Checklist : Administering Medications Iv Direct Into An Infusing Iv With Incompatible Iv Solution
Disclaimer: Always review and follow your agency policy regarding this specific skill.
- Review the advantages and disadvantages of IV medications .
- Be able to answer the preparation questions for intravenous medication in Table 7.8 before administering the medication.
- If the medication has been diluted and there is wastage, always discard unused diluted portion of the prepared IV medication before going to the bedside.
- Always follow agency policies and guidelines when preparing and administering medications.
- Always label the syringe with 2 patient identifiers, date, time, medication, concentration of the dose, dose, and your initials. Once the medication is prepared, never leave it unattended.
- NEVER administer an IV medication through an IV line that is infusing blood, blood products, heparin IV, insulin IV, cytotoxic medications, or parenteral nutrition solutions.
- Never administer an IV medication into an IV line that isnt patent.
- Check compatibilities of the medication to the primary solution.
- Central venous catheters may require special pre- and post-flushing procedures and specialized training.
- CVCs require at minimum a 10 ml syringe to decrease risk of catheter fracture.
- You will need a clock / watch timer to time the rate of administration.
- Perform hand hygiene before preparing medications.
Administered By Personal Insulin Pump
For patients with type 1 diabetes, a pre-filled insulin cartridge can also be inserted into a personal insulin pump.
This device is permanently worn by the patient and constantly delivers an infusion of insulin, at a rate defined by the user.
Figure: fitting a wearable insulin pump
The cartridge is changed every few days.
In the United Kingdom, only people with type 1 diabetes who meet essential criteria are entitled to a trial of insulin pump therapy.
Did you know? Research with new technology called the artificial pancreas has been shown to be effective in controlling blood glucose concentrations in people with type 1 diabetes, including pregnant women.This system continuously checks blood glucose levels and the calculates how much insulin is required before automatically delivering the correct amount of insulin through the pump. This leads to improved glucose control. For more information, see the guidelines for continuous glucose monitoring in Diabetes UK.
How Do You Give Intravenous Insulin Therapy
Intravenous insulin therapy for managing hyperglycemia requires a well-coordinated protocol in place and combined effort from the various health professionals in the hospital.
- The treating physician determines when IV insulin therapy should be started in consultation with the endocrinologist.
- The nurse administers the IV insulin and monitors the patients sugar levels with measurements at set intervals.
- The dosage is continually adjusted based on the patients sugar levels.
- The patient is weaned from intravenous insulin at the appropriate time.
Most hospitals follow an established protocol for hyperglycemia management in ICU patients, though there may be minor variations in protocols.
Barriers To Implementing A Continuous Insulin Infusion Protocol
Potential barriers to implementing an insulin infusion protocol include fear of hypoglycemia, confusion regarding appropriate glycemic targets, insufficient nurse-to-patient ratios, insufficient availability or convenience of glucose-monitoring devices, lack of administrative support, various system and procedural issues, and resistance to change. Before implementing an IV insulin infusion protocol, it is imperative to evaluate the current glycemic-related practices within the institution and address the following crucial questions: What is the current level of glycemic control? Who is checking patients blood glucose and how often? How interested is the staff in optimizing glycemic control, and do they have the support they need to achieve this goal?
Key steps to overcoming these barriers include building support with multidisciplinary champions, involving key staff members in the process, educating staff and administrators about the benefits of optimizing glycemic control, and internally marketing the clinical success of the protocol. Descriptions of several models of implementation have been published, including endocrinologist consultation models, glycemic control teams, and system-wide models. It is important to adapt whichever model is selected to meet the needs of the specific institution.
Table 77 Advantages And Disadvantages Of Intravenous Medications
Intravenous medications can deliver an immediate, fast-acting therapeutic effect, which is important in emergent situations such as cardiac arrest or narcotic overdose. They are useful to manage pain and nausea by quickly achieving therapeutic levels, and they are more consistently and completely absorbed compared with medications given by other routes of injection. Once an intravenous medication is delivered, it cannot be retrieved. When giving IV medications, there is very little opportunity to stop an injection if an adverse reaction or error occurs. IV medications, if given too quickly or incorrectly, can cause significant harm or death. Doses of short-acting medication can be titrated according to patient responses to drug therapy. Medication can be prepared quickly, and given over a shorter period of time compared to the IV piggyback route. Any toxic or adverse reaction will occur immediately and may be exacerbated by a rapidly injected medication. Minimal dilution is required for some medications, which is desirable for patients own fluid restrictions. Extravasation of certain medications into surrounding tissues can cause tissue damage, nerve damage, and scarring. There is minimal or no discomfort for the patient in comparison to SC and IM injections. Not all medications can be given via the direct IV route. Data source: Albert Health Services, 2009 Lynn, 2011 Perry et al., 2018
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Portland Protocol For Intravenous Insulin
The Portland Protocol targets a glucose level of 125-175 mg/dl and is started for all ICU patients if glucose level is more than 150 mg/dl, even if nondiabetic. Dosage of insulin is based on blood glucose levels, and is changed in proportion with change in levels. A chart specifies the dosage and their adjustments in relation to changes in glucose levels.
The Portland Protocol involves the following steps:
- Blood glucose level check upon admission
- Hemoglobin A1c measurement is taken
- Regular human insulin is mixed with normal saline before administration
- Intravenous insulin is initiated and blood glucose level checked every two hours
- Dextrose is administered in case of hypoglycemia
- If bedside measurement of glucose shows a level below 40 mg/dl or above 450 mg/dl, a confirmatory laboratory glucose test is done
- All patients who remain hyperglycemic should continue the protocol throughout the ICU stay.
- Nondiabetic, euglycemic patients can stop the protocol if target level is maintained with less than half a unit of insulin. The glucose level will be monitored for 24 hours and if the level goes above 150 mg/dl, the insulin protocol will be resumed.
- If diabetic patients continue to need insulin after three days post-surgery, and if their HbA1C is higher than 6% at admission time, further treatment will be designed in consultation with the endocrinologist.
How Insulin Is Supplied
- It can be drawn out of an insulin vial ONLY using an insulin syringe. When injecting insulin, it is important to allow at least 10 seconds before the needle is removed. This helps to ensure that the full insulin dose administered is absorbed. Wet skin at the injection site after the needle is removed could be insulin that has not been absorbed.
Figure: using an insulin syringe to draw insulin out of an insulin vial
- It can be provided as a prefilled pen device, which is disposed of once empty.
- It can be provided as a cartridge that can be loaded into an insulin pen.
Insulin should never be drawn out of a cartridge using a syringeFigure: insulin should never be drawn out of a cartridge using a syringe
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Optimal Range Of Glucose Control
The results of the experience with intravenous insulin and tight glucose control led to a re-examination of the optimal range of glucose control. Although control of hyperglycemia did reduce infection rates, especially after cardiothoracic surgery, a net benefit was tempered by higher rates of hypoglycemia and mortality. The ideal target blood glucose level in the intensive care setting has yet to be established but seems to be less than 180 mg/dL .
The lowest acceptable threshold for serum glucose has not been established. However, given the increased risk of hypoglycemia associated with insulin protocols that sought to control blood glucose levels between 80 and 110 mg/dL, a goal of less than 110 mg/dL cannot be endorsed. This was also the sentiment of a consensus statement that suggested a glucose target of 140-180 mg/dL in critically ill patients however, certain subgroups, such as patients undergoing cardiothoracic surgery, may benefit from a lower target range. Therefore, a glucose target of 110-140 mg/dL may eventually be a more appropriate range for this subgroup and other critically ill patients however, this level of control has not been subjected to rigorous investigation and determined with evidence-based support.
Rationale For Continuous Insulin Infusion
Stress-induced hyperglycemia is a commonly encountered problem in the acute-care setting. Elevated blood glucose levels in critically ill patients may result from the presence of excessive counterregulatory hormones and high levels of tissue and circulating cytokines. These metabolic changes can result in increased insulin resistance and a failure to suppress hepatic gluconeogenesis. Thus, hyperglycemia may be present even in inpatients without a diagnosis of diabetes. Studies have shown an association between hyperglycemia and an increased risk of infection, sepsis, renal failure,congestive heart failure, stroke, and neuropathy. The recognition of hyperglycemia as a contributor to poor outcomes has provided the rationale to pursue tight glycemic control.
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What Is Intravenous Insulin Therapy
Intravenous insulin therapy is a treatment procedure to control high blood sugar in ICU patients. Rapid and efficient control of hyperglycemia improves recovery rates and reduces mortality in critically ill patients.
Intravenous insulin therapy is performed only under medical supervision along with continuous monitoring of blood sugar levels and other vital parameters.
Self-administration of insulin by people with diabetes is always an injection in the fatty tissue under the skin , and never intravenous.
Georgia Hospital Association Intravenous Insulin Protocol
The Georgia Hospital Association Intravenous Insulin Protocol has also been referred to as the Davidson or Glucommander Protocol. The intravenous infusion protocol is for a target of 140-180 mg/dL.
Initial orders are as follows:
Discontinue previous diabetes medications.
Obtain a basic metabolic profile .
Record intravenous fluid . If the patient is receiving nothing by mouth and is not receiving total parenteral nutrition or continuous enteral feedings and has a blood glucose level of less than 250 mg/dL, the intravenous fluid selected and the rate of infusion should have a glucose source of 5 g/hr or more.
Intravenous insulin administration is as follows:
Mix 250 units of regular human insulin in 250 mL of normal saline .
Flush approximately 30 mL through the line prior to administration.
Do not use a filter or filtered set with insulin.
Piggyback the insulin drip into intravenous fluid using an intravenous infusion pump with a capability of 0.1 mL/hr.
Initiate the intravenous insulin flow sheet.
Blood glucose testing is as follows:
Check blood glucose levels initially and then every hour using a finger stick .
Do not alternate sites without physician approval.
After hourly readings remain in the desired range for 4 consecutive readings, testing can be reduced to every 2 hours.
The laboratory must verify as soon as possible all blood glucose readings of less than 40 or more than 500 mg/dL.
Treatment for hypoglycemia is as follows:
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Misadministration Of Iv Insulin Associated With Dose Measurement And Hyperkalemia Treatment
Problem: We are aware of numerous reports of serious errors associated with the misadministration of insulin. These events have involved various types of practitioners, including physician house officers , nurses, and a pharmacist. Human error associated with insulin dose measurement and hyperkalemia treatment was the predominant proximate cause of these events most of the human errors were associated with knowledge deficits regarding insulin concentration , the differences between insulin syringes and other parenteral syringes, and a perceived urgency with treating hyperkalemia.
In the most recent event, a physician ordered IV dextrose 50% injection along with 4 units of regular insulin IV for a patient with renal failure and severe hyperkalemia. However, a nurse drew 4 mL of insulin into a 10 mL syringe and administered the dose IV. The patient became severely hypoglycemic and had to be transferred to a critical care unit for treatment and monitoring.
We also recently became aware of a case in which a patient with hyperkalemia had orders to receive insulin and a 50% dextrose injection, but the patient received only the insulin portion of the treatment and experienced significant hypoglycemia.
Safe Practice Recommendations
Supply insulin syringes. Insulin syringes should be readily available in all patient care units, and steps should be taken to separate insulin syringes from other parenteral syringes so they cannot be inadvertently mixed-up.
What Are Some Other Side Effects Of Insulin Regular Iv Infusion
All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:
- Weight gain.
- Irritation where the shot is given.
These are not all of the side effects that may occur. If you have questions about side effects, call your doctor. Call your doctor for medical advice about side effects.
You may report side effects to the FDA at 1-800-332-1088. You may also report side effects at https://www.fda.gov/medwatch.
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Practical Aspects Of Prescribing Vriii
Withhold usual diabetes treatment during the VRIII but if the patient is on sub-cutaneous background/basal insulin prior to VRIII, continue this whilst on insulin infusion. All other diabetes medication should be withheld.
Actrapid is the most commonly used insulin for VRIII
Always ensure that the substrate is prescribed with VRIII to prevent the risk of hypoglycaemia . Intravenous Insulin infusion should not be administered without substrate unless undertaken in a critical care setting and upon senior advice.
Capillary blood glucose levels CBGs must be monitored hourly whilst on VRIII.
Review the patient within 6 hours to make sure that CBGs are in target range. If the CBGs are persistently above 12 mmol/L and NOT falling upgrade the scale and review again within 6 hours. Check ketones 4 hourly in patients with Type 1 diabetes and at least once in patients with Type 2 diabetes if CBG readings are persistently above 12 mmol/L whilst on VRIII.
Csii Related Adverse Events
The use of CSII is associated with a number of adverse events despite the progress in this technology and can be categorized into perfusion site or catheter problems, cutaneous reactions, metabolic adverse events, and pump software problems. These adverse events are common and can occur in 40% of users per year but they necessitate hospital admissions only in very rare cases . The most serious adverse events are related to metabolic control, particularly diabetic ketoacidosis that can result from perfusion site/catheter failure and prolonged insulin infusion interruption . In a recent online survey including adult patients and examining their perceptions about CSII use, the majority of participants perceived it positively, reporting improvements in glucose control without compromising their quality of life. However, technical issues related to perfusion site, catheter and cutaneous problems were quite common with only 3% of patients reporting no problems of any kind in the past year of use . Other major issues with CSII are the need to carry the pump at all times as well as associated costs leading to limited access and coverage in a lot of countries.
R.C.L. Page, in, 2014
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Drugs For Hormone Disorders
Taking these drugs with insulin regular may cause high blood sugar levels. Examples of these drugs include:
The insulin regular dosage your doctor prescribes will depend on several factors. These include:
- the type and severity of the condition youre using insulin regular to treat
- your age
- the form of insulin regular you take
- other medical conditions you may have
Typically, your doctor will start you on a low dosage and adjust it over time to reach the dosage thats right for you. Theyll ultimately prescribe the smallest dosage that provides the desired effect.
The following information describes dosages that are commonly used or recommended. However, be sure to take the dosage your doctor prescribes for you. Your doctor will determine the best dosage to suit your needs.
A Nurse’s Guide To Administering Iv Insulin
You have a patient that comes up to your unit with a blood sugar of 952. The labs are sent off and the patient is found to be in severe diabetic ketoacidosis .
The doctor puts in the orders for serial lab work, fluid boluses, electrolyte replacements, and an insulin drip. As a newer nurse, you are familiar with labs, boluses, your replacement protocols, but have never administered insulin through an IV. What nursing interventions do you need to perform to safely care for this patient?
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Organizational Recognition Of Tight Glycemic Control
Several organizations now support the use of tight glycemic control however, questions remain regarding the appropriate blood glucose targets. Today, both the American Diabetes Association and the American College of Endocrinology support keeping blood glucose levels in ICU patients as close to 110 mg/dl as possible. For noncritically ill patients, it is recommended that glucose levels not exceed 180 mg/dl, . The ACE guidelines recommend CII therapy for patients whose glucose levels must be brought under control promptly, including those who are critically ill or on prolonged NPO, nutritional status.
The Joint Commission recently proposed tight glucose control for the critically ill as a core quality-of-care measure for all U.S. hospitals that participate in the Medicare program. The Institute for Healthcare Improvement, together with an international initiative by several professional societies including the American Thoracic Society, is promoting a care bundle for severe sepsis that also includes intensive glycemic control.