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Intravenous Additives and

Infusion Study Guide.

Clinical Skills Teaching & Learning Centre Written by: Clinical Skills Lecturing Team

Reviewed by: Dr Jamie Fanning, Theme Lead Clinical Examination and Procedural Skills,

University of Liverpool

August 2020

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Contents Glossary ........................................................................................................................................................................ 4

Learning Objectives ...................................................................................................................................................... 5

Year 4 ........................................................................................................................................................................ 5

Introduction .................................................................................................................................................................. 6

Medication safety ......................................................................................................................................................... 7

Preparation ................................................................................................................................................................. 11

Methods of administration ..................................................................................................................................... 11

Intermittent infusion .............................................................................................................................................. 11

Continuous infusions .............................................................................................................................................. 11

Bolus IV injection .................................................................................................................................................... 12

Medication forms ................................................................................................................................................... 12

IV Fluids................................................................................................................................................................... 13

Considerations on when and how to administer drugs ......................................................................................... 14

Patient safety .......................................................................................................................................................... 14

Equipment .............................................................................................................................................................. 15

Administering the infusion ..................................................................................................................................... 17

Procedure ................................................................................................................................................................... 18

Preparation and administration of IV medicated bolus ......................................................................................... 18

Preparation and administration of medicated infusion ........................................................................................ 19

Preparation and administration of IV fluid infusion ............................................................................................... 20

Once you have your drug ready to administer in the correct form; ...................................................................... 21

Gravity infusion....................................................................................................................................................... 22

Infusion devices ...................................................................................................................................................... 23

Infusion pump ......................................................................................................................................................... 23

Syringe driver .......................................................................................................................................................... 24

Summary table ........................................................................................................................................................ 24

Post Procedure ........................................................................................................................................................... 25

Infiltration ............................................................................................................................................................... 25

Extravasation .......................................................................................................................................................... 25

Phlebitis .................................................................................................................................................................. 26

Anaphylaxis ............................................................................................................................................................. 27

Other considerations .............................................................................................................................................. 27

Fluid balance ........................................................................................................................................................... 28

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Documentation ........................................................................................................................................................... 30

Appendix 1 Clinical Skills sharps management for the School of Medicine, Liverpool .............................................. 32

Further Reading .......................................................................................................................................................... 33

References .................................................................................................................................................................. 33

Picture Credits ............................................................................................................................................................ 35

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Glossary

Admixture the action of adding an ingredient to something else Bolus a single dose of a drug administered over a short period of

time Blanching a whitish appearance of skin due to reduction of blood flow to

the area caused by infiltration of fluid into the surrounding tissue

Continuous infusion this is an infusion that is not interrupted and usually given for long periods

Extravasation injury damage to the tissue caused by vesicant drugs leaking into the surrounding tissue

First pass metabolism the reduction of a drugs bioavailability due to extensive biotransformation from passing through the liver, resulting in sub therapeutic drug levels

Infusion a method if introducing products into the circulation Infusion Device a medical device that delivers drugs in fluid form in controlled

amounts at a programmed rate Intermittent infusion this refers to infusions that will be given over short periods of

time Infiltration fluids or non-vesicant drugs has leaked into the surrounding

tissue

Phlebitis inflammation of the vein Patient controlled analgesia (PCA)

a method of patient controlled administration of analgesia

Priming the line filling the administration set with the fluid to be infused prior to administering it to the patient

Reconstitution the process of rehydrating a substance that has been dehydrated

Tracking this is where you are able to visibly see where a vein has become irritated as there is visible inflammation along the vein

TPN total parenteral nutrition, a method of feeding that bypasses the gastrointestinal tract

Vesicant Drugs drugs that can result in tissue necrosis or formation of blisters when accidentally infused into tissue surrounding a vein

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Learning Objectives

Year 4

• To understand the principles of Aseptic Non Touch Technique (ANTT) and its application

in relation to the preparation of intravenous fluids and the delivery of an infusion

• To understand the different infusion methods available

• To be able to assemble and run through an IV line using ANTT principles

• To understand how to reconstitute and administer IV medications

• Understand risks associated with IV administration

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Introduction Some drugs/fluids can only be given by an intravenous (IV) injection or infusion, meaning the

medication is given directly into the vein via different types of access methods such as; an

indwelling cannula, a mid line or central line, please see the cannulation study guide for more

information on these different access devices.

Commonly in hospital we would administer drug / fluid intravenously for:

• Infusion of IV fluids – resuscitation / rehydration or replacement / maintenance.

• IV injection of mediation.

• IV infusion of medications.

• Infusion of Blood and Blood products (this is taught in fifth year).

Some examples of why we would administer medications via the IV route are:

• The drug needs to have an immediate effect.

• Exact blood concentration is needed.

• The drug is not absorbed in the digestive tract.

• First pass metabolism needs to be skipped (allowing the drug to be directly absorbed into

the systemic circulation).

• The GI tract needs to be rested (post surgery).

Through this study guide and with the teaching session we will be teaching you how to prepare

IV fluid and intravenous drugs, we will also teach you the principles of how to administer them.

As a student doctor you are not a registered healthcare professional, meaning that in clinical

practice you are not able to administer IV drugs or fluids (with the exception of a flush for a

cannula as this is classed as a medical device), you can however assist with the preparation

process.

In accordance to the GMC good medical practice guidance; all registered doctors have a duty to

ensure that they maintain their competence, knowledge and skills for any procedure or

examination that they are undertaking. This includes the preparation and administration of any

IV drug or fluid.

NICE (2020) state that, hospitals should establish systems to ensure that all healthcare

professionals involved in prescribing and delivering IV fluid therapy are trained on the principles

covered in these recommendations, and are then formally assessed and reassessed at regular

intervals to demonstrate competence.

Healthcare professionals should receive training and education about, and be competent in,

recognising, assessing and preventing consequences of mismanaged IV fluid therapy.

Hospitals should have an IV fluids lead, responsible for training, clinical governance, audit and

review of IV fluid prescribing and patient outcome.

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All health care professionally have a duty to work together to prevent patient harm. Adverse

medication events are frequently multi-factual in nature and are a common cause of preventive

patient harm. To mitigate the risk of causing a medication error when administering and or

prescribing medication ensure that you follow the WHO (2009) five rights guidance as well as

local trust policy.

Medication safety Ensure that you have checked all of the patient details on the prescription chart, following the

WHO (2009) five rights which are:

• Right patient

• Right route

• Right drug

• Right dose

• Right time

Once the drug has been administered, ensure that it has been signed for on the prescription

chart or electronic equivalent. Some trust require all IV medications to be prepared, given and

signed by two practitioners to try to reduce the incidences of drug errors that may occur.

Before you administer intravenous medication, you must establish how the medication should be

administered. All medications will come with their own administration guidelines from the

manufacturer within the packaging. However, you should ensure that you are following up to date

national guidance for that medication. To do this you must access the online injectable medicines

guidance (also called the Medusa guide), your internal trust will have their own specific link to

this.

Below (figure1) is an example of what the medusa injectable medicines guide should look like.

Your trust should provide you with guidance on how to navigate the website once you have been

logged in (you will not need a login when accessing it through your intranet)

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Figure 1

The online injectable medicines guide will ensure that you are following up to date guidance

regarding the administration of the drug / fluid. You will also find all of the information needed

here on:

• Presentation of the drug/fluid

• Method of administration

• Instructions for reconstitution if needed

• What the drug should be flushed with

• How long/what rate to administer the drug/fluid over

• Interactions/compatibility with other IV drugs/fluids

• Size of vein the drug should be administered via (peripheral or central)

• Any additional considerations such as an additional filter needed (needed for

administration of Phenytoin infusion)

If the drug that you are administering is a Controlled Drug (CD) the drug must be signed out,

prepared and administered by two healthcare practitioners. This is due to CD’s having their own

strict policies for administration.

All intravenous drugs that do not come pre-mixed, but have been either further diluted or had

drugs added to them, must be labelled appropriately, (all clinical areas should have drug labels

available, figure 2) to ensure that everybody is able to know what the drug being delivered is.

To achieve this all drugs must have an appropriate drug label attached to them, there will be

some variations to what information is needed on the drug label but most labels will need as a

minimal

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• The drug

• The dilutant (if any)

• The date it was mixed

• Who mixed it

Figure 2

When administering IV fluids you must be very cautious when selecting the fluids that have be

prescribed as there is a very real possibility of selecting the wrong fluid bag. The fluids come in

very similar packaging and extreme care must be taken to select the correct fluids.

In this example (figure 3) the first bag of fluid is

glucose 5% and the second is glucose 10%. It

would be very easy to select the wrong

concentration of drug here as other than the

wording there is nothing else on the bag

highlighting the different strengths of the drug.

This could easily lead to a drug error and cause

patient harm.

Figure 3

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Many clinical areas have measures in place to ensure that fluids are stored and labelled

separately and clearly to reduce the likelihood of a drug error, other clinical areas may also

require a second checker for any intravenous medication administration.

In this example (figure 4) you can see the safety measure put

in place to make practitioners aware of potentially lethal

drugs that are already added to the fluids, with potassium

being highlighted here due to its potentially catastrophic

effects on the cardiovascular system. This safety measure is

in place to prevent an adverse medication incident

happening.

Figure 4

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Preparation and Patient Safety

Methods of administration

There are three main types of administration of intravenous medication, these are:

• Intermittent infusion

• Continuous infusion

• Bolus IV injection

Intermittent infusion Intermittent infusions are generally used for

1. The administration of a large amount of fluid in an emergency situation

2. Drugs that are given intermittently and generally in small volumes such as IV antibiotics

If it is not a large volume being given for fluid resuscitation, then commonly smaller amounts of

fluid are administered such as 50-100mls. They are administered over a set amount of time up to

120 minutes. The fluid being delivered may have had a drug mixed and added to it or may be pre

mixed and ready to be administered. A common example of an intermittent infusions would be

antibiotics, they may be prescribed to be delivered over 30 minutes to 2 hours and may be once

a day or every four hours for a set amount of time, 48 hours or 7 days etc., dependant on what

they are being used to treat. An intermittent infusion may be used when

• A peak plasma level is required therapeutically.

• The pharmacology of the drug requires this specific dilution.

• The drug will not remain stable for the time required to administer a more dilute volume.

Continuous infusions

Continuous infusions are generally use to deliver a set amount of drug or fluid continually until

the patient no longer needs it. The drug being delivered may be a small amount, such as 2ml/hr

of furosemide or a larger amount such as 125ml/hr of sodium chloride 0.9%. Dependant on the

amount of fluid being delivered the delivery device will be different.

A continuous infusion can be used when

• The drug to be administered must be highly diluted

• Maintenance of steady blood levels of the drug is required

• The patient is dehydrated and needs supplementary fluids

• The patient is NBM prior to surgery

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Bolus IV injection

This is commonly used for small volumes of a drug or fluid that can be given over a shorter

length of time, many drugs can be delivered via the bolus route, some will need to be mixed

first, others will come ready to draw up and be delivered straight away. Two commonly used

bolus drugs are sodium chloride 0.9%, which is used to ‘’flush’’ the access device before and

after administration of the drug and antibiotics which can be up to 10-20 millilitres dependant on

the drug. Some are able to be delivered rapidly whilst others need to be delivered slowly over 3-

10 minutes. A bolus may be used when

• A specific concentration of the drug is needed

• The drug cannot be further diluted for pharmacological or therapeutic reasons

• A peak blood level is required and cannot be achieved with small volume infusions

Medication forms Medications will come in a wide variety of forms in clinical practice. Not all medications are

stable in a liquid form so they need to be stored in an alternative format, such as a powder

(figure 5), until they need to be used. They will then need to be reconstituted (mixed) with a

dilutant to become a liquid form of medication that we are able to safely administer to a patient.

Here is an example of powder medications, they will need to

be diluted with a liquid to reconstitute the drug into a form

that is acceptable for intravenous administration.

Some drugs come ready prepared, ready-prepared infusions should be used whenever

available. Some examples of commonly used ready-made infusions are Potassium chloride

which is available in a variety of concentrations such as 10, 13.3, 20, 27, and 40 mmol/litre in

sodium chloride intravenous infusion (0.9%) and paracetamol (figure 6 right).

Figure 5

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Other medications are in liquid form, they are either ready to

administer (figure 6 right) as they are or may need to be

diluted to reduce their concentration (figure 6 left).

For more information on how to correctly draw up drugs from single vials and multiple and

single use ampoules then please see the separate injection study guide.

Many pre filled syringes are also available for bolus infusions of drugs, particularly emergency

drugs such as adrenaline 1 mg/10 ml 1:10,000 and atropine sulphate (figure 7) 1mg/5ml

Figure 7

IV Fluids Ensure that when you select you IV fluids for administration you are also checking:

• Ensure that the fluid is the correct fluid prescribed

• It’s the correct amount of fluid prescribed

• The correct amount of pre added drug if already pre mixed

• The fluid is in date

• The fluid bag is intact and there are no signs of tampering to the fluid

• There are no signs of debris in the fluid bag

• The fluid does not look discoloured (Gelofusion has a green/yellow colour normally)

Figure 6

Figure 8

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Considerations on when and how to administer drugs With drug reconstitution once the product has been reconstituted, addition to the infusion fluid

should be made immediately in order to minimise microbial contamination and, with certain

products, to prevent degradation or other formulation change which may occur

With drug addition to infusions it is important to mix thoroughly; additions should not be made to

an infusion container that has been connected to an administration set, as mixing is hampered.

If the solutions are not thoroughly mixed a concentrated layer of the drug may form owing to

differences in fluid density. However you may find that certain cytotoxic drugs are the exception

to this rule.

You may see some infusions being administered with a cover over them, this is due to certain

injections having to be protected from light during continuous infusion to minimise oxidation, e.g.

dacarbazine and sodium nitroprusside.

(BNF 2020)

Patient safety Ensure that you are in an appropriately clean area with adequate space and lighting to prepare

any medications.

On first meeting a patient introduce yourself and confirm that you have the correct patient with

their name and date of birth on either the paper or electronic prescription chart. If available

please check this with the name band, written documentation and the NHS number/ hospital

number/ first line of address.

Ensure that you have asked the patient if they have any drug allergies, never assume that the

prescription chart is correct. Check the prescription chart using the WHO five rights.

Ensure the procedure is explained to the patient in terms that they understand and gain

informed consent.

This procedure is not deemed to be intimate in nature, so a chaperone is not needed.

As you are adhering to the principles off ANTT Gloves and apron should be worm as per trust

policy. You must also ensure good hand hygiene by washing your hands before and after

touching the patient.

Ensure that you are familiar with local trust policies regarding the safe disposal of sharps.

If you sustain a needle stick injury whilst performing any procedure, ensure that you follow your

local trust policy and fill out any necessary documentation to report the injury. Appendix 1

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Prior to administering any medication via a peripheral access device, the patency of the devise

and the device itself needs to be assessed. When assessing a cannula the visual infusions

phlebitis score (VIP) should be used, the cannula should be flushed to ensure patency. For

more information on this please see the separate cannulation study guide.

Equipment Most fluid bags have two ports, one is to drive the spigot of the administration set into the fluid

bag, and the other port is where additions are added to the fluids, this port self-seals after the

drug has been added to the fluids.

Figure 9

Ensure that you have selected the correct administration set for the pump you will use, the

below administration set is one use for gravity infusions and infusion pumps.

The spigot from

the giving set is

inserted here

once the cap is

snapped off

Drugs are

injected

here

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Figure 10

This administration set is for the administration of blood, it has a double chamber and will have

a filter in it. This is a safety mechanism to ensure no blood clots are infused into the patient.

Figure 11

Please be aware that not all blood products should be administered with a blood giving set,

follow local guidance.

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If the drug to be administered is via a fluid administration set, then you must ensure that you

have primed the administration set prior to giving the infusion. This is to ensure that there is no

issue with the integrity of the giving set and to ensure that the patient is not given an air

embolus.

Administering the infusion Best practice when administering infusions is to deliver them via an appropriate infusion device,

however in clinical practice you may see fluids being administered via an administration set with

a calculated drip rate per hour, dependant on how long the fluids have been prescribed over. If

the fluids have additives in them already or if any additives are mixed to the fluids, then an

infusion device must be used. You may hear the infusion devices being called different names

in clinical practice, so please ensure you are aware of what your clinical area will call the

different devices.

You may see some clinical areas using an air inlet when

administering drugs from a rigid container (such as

paracetamol from a glass container), the air inlet is inserted

into the bung as well as the administration set, the air inlet

is needed to break the vacuum and allow fluid to flow.

Some administration sets (see figure 13)

come with an air inlet on the actual

administration set, so there is no need to

add a separate air inlet.

Figure 13

Figure 12

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Procedure The sequence of administering IV medication is done after gaining consent and performing

patient safety checks.

1. Clean preparation surfaces.

2. Washes hands using Ayliffe technique.

3. Prepares equipment, including checking expiry dates.

4. Dons personal protective equipment.

5. Mixes the Intravenous medication dependant on which form administering

6. Change PPE if not at patient bedside.

7. Flush infusion device (before and after if bolus) and administer medication.

8. Dispose of sharps immediately.

9. Sign for medication.

Preparation of bolus IV Injection

Figure 14

1. Withdraw the amount of dilutant you need to reconstitute the drug.

2. Insert the fluid into the ampoule.

3. Gently insert the fluid into the powder in the ampoule.

4. Withdraw the needle and syringe whilst gently agitating the ampoule. Discard used

needle and place fresh needle onto the syringe.

5. Allow appropriate time for the powder and fluid to mix.

Steps 1-4

covered

previously

1 2 3 4 5

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Figure 15

6. Insert the needle and syringe back into the reconstituted drug.

7. Withdraw the drug into the syringe.

8. Either change the needle for a fresh one if this is to be a bolus otherwise follow the steps

below to add to a fluid bag.

9. Ensure you label the syringe in administering a bolus IV injection

Preparation and administration of medicated infusion Once the medication has either been mixed and drawn up, or drawn up neat, you can now add

the drug to the fluid.

Figure 16

1. Line the drawn up medication with the bung for drug administration

2. Insert the needle fully into the fluid bag and add the drug

3. Ensure that you invert the fluid bag a few times to ensure the drug has been thoroughly

mixed

4. Label the fluid bag correctly with the additional drugs added

6 7 8

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5. Then follow the process below to insert the administration set and prime the line.

Preparation and administration of IV fluid infusion

Figure 17

Before you start to prepare any infusions always ensure that you have washed your hands and

are wearing appropriate PPE.

1. Gather equipment and check integrity, expiration dates etc.

2. Open packaging and place onto a clean preparation surface (ensure you are protecting

the key parts throughout).

3. Open the administration set.

4. Unravel the administration set to ensure it is not tangled.

5. Roll the clamp down to the closed position.

6. Snap of the cover of the spigot port.

7. Remove the protective cover from the spigot and insert into the port.

8. Gently squeeze and release the chamber of the administration set, this ensures there is

no air in the chamber. There will be a line on the chamber indicating how much fluid you

should squeeze into it.

1 2 3 4

5 6 7

8

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Figure 18

9. Hang up the fluid bag, open the roller clamp and allow the fluid to run through the

administration set until there is no air left in the tube.

Once you are next to the patient

10. Hang the fluid bag up and load into the infusion device if using one.

11. Clean the port on the cannula as per trust policy.

12. Flush the cannula with an appropriate flush.

13. Remove the cover from the administration set connection.

14. Connect to the cannula.

15. Open the roller clamp using it to adjust the rate of infusion or fully open the roller clamp if

an infusions device is being used.

Once you have your drug ready to administer in the correct form;

• Ensure that all of the drugs are labelled correctly.

• Draw up enough appropriate flushes for the access device (if the drug is being

administered for a long period you would draw up another flush to administer when the

infusion has finished).

9 10 11 12

13 14 15

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• Remove all dirty PPE.

• Go to the patient’s bed side, check the patients ID, wash hands and apply fresh PPE.

• Cleans the port on the cannula or access device for 30 seconds then allow it to dry for 30

seconds.

• Ensure the patency of the cannula by flushing it with an appropriate flush.

• Connects the giving set or the bolus syringe to the cleaned port.

• Administer medications as per guidance and prescription.

• Flushes the cannula after the medication has been administered.

• Ensure ANTT is followed at all times and that key parts are not contaminated.

• Checks that the patient has no discomfort or signs of infiltration or extravasation during

and post procedure.

• End procedure, remove PPE and signs the prescription chart.

Gravity infusion This system depends entirely on gravity to deliver the infusion. The

system consists of an administration set (otherwise known as a giving

set) that has a drip chamber and roller clamp to control the flow,

usually measured by counting the drops.

The drop rate will vary depending on the type of administration set

used. The number of drops per millilitre is dependent on the type of

administration set used and the viscosity of the infusion fluid. Increased

viscosity increases the size of the drop. For example, crystalloid

administered via an administration set is delivered at a rate of 20

drops/ml whereas packed red cells administered with a blood

administration set will be calculated at 15 drops/ml, due to the viscosity of the fluid. The drop

rate will be printed on the packaging of the administration set.

Volume to be infused

X

Drop rate

= Drops per minute

Time in hours 60 minutes

(Doherty & Lister 2015)

1000 ml X 20 = 33.3333333 (round to 33 drops per minute)

10 60

In this example 60 minutes is the conversion of the number of hours into minutes.

Figure 19

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Another way to work it out is

Total volume (ml) X Drop rate = Drops per minute

Time (min)

1000 ml X 20 = 33.3333333 (rounded to 33 drops per minute)

600

Infusion devices Infusion devices use pressure to overcome resistance along the fluid path to administer a set

amount of fluid per hour, they are also capable of accurate delivery of medication over a variety

of flow rates. If there is an issue with the pressure in the administration set, such as kinking in

the line or the fluid bag or syringe is empty, the pump will alarm to indicate that there is a

problem with the administration of the drug and stop the infusion. The infusion pumps will also

recognise if there is air in the administration set thus ensuring that an air embolus is not

administered to the patient. There are a variety of infusion devices you may see in clinical

practice, here are some of the most commonly used.

Infusion pump An infusion pump draws fluid from a standard

bag of intravenous fluid and controls the rate

of flow. It provides accurate and continuous

therapy. Because it can use any size of bag of

intravenous fluids, an infusion pump can be

used to deliver fluids at either a very slow or a

very fast infusion rate. Infusion pumps are

generally used for large volumes of fluid,

however they can be used for IV antibiotics

which are smaller volumes. Some pumps are

able to control a single intravenous line,

whereas, other pumps have 3 pumps built into one device. These triple pumps are used to save

space.

Figure 20

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Syringe driver

A syringe driver (sometimes called syringe

pump) is a different type of infusion device.

Instead of drawing fluid from an infusion bag,

intravenous medications are drawn into a

syringe and driven by a pump into the patient.

Because a syringe pumps contain a maximum

delivery of 50ml, syringe pumps are used to

deliver medication that have a small volume.

Syringe pumps are used for patient controlled

analgesia (PCA) delivery however they require a dedicated syringe driver (not seen in figure 18)

that encases the driver of the pump.

You may also see the syringe driver on the right in clinical

practice. These are more commonly used in palliative care

patients and are subcutaneous not intravenous, they run on

a 20 ml syringe and are battery driven not mains controlled.

Follow link here for examples on how to load a pump

Summary table Infusion

device

Appropriate

if additives

are in the

fluid

Mains /

Battery

power

driven

Continual

infusions

Strict

infusion

rate

needed

Fluid

infused

does not

need to be

strictly

precise

Patient

triggered

Gravity

Infusion

(no pump)

✓ ✓

Infusion

pump

✓ ✓ ✓ ✓

PCA ✓ ✓ May also

have

✓

Syringe

drivers

✓ ✓ ✓ ✓

Figure 21

Figure 22

https://www.bd.com/en-uk/about-bd/video-gallery?video=4328013294001

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Post Procedure

Infiltration Infiltration is commonly caused by non-vesicant

drugs leaking into the surrounding tissue. This is

caused by the tip of the cannula no longer being in

the lumen of the vein. This can be prevented by

ensuring that an IV line is flushed prior to its use to

ensure patency, if the line is no longer in the vein,

there will be an obvious accumulation of fluid in the

surrounding tissue, the tissue will also feel cold as

the fluid will be room temperature rather than body

temperature. If there is any infiltration, the line must

not be used and a new cannula must be sited.

Gentle pressure with gauze on the affected area

should allow the fluid to be absorbed back into the

tissue. If there is a large amount of fluid that has

been absorbed this must be reported immediately

as the patient may be at risk of developing

neurological damage.

Extravasation

This can be caused in a similar manner to

infiltration, where the line is no longer in

the vein, or where the needle used to

insert the line punctured both sides of the

vessel wall, allowing drugs to leak out

from the vessel. If the medication is

leaking out into the surrounding tissue,

then there will be a reduced uptake of the

medication, this is particularly an issue in

sedation medication as it will cause a

prolonged medicinal sedation affect. The

initial response of the surrounding tissue

will be localised vasoconstriction, this will

in turn decrease the blood flow to the tissue (mild irritation as seen in the image). If this vascular

constriction is prolonged or the drug is irritating enough, necrosis and sloughing of the tissue

may occur. Careful monitoring of the surrounding area should follow any known extravasation

injury. Please be aware that some cytotoxic drugs can cause a delayed extravasation injury,

patients should be aware of what signs and symptoms to look out for following cytotoxic drug

administration.

Figure 23

Figure 24

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Signs of infiltration/extravasation:

• Pain or tenderness around the IV site.

• Swelling around the site.

• Blanching (lighter skin around the IV site).

• Redness around the site.

• IV not working.

• Cool skin temp around the site.

Phlebitis Cannula related phlebitis is caused by the

inflammation of the tunica intima of a superficial

vein. The inflammation of the tunica intima is

caused by either chemical, bacterial or mechanical

sources. If left untreated it can lead to infection or

thrombus formation. Chemical phlebitis is caused

by the drug or infusion being infused through the

vein. Bacterial phlebitis is caused by the

introductions of bacteria into the vein. Mechanical

phlebitis often occurs when the size of the cannula

that has been inserted into the vein it too big. Signs

of phlebitis are erythema and oedema along the

venous tract, all cannulas should be regularly

checked for any signs of phlebitis using the VIP

score, if there are any signs then the cannula

should be removed and re-sited as soon as

possible.

Signs of phlebitis:

• Pain and tenderness around the IV site.

• Redness following the course of the vein (tracking).

• Bulging of the vein.

Figure 25

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Anaphylaxis

As with any medication, there is always a risk

that the patient may be allergic to it, especially

if the patient has not been exposed to the

medication beforehand. Always ensure that

you have checked the patient’s allergy status

prior to administering any medication. Always

ensure that you are aware of where the

emergency trollies are in your clinical area and

how to summon the emergency team. If the

patient is showing any signs of Anaphylaxis

you must stop the infusion.

Signs of anaphylaxis

• Rapid onset of illness – Do not underestimate how quickly it can occur

• Hoarse voice

• Urticarial rash – itchy

• Vomiting/ abdominal pain/ diarrhoea

• Inspiratory stridor.

• Upper airway compromise (noisy breathing/ increased respiratory rate) - SpO2 will fall

• Expiratory wheeze. Lower airway, alveoli collapsing - SpO2 will fall

• Oedema around the face, lips and airways (stridor) - SpO2 will fall

• Cardiovascular collapse - SpO2 will fall/ be unrecordable

• Loss or diminished consciousness

Ensure you follow the resuscitation Council guidelines on Anaphylaxis treatment.

Other considerations • Line care – ensure you are performing a VIP on every cannula you see.

• Infusion checks – regular pump and fluids being delivered via gravity infusions checks

should be performed to ensure the infusion is being administered at the correct rate and

is not causing any of the above complications.

Figure 26

28

• Repeat bloods – certain drugs such as Gentamycin require bloods to be taken to ensure

the drug is having the required therapeutic effect

• Clinical observations – certain drugs require an increase in clinical observations as the

may have undesirable effects on the patient, blood transfusions require set observations

to be taken.

• Rate changes – some drugs will need to have rate changes, a patient who is having a

variable rate insulin infusion may need their rate to be changed depending on their blood

sugars.

Please also be aware that medications can cause patients to have unwanted medication

reactions such as

• Tachycardia

• Hypertension

• Arrythmia

• Rash

If your patients condition changes or they display any new symptoms that are isolated and you

are sure are not due to the patient developing anaphylaxis thaen refer to the BNF/online

injectable medicines guide to establish if the medication you have adminustered is the cause of

the condition change.

Fluid balance Some patient may be placed on a fluid balance chart (figure 27). This can be due to many

reasons such as:

• On a fluid restriction due to heart failure

• Patient has sepsis

• Patient has a poor oral intake

• Patient is in ITU

If the patient is on a fluid balance chart, you must ensure that any fluid you administer to the

patient, including flushes, are charted on the fluid balance so their input/output can be

monitored closely.

29

Figure 27

30

Documentation Always ensure that you have documented the procedure thoroughly. Ensure that you have

signed for any medication administered and documented on the patency and VIP score of the

cannula used. Below are two examples of prescriptions chart used for IV medication (fig 28) and

IV fluids (fig 29) ensure that you have signed for the drug/fluid correctly once it has been

administered as highlighted.

Figure 28

31

Figure 29

32

Appendix 1 Clinical Skills sharps management for the

School of Medicine, Liverpool If you sustain a sharps injury in clinical practice, please also adhere to Trust policy, if you

sustain an injury in CSTLC, such as in the Learning Zone please also adhere to the CSTLC

policy.

Remove

• Remove sharp

• Sharps with unknown contaminants may need to be retained for analysis

Sqeeze it

• Squeeze the site to make it bleed

Wash it

• Wash the site thoroughly with soap under running water

• Do not scrub

Dry it

• Dry the site thoroughly

Dress it

• Apply a dressing to the site

Report it

• Report the injury to your supervisor and manager of the clinical area

• Dr Beddoes(ebeddoes@liv.ac.uk) must be emailed with all injuries sustained in clinical practice.

Document it

• Complete an incident form

• Attend Occupational Health or Accident and Emergency Department

33

Further Reading For further advise on how to recognise and treat patient with anaphylaxis follow the below link

which will take you to the RC UK page for further up to date guidance on Anaphylaxis.

https://www.resus.org.uk/anaphylaxis/emergency-treatment-of-anaphylactic-reactions/

Medusa online injectable medication further reading link,

https://medusa.wales.nhs.uk/docs/Use%20of%20IV%20%20Monograph%20&%20headings%2

0'help'%20text%20-%20adult%20IV%20%20Sept%2017%20mastercopy.pdf

BD Alaris™ GP-loading Alaris GP

https://www.bd.com/en-uk/about-bd/video-gallery?video=4328013294001

References British National Formulary (2020) guidance on intravenous infusions. Available at:

https://bnf.nice.org.uk/guidance/guidance-on-intravenous-infusions.html Accessed: 10

February 2020).

Chernecky, C., Butler, S.W., Graham, P. & Infortuna, H. (2002) Drug Calculations and Drug

Administration. Philadelphia: W.B. Saunders.

Dougherty, L. (2002) Delivery of intravenous therapy. Nursing Standard, 16(16), 45-56.

Dougherty, L. and Lister, S. E. (2015) The Royal Marsden manual of clinical nursing

procedures. Ninth edition. Wiley Blackwell (Online access with purchase: Askews (Medicine)

(Annual limit multiple access) (DDA)). Available at: https://search-ebscohost-

com.liverpool.idm.oclc.org/login.aspx?direct=true&db=cat00003a&AN=lvp.b5097911&site=eds-

live&scope=site (Accessed: 7 August 2020).

Malamed, S. Sedation: A Guide to Patient Management. [ClinicalKey Student]. Retrieved from

https://clinicalkeymeded.elsevier.com/#/books/9780323400534/

Hyde, L. (2008) Legal and professional aspects of IV therapy. In: Dougherty, L. & Lamb, J. (eds)

intravenous therapy in nursing practice, 2nd edn. Oxford: Blackwell Publishing.

RCN (2010) standards for Infusion Therapy, 3rd edn. London: Royal College of Nursing.

MHRA (2010b) Device Bulletin Infusion Systems. DB 2003 (02) v2.0 November. London:

Medicines and Healthcare Products Regulatory Agency.

MHRA (2011) Report on Devices Adverse Incidents in 2010. DB2011(02). Available at

www.mhra.gov.uk/home/groups/dts-bs/documents/publications/con129234.pdf

https://www.resus.org.uk/anaphylaxis/emergency-treatment-of-anaphylactic-reactions/https://medusa.wales.nhs.uk/docs/Use%20of%20IV%20%20Monograph%20&%20headings%20'help'%20text%20-%20adult%20IV%20%20Sept%2017%20mastercopy.pdfhttps://medusa.wales.nhs.uk/docs/Use%20of%20IV%20%20Monograph%20&%20headings%20'help'%20text%20-%20adult%20IV%20%20Sept%2017%20mastercopy.pdfhttps://www.bd.com/en-uk/about-bd/video-gallery?video=4328013294001https://www.bd.com/en-uk/about-bd/video-gallery?video=4328013294001https://bnf.nice.org.uk/guidance/guidance-on-intravenous-infusions.htmlhttps://search-ebscohost-com.liverpool.idm.oclc.org/login.aspx?direct=true&db=cat00003a&AN=lvp.b5097911&site=eds-live&scope=sitehttps://search-ebscohost-com.liverpool.idm.oclc.org/login.aspx?direct=true&db=cat00003a&AN=lvp.b5097911&site=eds-live&scope=sitehttps://search-ebscohost-com.liverpool.idm.oclc.org/login.aspx?direct=true&db=cat00003a&AN=lvp.b5097911&site=eds-live&scope=sitehttp://www.mhra.gov.uk/home/groups/dts-bs/documents/publications/con129234.pdf

34

Loveday, H.P., Wilson, J.A., Pratt .R.J., Golsorkhi. M. Tingle, A. Bak, A. Browne, J. Prieto, J.

Wilcox, M. (2014) epic3: National Evidence-Based Guidelines for Preventing Healthcare-

Associated Infections in NHS Hospitals in England. Available at

https://improvement.nhs.uk/documents/847/epic3_National_Evidence-

Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdf

NICE (2016) Intravenous fluid therapy in adults in hospital

https://pathways.nice.org.uk/pathways/intravenous-fluid-therapy-in-

hospital#path=view%3A/pathways/intravenous-fluid-therapy-in-hospital/intravenous-fluid-

therapy-in-adults-in-hospital.xml&content=view-node%3Anodes-principles-and-protocols

WHO (2009); WHO guidelines on hand hygiene in Health Care; https://www.who.int/infection-

prevention/tools/hand-hygiene/en/ [Accessed 13/02/2020]

World Health Organization. (2009). WHO patient safety curriculum guide for medical schools.

WHO https://www.who.int/patientsafety/education/curriculum/who_mc_topic-11.pdf

https://improvement.nhs.uk/documents/847/epic3_National_Evidence-Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdfhttps://improvement.nhs.uk/documents/847/epic3_National_Evidence-Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdfhttps://pathways.nice.org.uk/pathways/intravenous-fluid-therapy-in-hospital#path=view%3A/pathways/intravenous-fluid-therapy-in-hospital/intravenous-fluid-therapy-in-adults-in-hospital.xml&content=view-node%3Anodes-principles-and-protocolshttps://pathways.nice.org.uk/pathways/intravenous-fluid-therapy-in-hospital#path=view%3A/pathways/intravenous-fluid-therapy-in-hospital/intravenous-fluid-therapy-in-adults-in-hospital.xml&content=view-node%3Anodes-principles-and-protocolshttps://pathways.nice.org.uk/pathways/intravenous-fluid-therapy-in-hospital#path=view%3A/pathways/intravenous-fluid-therapy-in-hospital/intravenous-fluid-therapy-in-adults-in-hospital.xml&content=view-node%3Anodes-principles-and-protocolshttps://www.who.int/infection-prevention/tools/hand-hygiene/en/https://www.who.int/infection-prevention/tools/hand-hygiene/en/https://www.who.int/patientsafety/education/curriculum/who_mc_topic-11.pdf

35

Picture Credits

Figure 1: Medusa online injectable medicines guide, Charing Cross hospital

Figure 2: Medication labelling copyright CSTLC

Figure 3: Assortment of fluids copyright CSTLC

Figure 4: Assortment of fluids copyright CSTLC

Figure 5: Drug forms copyright CSTLC

Figure 6: Drug forms copyright CSTLC

Figure 7: Drug forms copyright CSTLC

Figure 8: Assortment of fluids copyright CSTLC

Figure 9: Fluid bag ports copyright CSTLC

Figure 10: Administration sets copyright CSTLC

Figure 11: Blood administration set copyright CSTLC

Figure 12: Air inlet Public Domain, https://commons.wikimedia.org/w/index.php?curid=23321521

Figure 13: Infusion set with air inlet (2020). BD available at https://www.bd.com/en-

us/offerings/capabilities/infusion-therapy/iv-administration-sets/iv-gravity-and-secondary-

sets/secondary-administration-sets (Accessed: 06/08/20)

Figure 14 & 15: Preparation of IV Bolus injection. Copyright CSTLC

Figure 16: Preparing and administration of medicated infusion. Copyright CSTLC

Figure 17: Preparation and administration of IV fluid. Copyright CSTLC

Figure 18: Flushing the Cannula. Copyright CSTLC

Figure 19: Fluid on a drip stand. Copyright CSTLC

Figure 20: Pumps by I, Broken Sphere, CC BY-SA 3.0,

https://commons.wikimedia.org/w/index.php?curid=3460719 & Copyright CSTLC

Figure 21: Pumps. Copyright. CSTLC

Figure 22: Pumps. Copyright. CSTLC

Figure 23: Clinical skills Ltd (2020). Flush the cannula b. Available at:

https://www.clinicalskills.net/sites/default/files/atoms/files/INTRAVENOUS%20INFUSIONS%20

PROBLEM%20SOLVING%20P1-3%20300517.pdf (Accessed: 15/07/20).

Figure 24: Clinical skills Ltd (2020). Extravasation. Available at:

https://www.clinicalskills.net/sites/default/files/atoms/files/CARE-AND-MAINTENANCE-OF-A-

PERIPHERAL-IV-CANNULA_P1-P6.pdf (Accessed: 15/07/20).

Figure 25: Phlebitis copyright CSTLC

Figure 26: Anaphylaxis Garrett, Jackie P.D., Netter's Pediatrics, 18, 108-113Anaphylaxis.

Copyright © 2011 Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

https://commons.wikimedia.org/w/index.php?curid=23321521https://commons.wikimedia.org/w/index.php?curid=23321521https://www.bd.com/en-us/offerings/capabilities/infusion-therapy/iv-administration-sets/iv-gravity-and-secondary-sets/secondary-administration-setshttps://www.bd.com/en-us/offerings/capabilities/infusion-therapy/iv-administration-sets/iv-gravity-and-secondary-sets/secondary-administration-setshttps://www.bd.com/en-us/offerings/capabilities/infusion-therapy/iv-administration-sets/iv-gravity-and-secondary-sets/secondary-administration-setshttps://commons.wikimedia.org/w/index.php?curid=3460719https://www.clinicalskills.net/sites/default/files/atoms/files/INTRAVENOUS%20INFUSIONS%20PROBLEM%20SOLVING%20P1-3%20300517.pdfhttps://www.clinicalskills.net/sites/default/files/atoms/files/INTRAVENOUS%20INFUSIONS%20PROBLEM%20SOLVING%20P1-3%20300517.pdfhttps://www.clinicalskills.net/sites/default/files/atoms/files/CARE-AND-MAINTENANCE-OF-A-PERIPHERAL-IV-CANNULA_P1-P6.pdfhttps://www.clinicalskills.net/sites/default/files/atoms/files/CARE-AND-MAINTENANCE-OF-A-PERIPHERAL-IV-CANNULA_P1-P6.pdf

36

Figure 27: Pinnington,S., Ingleby,S., Hanumapura,P., & Waring,D. Assessing and documenting

fluid balance.Nursing Standarddoi:10.7748/ns.2016.e10432

Figure 28: Example of a prescription chart. Copyright CSTLC

Figure 29: Example of a fluid prescription chart: Copyright CSTLC