Download Complications of IV drug Therapy

Intravenous medicine
Administration
Nursing Aspects
September 2009
1
Risk Assessment
• Is the treatment necessary?
• Is there a lower risk alternative?
February 2009
2
Patient assessment
• Ask yourself about the patient, are there any
conditions you will have to note:
• Renal
– Fluid restriction
• Liver
– Fluid restriction
– sodium restriction
• Diabetes
– Dextrose restriction
• High serum sodium
– Normal values? 135-145 mmol/l
February 2009
3
Allergies
• Does the patient have any allergy
• May range from mild itch to full blown
anaphylaxis
•
giving? Do these contain Penicillin?
– Amoxicillin?
– Co amoxiclav (Augmentin)?
– Co-trimoxazole (septrin)?
– Tazocin?
– Gentamicin?
February 2009
4
Prior to preparation
• Staff trained appropriately
– Only those who have completed
NHSGG&C’s training programme and
maintained their professional knowledge
and competence may perform IV medicine
administration
• 2 people check medicine, prescription and
any calculation
• Read information (monograph) before
preparation
2009 area, wash hands
5
• February
Clean
Risk assessment of medicine
• What factors should we
take in to consideration:
– Stability
– Special procedure for
making up
• What else can be drawn
up into the vial?
– Needle size 23g or use
a blunt filter needle
– Reconstitution device
February 2009
6
General Principles for the
Preparation of medicines
• Prepare medicines immediately before use
• Peel wrappers from needles and syringes
• Disinfect all vial/ampoule closures/infusion
ports with 70% alcohol solution and allow to
dry
• Do not add any more than one medicine to any
solution
• No interruptions while prescribing, preparing or
administering medicines
February 2009
7
Recent critical incident
• Patient prescribed clarithromicin
• Nurse prepared
• Interrupted and left syringe with neat
clarithromicin on side with chart
• FY1 asked to give the medicine
• Saw syringe and vial
• Gave undiluted medicine to patient
Always label a medicine if left unattended
If interrupted,
February 2009
and start again.
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Site
Where do you want to give the medicine?
• Peripheral
• Central
February 2009
9
Delivery
How do you want to give it?
• Bolus
• Intermittent
• Continuous
If you are using a pump do you know how it
works? If not...ASK and CHECK
February 2009
10
Important Aspects
The Prescription:
 Clear, legible and signed
 Read carefully
 Question any changes
The Patient:
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Ensure correct patient
Obtain consent from patient
Ascertain allergy history
Know other medication the patient is receiving
Observe response during and after administration
– document any reactions
February 2009
11
Important Aspects
Administration of the medicine:
• Never administer a medicine prepared by
another practitioner when not in their presence
• Check that the medicine has not already been
administered
February 2009
12
Flushing
• 10ml syringes used for flushing
• Flush with sodium chloride 0.9%
solution before, between and after
administration of each medication
unless the medication is not
compatible with NaCl
• Push pause method
• Positive pressure
• Flush must be prescribed or covered
by a PGD
February 2009
13
Complications - Speedshock
• Rapid administration of a medicine
• Toxic levels in the blood
• Floods organs rich in blood, i.e heart,
liver, brain
• Fainting, shock and cardiac arrest
February 2009
14
Complications -Phlebitis
• Irritant medications
• Cannula too big
• Cannula not
secured
February 2009
15
Documentation
• Document
administration
• Document
cannula condition
– phlebitis score
• Document fluid
administered
February 2009
16
Complications -Infiltration
• Leakage of fluid from the vein to the
surrounding tissues.
• Caused by cannula piercing the
vessel wall.
• Pain, paraesthesia, cold
• Prevention?
• Treatment?
February 2009
17
Complications -Extravasation
• Leakage of a vesicant
fluid into surrounding
tissues.
• E.g. cytotoxic, sodium
bicarbonate, phenytoin,
dopamine, calcium chloride,
potassium, amiodarone)
• Treatment
– Stop infusion
– Leave cannula in
– Mark area
– Seek medical advice
February 2009
18
Case study
• Patient prescribed regular vancomicin
• Cannula difficulties mean infusion
rarely completed
• Medicine signed as given on all
occasions
• What effect does this have on blood
levels?
February 2009
19
Emergency treatment of
anaphylactic reactions
See also page 18 of intravenous
medicines self-directed learning
package (adults)
February 2009
20
What is …
• Anaphylaxis is a severe life threatening,
generalized or systemic hypersensitivity
reaction.
• It is characterised by rapidly developing life
threatening airway and/or breathing or
circulation problems
• There are usually skin and/or mucosal
changes
February 2009
21
What causes anaphylaxis
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Stings - 47
Nuts -32,
Food -13
Antibiotics – 27
Anaesthetics drugs – 35
Other drugs – 15
Contrast media – 11
Other – 4
Pumphrey RS suspected triggers for fatal anaphylactic
reactions in UK 1992- 2001
February 2009
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Recognition and treatment
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ABCDE Approach
Treat life threatening problems
Assess effects of treatment
Call for help early 2222
Diagnosis is not always obvious
February 2009
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Airway
• Swelling to the throat or tongue
• Difficulty breathing and swallowing
sensation of throat ‘closing up’
• Hoarse voice
• Stridor
February 2009
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Breathing
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Shortness of breath
Increased respiratory rate
Wheeze
Patient becoming tired
Confusion caused by hypoxia
Cyanosis – a late sign
Respiratory arrest
February 2009
25
Circulation
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Signs of shock – pale, clammy
Tachycardia
Hypotension
Decreased conscious level
Chest pain/ angina
Cardiac arrest
Do not stand the patient up
February 2009
26
Disability
• Sense of impending doom
• Anxiety, panic
• Decreased conscious level caused by
airway, breathing or circulation
problem
February 2009
27
Exposure
• Skin changes – often the first feature
present in over 80% of anaphylactic
reaction.
• Erythema – patchy, generalised red
rash
• Urticaria – hives, nettle rash, weals or
welts anywhere on the body.
• Angioedema – swelling of deeper
tissues e.g eyelids, lips, mouth and/or
throat
February 2009
28
Treatment
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A. Establish airway
B. High flow oxygen
C. IV fluid challenge
Monitor – vital signs and responses to
treatment
• Intra-muscular adrenaline
• Chlorphenamine
• Hydrocortisone
February 2009
29
Intra Muscular Adrenaline
• IM doses of 1:1000 adrenaline (repeat
once after 5 min if no better)
• Adult or child more than 12 years: 500
micrograms IM (0.5 mL)
• Child 6 -12 years: 300 micrograms IM
(0.3 mL)
• Child 6 months - 6 years: 150
micrograms IM ( 0.15)
February 2009
30
Adrenaline
• Caution with Intravenous adrenaline
• For use only by experts.
• For use only on monitored patients
February 2009
31
Fluids
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Once IV access established
500 –1000mL IV bolus in adult
20mL/Kg IV bolus in child
Monitor response - give further bolus
as necessary
• Colloid or crystalloid - 0.9% sodium chloride
or Hartmann’s
• Avoid colloid, if colloid thought to have
• caused reaction
February 2009
32
Steroids and antihistamines
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Hydrocortisone and chlorphenamine
Second line drugs
Use after initial resuscitation started
Do not delay initial ABC treatments
February 2009
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Anaphylaxis
•Recognition and early treatment
•ABCDE approach
•Adrenaline
•Investigate
•Specialist follow up
•Education –avoid trigger
•Consider auto-injector
February 2009
34
• Further information on anaphylaxis is
available at: www.resus.org.uk
February 2009
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