICU and CCU".
• Always prepare medications with the seven rights x 3 when medications are taken out of storage, dumped and put away.
• Many intermittent intravenous medications are prepared in the pharmacy and still require a complete review (seven times x 3) before administration.
• The IV solution bag must be labeled on the medication cart with the patient's name, date, time, medication, dosage, and initials.
• Calculate IV rate (gravity or IV pump) before bed.

Using sterile technique, prepare IV drug per agency guidelines using the PDTM and the seven rights x 3. Many overlapping drugs are prepared in pharmacies and still require full validation (seven rights x 3) prior to administration. Checklist 63 lists steps for administering intermittent IV medication by gravity or IV infusion pump.

Checklist 64 lists steps for administering intermittent IV medication using an existing secondary line, gravity, or IV infusion pump.

Continuous intravenous infusion (drugs)

Acontinuous intravenous infusionis the infusion of a parenteral drug for several hours (continuous drip) to days. It involves adding medication to a sterile IV solution (100 to 1000 mL bags) and then connecting the IV solution as a primary infusion. The continuous drip must be prescribed by the physician and listed on the PDTM as a drug to be administered as a continuous IV infusion. Most continuous intravenous infusions are given over a short period of time. Examples of drugs for continuous intravenous infusion are heparin, insulin R and pantaprazole. Continuous intravenous infusions may come pre-filled from the pharmacy and are labeled with the patient's name; IV solution; volume, quantity and concentration of medication; initials RN; and date and time of preparation (Alberta Health Services, 2009). Always consult the PDTM for guidance on administration, timing and titration of continuous infusions.

An electronic infusion device (EID) must be used to infuse continuous IV medications. Laboratory evaluations and values ​​should be monitored according to PDTM guidelines. A healthcare professional should evaluate maintenance medication for dose, rate, and patency of the IV site and evaluate the patient for medication and therapeutic side effects. The Institute for Safe Medication Practices (ISMP) (2013) recommends that all high-alert medications be independently double-checked for potentially harmful errors before they reach the patient. Independent duplicate tests have been shown to detect up to 95% of errors (ISMP Canada, 2013).