Intravenous Bolus Injections

What it is

Advantages of giving intravenous bolus injections

By-passes barriers to absorption

Control over rate of administration

Rapid speed of action

May be used in emergency situations

Titration of dose

Accurate assessment of dose given - total absorption - equal systemic distribution

Comfort

Some drugs may only be given iv.

Avoidance of first pass metabolism

May be given when nil by mouth

Prevents muscle damage

Possible complications of intravenous bolus injections

Rapid onset of any adverse reactions

Overdose

Speed shock

Allergies and anaphylaxis

System disconnection

Extravasation

Phlebitis

Emboli introduction

Fluid or drug incompatibility

Bacteraemia and septicaemia

Particulate introduction

Inability to recall drug

Practical considerations

Variations in dose

Rate of administration

Cannula is blocked

Loading dose

Check with two nurses

Stages in the procedure

Explain the procedure to the patient.

Wash hands.

The drugs to be given and their dilutants are checked according to local protocols.

Check the labelling information to ensure that the preparation may be given by the intravenous route.

Ensuring asepsis, drugs are drawn up into the syringe appropriately to prevent aerosolization. Solids must be completely dissolved.

A green needle or smaller is used to draw up preparations from glass vials to prevent injection of glass micro-shards.

Inspect the entry site of the cannula for inflammation, infection and patency.

Flush the cannula through with 0.9% normal saline if required.

Connect the syringe and start to give the drug at an appropriate rate.

Monitor the patient for any local pain, reactions or tissuing.

Monitor the patient for any systemic effects throughout the procedure ie. side effects and adverse reactions.

If more than one drug is to be given, flush the system through with normal 0.9% saline after each drug has been administered.

Flush with 0.9% normal saline at the end of the procedure to ensure complete administration of the drug and continued cannula patency.

Close any taps on entry ports.

Safely dispose of all clinical materials used.

Continue to observe the patient for effects, side effects or adverse reactions.

Practitioner knowledge base

Half life

Legal and ethical aspects

Scope of Professional Practice

Code of Professional Conduct

Local procedures

Practitioner safety

Avoid contact with preparations

Develop a safe way to open ampoules

Ensure no contact with body fluids

Safe disposal of used clinical materials

Intravenous Bolus Injections

Aim

To administer safely intravenous bolus injections by an established intravenous route.

Objectives

Demonstrate awareness of the role of the Nurse in relation to the Scope of Professional Practice (1992) and the Code of Professional Conduct, (1992).

Describe the nature of the systemic and pulmonary circulatory systems.

List the drugs that the practitioner will give intravenously in their clinical environment.

List the indications, special precautions, contra indications and side effects of all drugs to be given.

Discuss the purpose of various administration times used for different medications.

Demonstrate an awareness of the possible local complications associated with intravenous drug administration.

Demonstrate awareness of the possible systemic complications associated with intravenous drug administration.

Describe the nurses role in management for all possible complications.

Describe the nurses role in the maintenance of asepsis

Discuss the local protocols for the safe administration of medication including drug calculations and identification of patients.

Advantages of the IV route

- Rapid therapeutic effect of the drug

- Total absorption of drug

- Controlled rate of administration

- Less pain

- Some drugs cannot be given by any other route

Disadvantages of the IV route

- Inability to recall drug

- Drugs may be given too rapidly

- Complications - Microbial contamination

- Vascular irritation

- Drug complications or interactions.

Practitioner safety

Avoid all contact with preparations eg. antibiotics may cause antibody formation. Wear gloves if required. Equalise pressures in rubber topped vials to prevent aerosolization.

Do not re-sheath needles after administration of a drug to avoid needle stick injury.

Speed of delivery

Intravenous drugs should be given slowly

If some preparations are given too rapidly adverse reactions may occur.

NB. Adverse reactions may occur even though the whole dose may not have been given. If any reaction is suspected the injection must be stopped.

This is a particular danger with electrolytes and adrenalin.

Potassium Chloride must never be give by bolus injection as it will cause ventricular fibrillation

Patient Safety

Some intramuscular or subcutaneous preparations may be problematic if given intravenously,

* Oily preparations may form emboli

* The effect of the drug may occur too rapidly eg. acute hypoglycaemia with IV insulin

* Be especially careful when two preparations of the same drug are available, eg. IM and IV Parentrovite.

Observe the vein for signs of thrombophlebitis, inflammation and infection.

Observe for inflamed lymphatic vessels, eg redness, tracking lymphadenopathy.

With the IV route the lymphatics are by-passed and any infection will immediately become a bacteraemia or viraemia.

Equipment

IV bolus injections may be given via the injection site of an IV administration, an IV cannula already in place or an extension set or multiple adaptor.

* Clinically clean tray

* Patients prescription chart

* Sterile needles and syringes

* 0.9% normal saline for injection

* Sharps containers

* Preparation to be injected as a bolus

Skills Article

Intravenous bolus injections

Knowledge base

In terms of dexterity skills giving intravenous bolus injections is straight forward. However because the effects and adverse effects of an intravenous injection manifest themselves within seconds of administration the person giving the drug must be able to recognise and manage any complication which may occur. It is therefore essential that as well as learning the practical procedure the nurse should be aware of the indications, contra-indications, side effects, possible adverse effects and normal dose of every drug they give.

Advantages of intravenous administration

These include the bypassing of any barriers to absorption and the prevention of first pass metabolism in the liver. These factors sometimes allow lower doses to be given which in turn reduce the likelihood of toxic effects. Intravenous drugs work within seconds so will be rapidly effective in emergency situations or in ill patients. High therapeutic plasma concentrations may be established relatively rapidly, this may be important in antibiotic therapy. Some drugs may be titrated with the individual patients clinical condition and with the observed effect of the drug, such as when giving analgesia. Pain and muscle damage associated with the intramuscular route are avoided.

Disadvantages of intravenous administration

Once the drug is given it is impossible to recall. Any adverse reactions to the preparation may present within seconds of administration. If the drug is given too quickly there is a risk of speed shock, (Lamb 1993). There may be venous haemorrhage if the cannula is pulled out in a confused patient. Other complications include extravasation, phlebitis, emboli introduction, systemic infection, particulate introduction and severe allergic reactions. Air must never be allowed to enter a vein.

Practical aspects

An intravenous cannula must first be located in a peripheral vein. The procedure is explained to the patient and the nurse washes his or her hands. The drugs to be given and their dilutants are checked according to local protocols. This will normally involve two qualified nurses. Most intravenous preparations which need to be reconstituted use sterile water or saline, it is essential to follow the manufactures recommendations. Labelling information on the vial must always be checked to ensure that the preparation may be given via the intravenous route as some may only be given by intramuscular injection.

Ensuring asepsis, drugs are drawn up into the syringe. Unnecessary aerosolization is prevented; this may mean injecting air into vials before the preparation is drawn up. Solids must be completely dissolved. A green needle (21G) or smaller is used for drawing up preparations to reduce aspiration of particulate contaminants such as glass micro-shards and small pieces of plastic or rubber from ampoules or vials.

The entry site should be inspected for inflammation, infection and likely patency. If there is any question of a blocked cannula or tissueing the cannula may be flushed through with 0.9% injectable normal saline, (MacCara 1983). If resistance is felt at this stage the saline should not be forced through as this may have the effect of introducing a blood clot from the cannula into the venous circulation. This will then travel through the right side of the heart and lodge in a pulmonary vessel.

The syringe is connected to the cannula ensuring a fluid tight seal. Preparations must be given at an appropriate rate, some drugs may be given relatively quickly but most should be given slowly. If no specific rate is prescribed a "rule of thumb" has been suggested, this is to make up the injection as recommended by the manufacturers and to give one ml per minute, (Burman and Berkowity 1986).

Throughout the procedure the systemic condition of the patient is closely observed for the effects of the drug and any side effects or adverse reactions. The cannula site should be monitored for any local pain or swelling which may indicate tissuing.

If more than one drug is to be given the system should be flushed through with 0.9% saline. This will ensure all of the previous drug is flushed through the cannula before the next one is introduced. No two drugs should be allowed to come into contact in the cannula unless it is known that they may be mixed. After the final drug has been administered the cannula should again be flushed through with 0.9% saline to ensure complete administration. If this is not done some of the drug may be left in the cannula.

After removal of the syringe any taps or entry ports should be closed. All clinical materials should then be safely disposed off. After the administration of the drug the patient should continue to be observed for effects of the drug, side effects or adverse reactions.

Anaphylaxis

This is a very rare but potentially life threatening complication of drug administration. All nurses administering intravenous drugs should be aware of the clinical features and management of this adverse reaction. The clinical presentations include angio-oedema, urticaria, dyspnoea, bronchospasm and hypotension. Other possible features include rhinitis, conjunctivitis, abdominal pain, vomiting, diarrhoea and a sense of impending doom, (Resuscitation Council 1999). In all patients with clinical signs of shock, airway swelling or definite breathing difficulty 0.5 milligrams of intramuscular adrenaline should be given and an emergency medical opinion taken. Intravenous adrenaline must never be given as it may cause ventricular fibrillation.

Scope of practice

Intravenous therapy is not addressed during basic nurse education. The documents covering such practice are the Scope of Professional Practice (1992), and the Code of Professional Conduct, (1992). These indicate that each practitioner is responsible for their own practice and for keeping up to date. In practice this usually means attending locally organised teaching sessions on intravenous therapy followed by a period of supervised clinical practice. The individual must have full agreement with his or her manager on the scope of their practice.

References

Burman R. Berkowity HS. IV. bolus: effective, but potentially hazardous. Critical Care Nurse. 1986, 6(1):22-28.

Heath HBM. Foundations in Nursing Theory and Practice. Mosby. London. 1995.

Lamb J, Peripheral IV therapy. Nursing Standard. 1993, 7(36):31-6.

MacCara ME. Extravasation: A hazard of intravenous therapy. Drug Intelligence and Clinical Pharmacy. 1983, 17(10):713-7.

Resuscitation Council. Emergency medical treatment of anaphylactic reactions - Consensus Guidelines. Resuscitation 1999, 41 93-99

UKCC. Scope of Professional Practice. 1992.

UKCC. Code of Professional Conduct. 1992.