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  • 1. PAEDIATRIC CRITICAL CARE NETWORK CRITICAL CARE AND STABILISATION INTRAVENOUS DRUG TRAINING WORKBOOK Hospital site………………………………………………………………………………………………………………………………………………. Authors: M Milner, M Augey, F Knox, L Daniel, S Langworth, J Hargreaves, J McEnaney (Pharmacist), S Jefferson, C Howard, L Clancy, V Brown Owner: PCC Network Date of Issue April 2007 Review date June 2009 Version 1
  • 2. CONTENTS Page number Statement of intent 3 Aim and objectives 4 Introduction 5 Domain 1 Preparing self, child and family 6 Preparation of self 6 Preparation of child and family 7 Gaining consent 7 Domain 2 Medicines management including drug calculation, uses, side effects and formulas 9 Medicines management 9 Medicines management – good practice 10 Exercises 1 – 3 10 Conversion of units 11 Exercises 4 – 5 12 Pharmacy aspects of critical care 12 Bolus or IV infusion of medications 15 Exercises 6 - 8 15 Drug calculations 16 Bolus dose calculations 16 Exercise 9 16 Infusion calculations and preparation 17 Infusion rate calculation 17 Exercise 10 18 Domain 3 How to administer stabilisation drugs safely including risks and hazards 19 Principles 19 Risks and hazards 19 Extravasation and infiltration 20 Management of extravasation and infiltration 22 Complications of IV drug administration 22 Domain 4 Professional and legal issues 24 References 27 Appendix 1 Cannula Record 28 Appendix 2 Detection & Advice Scale for Peripheral Phlebitis 29 Appendix 3 VIP Score 30 2
  • 3. TRAINING PACKAGE The training package will consist of the following elements: - • A study period including both theoretical and practical teaching • Training booklet • A period of supervised practice • Assessment of competence both in practical and theoretical work • Declaration of competence Statement of Intent Practitioners who have received training, supervised practice and who have been declared competent in these procedures may perform IV drug administration and calculation for critically ill children. The purpose of practitioners developing competence in calculation and administration of stabilisation drugs is to: Ensure children/young people with the potential to become critically ill receive a safe, effective and efficient level of care as determined and initiated by a practitioner with recognised knowledge and skills in the calculation and administration of medications required for their care. 3
  • 4. AIM AND OBJECTIVES Our aim is to provide you with the knowledge, skills and understanding essential for performing safe IV drug calculation and administration for the care of critically ill children. This training package has been designed to include KSF (Agenda for Change, DOH, 1999). The package is laid out in the core domains related to care of the child and family, calculation of medications and the safe administration of drugs required in the stabilisation of a critically ill child. The core domains are: 1. Preparing self, child and family. 2. Medicines management, including drug calculation, uses, side effects and formulas. 3. How to administer medications safely. 4. Professional and legal issues. Each section introduces the learning outcomes, then covers the relevant theoretical practical content required and concludes with core competency assessment criteria. This document is for circulation around all the hospitals that refer children to the Leeds PICU in the West Yorkshire and North East Yorkshire, and as such will be seen by many members of staff. The Paediatric Critical Care Network acknowledges that each hospital will have their own individual guidelines and procedures on the administration of intravenous medication and infection control policies. This document is aimed at supplementing local policies to provide information and training on stabilisation drugs and drugs required in the management of the critically ill child. 4
  • 5. INTRODUCTION The evidence base for this teaching package is taken from current literature available on this subject. Recommendations made without strong evidence were formed by expert opinion and are thought to reflect good practice. The calculation of medication doses for use in the resuscitation or stabilisation area largely remains the same as it does for calculating a dose of paracetamol. The Paediatric Critical Care Network is aware that the thought of calculating medications in a resuscitation or stabilisation scenario can often be stressful to the nurse before they even lay hands on a calculator and therefore this workbook has been devised to: • Identify some realistic and achievable learning outcomes • Make you aware of:- Medicine management issues Professional Accountability and NMC guidance Drug doses and calculations, taking you step by step through drug calculations The types of drugs commonly used in critical care Risks and hazards of IV drug administration in critical care There will also be the opportunity for you to work through some questions set throughout the workbook. 5
  • 6. DOMAIN 1 Preparing self, child and family Learning outcomes • To understand the necessary competencies required in the preparation and administration of IV medication to a critically ill child • To ensure the child and family are prepared wherever possible and understand the effects of drugs administered to the critically ill child Preparation of self Preparing medicines for children and young people can be a complex process. Health care professionals who are prescribing, dispensing or administering medicines for children and young people need to be competent particularly regarding the risks and benefits or medicines, calculations, shared decision making and in accessing best evidence (NSF 2004). Many medicines available for children are only available in adult dose preparations and will often require complex drug calculations when preparing doses. The medicines for children section of the children’s NSF (2004) emphasises that individuals who administer medicines to children should demonstrate their competence in dose and infusion calculations. Medicines can be given intravenously by several methods; continuous, intermittent or bolus. A fluid bag or syringe is used for continuous infusions and burette or syringe for intermittent infusions. A bolus can be given into a running infusion, an injection access site, or as a flush, as with Sodium Chloride 0.9%. It is important that the correct methods for administration of a medication are used. The nurse administering a medication needs to be familiar with the drug dosage, side effects and the method of administration. Drugs used for the stabilisation of a critically ill child are often required urgently, it is therefore essential that the nurse is familiar with the drugs likely to be used and their side effects and competent at calculating complex drug dosages. 6
  • 7. Preparation of child and family It is often the case that the critically ill child will not be aware of IV drug administration due to their severity of illness; however it is always important to consider that the child may be aware despite their level of consciousness. Any practitioner working with children and young people must be able to communicate effectively. Communication can be verbal, non verbal and abstract, you may need to use more than one of these techniques when communicating with the child and family. Listening is a key element of effective communication. To engage in active listening you should take note of all aspects of the conversation and any gestures of expressions that suggest an underlying message or anxiety. This can be extremely difficult in a critical care environment but nevertheless still extremely important. Where a procedure may cause discomfort it is always still essential to be truthful to the child or young person. Gaining consent Any informed and competent person can authorise a medical procedure once the implications, side effects and alternatives have been appropriately explained. In most situations it is desirable to have the parents consent to a procedure as well as the child’s. In a critical care situation it is often only the parents who are in a position to consent as the child may not be conscious. It is still important however to talk to the child and explain what you are doing in terms they are likely to understand given their age and cognitive ability. Consent can be verbal written or implied by the child’s actions, such as holding out an arm ready for intravenous medications to be administered. For children to willingly allow someone to do something which may be uncomfortable or painful they must be able to control their anxiety and trust the person performing the procedure. It is therefore important that you prepare the child and family for administration of medications with honest factual information about the medicine you are administering and the likely effects of the drug. If a child is wriggling or screaming you can assume they are not consenting to the procedure. You should consider the use of distraction techniques where appropriate during the administration of intravenous medications. 7
  • 8. Nurses and parents may gently hold a child’s arm still to ensure the child’s safety. Restraint should only be used if all other measures to create a safe environment and keep the child still have been tried. 8
  • 9. DOMAIN 2 Medicines management, including drug calculation, uses, side effects and formulas Learning Outcomes • To be able to discuss the implications of administering medicines to children in relation to employer’s practice policy and NMC guidance. • To describe the factors that determine whether an intravenous medicine is given by bolus or infusion • To calculate medicine doses and infusion rates safely, using recognised formulae. Be able to identify how this can best be carried out. • To demonstrate how to correctly make up prescribed infusions and boluses. • To understand the various definitions and measurements used in calculating drugs • To understand the various types of drugs used in care the critically ill child and their side effects Medicines management Implications of administering medicines to children It is the responsibility of the individual clinician (nursing or medical) to ensure that they are familiar their Trust policies and guidelines for the administration of intravenous medications and that their practice adheres to these policies at all times. The Paediatric Critical Care Network has produced this package to support and educate staff when preparing and administering medications for the critically ill child. It is in the interests of each individual nurse to ensure that they are familiar with the content of the Nursing & Midwifery Council document 9
  • 10. “Guidelines for the Administration of Medicines 2004” which contains information within it that is specific to the issues around administration of a medication. As a regulatory body for nurses, midwives and specialist community public health nurses, the primary function of the NMC is public protection through professional standards (NMC 2004). These standards are clearly laid out in this document and seek to provide support and advice for nurses to enable them to practice both professionally and safely in relation to the administration of a medication. As a registered nurse…”You are personally accountable for your practice. This means that you are answerable for your actions and omissions, regardless of advice or directions from another professional” (NMC 2002). The inference here is that if you are not happy to continue, for whatever reason, then you must not proceed. This will ensure the safety of the patient and maintain the professionalism of the nurse. It is then of course the responsibility of the nurse to ensure that their ward sister/area manager is aware of their requirement for further education & training. Medicines management good practice • Wherever possible, ensure that another member of staff is available to undertake this task with you. • Use your own calculator and work out the equations on your own and independently from your colleague. • When both of you have finished, then compare answers. • Be sure that you are happy with how the equation was calculated. • Remember your professional accountability. • Don’t be rushed. Feel confident to inform other members of the team that you are ensuring the calculations and drug preparations are correct. Exercise 1: Identify what actions you would take in a stabilisation scenario if an anaesthetist asked you to prepare a range of anaesthetic medication that you were not familiar with. Exercise 2: It is your first time in the stabilisation area and you are attempting to observe the activity only. However you are asked by a member of medical staff to calculate the dose range and hourly rates of 3 different infusions. You are inexperienced and don’t fully understand what you are being asked to do. Identify your actions and rationales 10
  • 11. Exercise 3: The child you are caring for is now stable, intubated, and has settled well on the ventilator. You notice that none of the anaesthetic or induction medication has been prescribed and the anaesthetic staff are now leaving. Identify what the issues are and how you think you would deal with them. Conversion of units 1 Kg = 1000 g 1g = 1000 mg 1 mg = 1000 micrograms 1 microgram = 1000 nanograms To avoid prescription and interpretation errors: Quantities <1g should be converted to milligram i.e. 0.5g express as 500mg Quantities <1mg should be converted to micrograms i.e. 0.1mg express as 100micrograms Ratio of concentrations 1 in 1000 means 1g in 1000mL (i.e. 1mg/mL) Percentages 0.1% w/v means 0.1g in 100mL (i.e. 1g in 1000mL or 1mg/mL) Definitions BOLUS: A direct intravenous injection of a concentrated solution of drug administered over a short period of time, usually over 2 to 10 minutes INTERMITTENT INFUSION: An intravenous injection of a relatively dilute concentration of drug, administered as an infusion, over a period of 20minutes to 4 hours. 11
  • 12. CONTINUOUS INFUSION: An intravenous injection of a dilute concentration of drug, which may be administered at a continuous rate over 6 to 24 hours. Displacement values This is where the volume, which the powder being reconstituted occupies, is significant, and must be allowed for when making up to the final volume. This is applicable to paediatrics when calculating doses from part vials (e.g. Cefotaxime 500mg add 1.8mls water this will reconstitute to 2mls volume). Exercise 4: To demonstrate the ability of converting metric units Convert the following to appropriate metric units: • 0.675mg • 0.0075mg • 0.04g • 0.07mg • 0.625mg • 0.25micrograms Exercise 5: Calculate the following: 1) How many millilitres is 1/5 of a litre 2) Digoxin elixir is labelled 0.25mg in 5mL. You are required to give a dose of 62.5microgram. What volume will you give? 3) Calculate the volume required for the following doses: 4) Gentamicin 20mg/2mL, give 2.5mg 5) Flucloxacillin 250mg/2.5mL, give 40mg 6) Furosemide 20mg/2mL, give 1mg 7) Atropine 600microgram/mL, give 60micrograms 8) Adrenaline 1: 10 000 solution, give 10 micrograms 9) Adrenaline 1: 1000 solution, give 150 micrograms Pharmacy aspects of critical care Drugs used in critical care include: anaesthetic agents, sedative and analgesic drugs, muscle relaxants and inotropes. 12
  • 13. This section aims to provide information on why these drugs are used, how they are used and any common side effects they may cause. Anaesthetic agents Examples of intravenous anaesthetic agents include: Etomidate, Ketamine and Propofol. Etomidate is administered for the induction of anaesthesia. The effect may last for 6 to 10 minutes with a single dose. Recovery is usually rapid without a hangover effect. Etomidate has no analgesic properties and causes less hypotension than other drugs used for induction. Ketamine is very rarely used as an anaesthetic agent now. Side effects include extraneous muscle movements and arterial pressure may rise with tachycardia. The main disadvantage of Ketamine is the high incidence of hallucinations, nightmares and other transient psychotic events. Ketamine is contra- indicated in patients with hypertension and best avoided in those individuals prone to hallucinations or nightmares. Propofol is also used for the induction of anaesthesia. It also causes rapid recovery without a hangover effect. Adverse effects include: convulsions, anaphylaxis and bradycardia. Sedative and analgesic drugs This group of drugs includes opioid analgesics such as morphine and fentanyl. These drugs are controlled drugs; local policy of handling controlled drugs must be followed. The main side effects of opiod analgesics are: respiratory depression, cardiovascular depression and nausea and vomiting. Fentanyl is being used more often because it has an onset of action of 1 –2 minutes. The initial doses of fentanyl are followed by successive intravenous injections or by intravenous infusion. Common side effects of fentanyl include: muscle rigidity, hypotension, bradycardia, respiratory depression and nausea and vomiting. Muscle relaxants Muscle relaxants are also known as neuromuscular blocking drugs. By specific blockade of the neuromuscular junction they enable light levels of 13
  • 14. anaesthesia to be employed with adequate relaxation of the muscles of the abdomen and diaphragm. The muscle relaxants can be divided into two groups: non-depolarising (atracurium, pancuronium) and depolarising (suxamethonium). Non-depolarising muscle relaxants compete with acetylcholine for receptor sites at the neuromuscular junction. Their action may be reversed with anticholinesterases such as neostigmine. Non-depolarising agents have a slower onset of action than suxamethonium. They have no sedative or analgesic effects. Side effects include: histamine release that can cause skin flushing, hypotension, tachycardia, bronchospasm and rarely anaphylactoid reactions. Depolarising muscle relaxants i.e. Suxamethonium, has the most rapid onset of action of any of the muscle relaxants. Its duration of action is about 2 to 6 minutes following I.V. doses. Unlike the non-depolarising muscle relaxants its action cannot be reversed and recovery is spontaneous. Bradycardia may occur; pre-medication with atropine reduces bradycardia as well as the excessive salivation associated with suxamethonium use. Inotropes The cardiac stimulants dobutamine, dopamine and noradrenaline are used to manage low cardiac output states and shock due to other causes. Dobutamine: principal adverse effects are ectopic heartbeats, increased heart rate, angina, chest pain, palpitation and elevations in blood pressure, all of which are dose dependent. Dobutamine can be administered peripherally with caution: extravasation may cause tissue sloughing and necrosis. Dopamine: Side effects include: ectopic beats, tachycardia, hypotension, vasoconstriction, nausea, vomiting and headache. Peripheral infusions should be avoided as vasoconstriction and gangrene may occur. Monitor for signs of peripheral ischaemia. Adrenalin: Side effects include vasoconstriction, hypertension, and increased cardiac contractility. Can be administered by intravenous, intraosseous and endotracheal route. 14
  • 15. Noradrenaline: Side effects include: hypertension, bradycardia, headache and peripheral ischaemia. Extravasation of noradrenaline leads to sloughing and necrosis around the infusion site. Administer via central line only. Bolus or IV infusion of medications When you consider their use in the stabilisation of a sick child, the usual practice is to administer a rapid sequence induction (RSI) of either 2 or 3 different types of medication. Boluses are given first to ensure that effective therapeutic levels are reached. The rapid sequence induction is usually made up of sedation, analgesia and paralysis. Following the induction of the child and once they are settled and asleep, the practice then is to commence infusions of (usually) the same medication in order to maintain therapeutic levels. Although the Leeds Teaching Hospitals Paediatric Intensive Care Units Guidance “Operational Policies and Clinical Protocols” (2003) is available in all the hospitals across the network, it is acknowledged that there will be occasions when the anaesthetic staff that attend to support and work with you will not be familiar with this guidance nor the drug regime identified within it. If this occurs in your clinical area the following guide to working out the calculations will remain the same and as always as an accountable professional it will be your responsibility to review the prescription if you are preparing it. Be happy that the dose prescribed on the drug chart is correct. Exercise 6: You have been asked “over the phone” to prepare the rapid sequence induction medication for the anaesthetist prior to his arrival. What are the relevant issues here and what are you actions? Exercise 7: A new member of medical staff asks you what the preferred drugs of choice are in your hospital for the RSI of infants. Identify what your actual practice would be and then discuss if this is correct. What are you options for ensuring that he obtains the correct information? 15
  • 16. Exercise 8: Identify what your worries and concerns are about calculating and preparing medication for use in a resuscitation or stabilisation scenario. Drug calculations Paediatric Medication Formula What you want x Volume it comes in = Vol in mls reqd What you’ve got You use this paediatric medication formula for all drug calculations from a simple calculation for paracetamol to a more advanced calculation for morphine. Bolus Dose Preparation Example • In all these equations, the child’s weight will be 3.2 kg • Take Morphine 10 mg in 1 ml ampoules • Add 9 mls of 0.9% saline; this will now give you a concentration of 10 mg in 10 mls or 1 mg in 1 ml • This will improve the precision for measuring small volumes • The bolus dose of morphine is between 50 – 100 microgram / kg • Look at the units the dose is prescribed in and the unit the medication comes in. In this case your prescription is in mcg and your drug is in mg. Convert the mcg to mg by dividing by 1000. You are now working with the same units that will form part of your equation. • If the prescription were either 50 or 100 microgram / kg you now have all the information you require to prepare the bolus dose • 50 micrograms divided by 1000 = 0.05 mg x kg (3.2 kg) = 0.16 mg • Create your usual equation: 0.16mg x 10 mls = 0.16 mls 10 mg Exercise 9. How will you calculate the bolus dose for 100 micrograms / kg? It’s your turn to do this equation. Remember….are the units the same and how to convert them to create a workable equation. 16
  • 17. Infusion calculations and preparation You need to identify from the prescription the final total volume required. This means the infusion fluid & the drug will add up to the total volume and not the total volume of the infusion alone with the drug added on top. Example • Using the same 10 mg in 10 ml solution of Morphine • The infusion preparation will be 1 mg per kg in 50 ml of 0.9% Saline or 5 % Dextrose. • To make a final total volume of 50 mls, you need to work out: How much infusion fluid you require and How much in volume of the drug you will require Therefore 1 mg / kg = 1 mg x 3.2 kg = 3.2mg = 3.2 ml of morphine To make this up to 50 ml add to 46.8 ml of infusion fluid: 3.2 ml morphine 46.8 ml fluid 50 ml total volume Infusion Rate Calculation The infusion can be run between 10 - 40 micrograms / kg / hr. 10 micrograms / kg / hr = 32 micrograms/hr. Convert the micrograms to mg = 0.032 mg / hr. You now have all the information you require to calculate the infusion rate. Example The equation for 10 micrograms / kg / hr will be: (32 micrograms)0.032 mg x 50 mls = 0.5 mls / hr 3.2 mg Dose /kg/hr in mg x Total volume in mls = rate in mls /hr Concentration in mg of drug in total volume This equation will work whenever your prescription is in mgs per hour. What do we do if the prescription in mg / kg / min? Again, look at these steps and the resulting equation: • For example Midazolam 10 mg in 2 ml vials • The infusion preparation is 3 mg / kg in 25 ml 5% Dextrose. • As before, identify how much drug you require; 3mg x 3.2 kg = 9.6 mg 17
  • 18. 1st step. How much of the drug do you need in mls? 9.6mg x 2ml = 1.92 ml of Midazolam 10 mg 1.92 ml Midazolam 23.08 ml 5 % Dextrose = 25 ml total volume Calculating the rate • Infusion dose range is 3 - 6 micrograms / kg / min • Look at the prescription & identity the steps you need to make • Convert mcg to mg because the infusion has been calculated and prepared as mgs • Convert minutes into hours because that is the value the infusion pumps work in Example 3 micrograms x 3.2kg = 9.6 micrograms / minute X 60 mins (convert to hours) = 576 micrograms / hour Convert micrograms to mg (divide by 1000) = 0.576 mg / hr Again you have all the required information to create the familiar equation: 0.576 mg x 25 mls = 1.5 mls / hour 9.6 mgs Exercise 10. Work out the infusion rates for 4, 5 & 6 mcg / kg / min. Remember though that once you have prepared the syringe, the amount of drug (in mgs) within the syringe will remain the same. 18
  • 19. DOMAIN 3 How to administer stabilisation drugs safely including risks and hazards Learning outcomes • Explain the principles of administration via different types of devices • Outline the nurses responsibilities in the administration of IV infusions through infusion devices • Recognise the potential complications and risks involved when administering infusions via infusion devices • Discuss the need for accurate documentation and adverse incident reporting Principles An infusion device is a piece of equipment intended to regulate the flow of liquids into a patient under positive pressure generated by a pump. (British Standards institute 1998) Infusion devices are powered items of equipment which together with an appropriate administration set provide an accurate flow of fluids over a prescribed period of time. Infusion devices are reported as the most common pieces of medical equipment involved in adverse incidents. It is essential therefore that nurses can use infusion devices safely if errors are to be prevented. All nurses must be familiar with the equipment used in their local hospital and appropriately trained in the use of medical equipment. (Please be guided by your local policies for equipment use.) Risks and Hazards Intravenous medication may produce unexpected adverse reactions. The use of this route although effective can also be hazardous. Any adverse effects must be recorded and reported. It is the responsibility of the nurse to ensure she /he has appropriate and adequate training to ensure safety and competency for administration of I.V. 19
  • 20. drugs. Nurses must have knowledge of Standards for the Administration of Medicines (N.M.C) I.V. drugs have a rapid onset of action and once administered cannot be removed from the circulation. I.V. drugs take longer to administer than the oral equivalent. If more than one drug is being administered simultaneously these may be incompatible. Risk of incorrect preparation due to e.g. incorrect calculation, measurement, or dilution. Risk of incorrect administration due to e.g. incorrect rate, equipment failure. Most drugs and fluids administered I.V. show some degree of irritancy to the vein and may lead to phlebitis and thrombophlebitis. Increased risk of microbial contamination. Increased risk of anaphylaxis. Extravasation and infiltration Severe damage is more common in neonates and children. Use tools such as the Visual Inspection Score (see appendix 1 and 2) to assess for evidence of infiltration as per local policies, or visually inspect cannula integrity. Infants in special care baby units are more at risk due to immature skin. Infants and young children may not be able to localise and report pain. Extravasation and Infiltration are both more commonly known as tissuing. Extravasation,- the inadvertent administration of typically a vesicant or other drug, which has the potential to cause severe tissue damage and necrosis (Weinstein 2001). Infiltration,- the inadvertent administration of a non-vesicant solution into surrounding tissue, may cause local tissue inflammation and discomfort but does not result in necrosis (Weinstein 2001). Vesicant – an agent, which causes blistering of the skin and tissue injury (Weinstein 2001). Non-vesicant – an agent, which does not cause blistering of the skin (Weinstein 2001). 20
  • 21. Additional Measures to Prevent Extravasation All vesicant drugs should be identified by a pharmacist. Ideally drugs liable to cause extravasation should be given via a central line. Vesicant drugs should be diluted as much as possible. Vesicant drugs should be administered first when venous integrity is greatest (the longer the cannula in situ the less healthy the vein) Soft tissue damage may be due to a number of factors related to the physicochemical properties of the drug or infusate, it is well documented that a number of physicochemical factors influence and usually increase the extravasation risk of individual drugs, these are: The ability to bind directly to D.N.A (cytotoxic drugs) The ability to replicate cells (cytotoxic, antiviral) The ability to cause tissue or vascular dilatation The PH, osmolarity, and exipience in the formulation of the drug. PHYSIOCHEMICAL FACTORS DRUG Hyperosmolar agents Glucose Hypertonic saline Potassium chloride Calcium chloride Sodium bicarbonate Parental nutrition x-ray contrast medium Antibiotics Acid and alkaline agents Thiopentone (PH 10.5) Methohexitone Etomidate Phenytoin (pH 10.5) Amphotericin Methylene Blue Vascular Tone agents Adrenaline Vasoconstrictors – can cause ischaemic Noradrenaline necrosis by restricting local blood flow. Metaramind Vasodilotors – may exacerbate effect of Dopamine extravasation by increasing local blood flow Dobutamine and enlarging area of injury Vasopressin 21
  • 22. Prostaglandins Epoprostenol Cellular Toxicity – direct toxic effect on Acyclovir tissues Management of extravasation / infiltration (Use local policy) • Apply sterile dressing • Elevate limb to minimise swelling • Encourage movement • Document event in patient’s notes • Assess wound site twice daily and record observations • Follow local Trust policy to complete and incident form The management of the extravasation of drugs or solutes is controversial and there is little documented evidence of effectiveness. It is essential that any extravasation, which occurs, be recorded. Treatment depends on the nature of the offending substance; some antidotes can act as irritants or vesicants and cause further damage. In the event of extravasation refer to local trust policy, contact pharmacy. Detailed information can be accessed at the National Extravasation Service website www.extravasation.org.uk Complications of intravenous drug administration COMPLICATIONS CAUSE ACTION ANAPHYLAXIS Hypersensitivity to Airway, breathing, circulation and medication blood pressure management. Administration of epinephrine (Adrenaline). Document allergies EXTRAVASATON Inadversant administration Stop infusion and follow local of vesicant medication into extravasation policy surrounding tissue instead of intended pathway 22
  • 23. MEDICINE TOXICITY Plasma levels exceed Check drug levels prior to therapeutic level i.e. high administration dose, failure to excrete or toxic metabolites PAIN PH of infusion Dilution Slow infusion INFILLTRATION Inadvertent administration Stop infusion of non-vesicant medication Remove cannula into surrounding tissue PHLEBITIS Small veins in children, and Dilute or give via central vein reduced blood flow around device, irritant medications SPEED SHOCK Medicine given too quickly Stop drug, causing,hypotension, Monitor vital signs, tachycardia, facial swelling, Treat symptoms, distress Medical assistance. FLUID OVERLOAD Impaired renal function, Include intravenous medications Medicine diluted in large in fluid balance volume INFECTION Increased risk of local and Keep lines, lumens, and /CONTAMINATION systemic infection due to obturators to a minimum. intravenous device Inspect site regularly. Sterile equipment, Aseptic technique. Hand washing AIR THROMBO OR Air or particles enter Medical assistance, PARTICLE EMBOLISM circulation, Monitor vital signs. Can be fatal Prevention: good infusion care. Secure obturators. Removal of air from system. No forced flushing. Needle free system 23
  • 24. DOMAIN 4 Professional and legal issues Learning Outcomes: • Discuss the legal and professional issues associated with preparation, management, calculation and administration of intravenous drugs for the critically ill child • Outline current evidence to support best practice in the safe administration of medications • Give an account of the local and professional policies relevant to the safe administration of intravenous medications for critically ill children • Describe legal requirements for good practice in relation to the safe administration of intravenous medications • Reflect on own practice identifying accountability and competency issues. Accountability As a registered practitioner you are accountable to: - • The public - Criminal Law • The patient - Civil Law • The employer – vicarious liability • The profession – Through professional governing body. Vicarious Liability The trust will accept legal responsibility for the negligence of a practitioner providing: • They are an employee of the Trust 24
  • 25. • They were acting within the course of their employment when the negligence occurred • They were following Trust Policies and Procedures • These principles for practice should enhance trust and confidence within a health care team and promote further collaborative work between medical and nursing practitioners. Code of professional Conduct (NMC, 2002) The code provides a statement of the values of the profession and establishes the framework within which practitioners practice and conduct themselves. Scope of Practice (UKCC, 1997) The six principles of the Scope of Practice underpin a nurse’s, midwife’s or health visitor’s approach to taking on responsibilities beyond the traditional boundaries of practice, and state that they must: • Be satisfied that patient and client needs are paramount • Aim to keep up-to-date and develop knowledge, skills and competence • Recognise limits to personal knowledge and skill, and remedy deficiencies • Ensure that existing nursing care is not compromised by new developments and responsibilities • Acknowledge personal accountability • Avoid inappropriate delegation. These principles for practice should enhance trust and confidence within a health care team and promote further collaborative work between medical and nursing practitioners. The practice of nursing and education will continue to be shaped by developments in care and treatment, and by other events, which influence it. In order to bring into proper focus the professional responsibility and consequent accountability of individual practitioners it is the principles for practice, rather than certificates for tasks, which should form the basis for adjustments to the scope. 25
  • 26. Case Law • Team liability does not exist as a concept in law. • Standards are variable and will rise as knowledge and experience develops. However, ignorance is no defence! • Essentially the professions develop their own standards but these are subject to the scrutiny of the courts. • We are not insured to practise on one another. Documentation: Documentation is a vital part of any procedure, accurate and concise documentation is not only good practice, but also a requirement of the NMC (2002) 26
  • 27. REFERENCES British Standards Institute (1997) IEC 601 -2-24 Medical Electrical Equipment Part 2. Particular requirements for safety of infusion pumps and controllers. London BSI Department of Health (2004) The NHS Knowledge and Skills framework (NHS KSF) and the development review process. Department of Health Publications London Department of Health (2004) National Service Framework for Children and Young People Department of Health Publications London Dixon A Evans C (2006) Intravenous therapy: legal and professional issues Infant Vol 2 (2) Evans C Dixon A (2006) Intravenous therapy: Practice issues Infant Vol 2(4) Leeds Teaching Hospitals Paediatric Intensive Care Units (2003) Operational Policies & Clinical Protocols National Extravasation Service website www.extravasation.org.uk Nursing and Midwifery Council (2002) Code of Professional Conduct NMC. London. Nursing and Midwifery Council (2004) Guidelines for the administration of medicines. NMC. London. Royal College of Nursing (2005) Competencies an education and training competency framework for administrating medicines intravenously to children and young people RCN London Royal College of Nursing (2003) Restraining, Holding Still and Containing Children and Young People: Guidance for Nursing staff, London: RCN. Publication code 000 999. Weinstein (2001) Plumers principles and practice of IV therapy 27
  • 28. Appendix 1 Please affix patient ID sticker Patient Name: DO NOT DESTROY - PLEASE FILE IN PATIENTS MEDICAL RECORDS Date of birth: INTRAVENOUS CANNULA RECORD Casenote Number: INSERTION RECORD Please indicate insertion site: DATE Date:________ Lot No: ________ VIP SCORE ( 0—5) Size: ____g No. of attempts: ___ First insertion: or Re-site: Continuous Y Y Y Y Y Infusion N N N N N Reason for insertion: Dressing renewed Y Y Y Y Y Reason for re-site: N N N N N Inserted by: Staff initials (Signature, date & designation) (Please state time, initials & designation) REMOVAL RECORD Date: ________ No. days in situ: ___ Cannula flushed as Per Trust Patient VIP score on removal: ____ Group Directive/ Reason for removal: Policy Removed by: R L (Please state time, initials & designation) (Signature, date & designation) INSERTION RECORD Please indicate insertion site: DATE Date:________ Lot No: ________ VIP SCORE ( 0—5) Size: ____g No. of attempts: ___ First insertion: or Re-site: Continuous Y Y Y Y Y Infusion N N N N N Reason for insertion: Dressing renewed Y Y Y Y Y Reason for re-site: N N N N N Inserted by: Staff initials (Signature, date & designation) (Please state time, initials & designation) REMOVAL RECORD Date: ________ No. days in situ: ___ Cannula flushed as Per Trust Patient VIP score on removal: ____ Group Directive/ Reason for removal: Policy Removed by: R L (Please state time, initials & designation) (Signature, date & designation) INSERTION RECORD Please indicate insertion site: DATE Date:________ Lot No: ________ VIP SCORE ( 0—5) Size: ____g No. of attempts: ___ First insertion: or Re-site: Continuous Y Y Y Y Y Infusion N N N N N Reason for insertion: Dressing renewed Y Y Y Y Y Reason for re-site: N N N N N Inserted by: Staff initials (Signature, date & designation) (Please state time, initials & designation) REMOVAL RECORD Date: ________ No. days in situ: ___ Cannula flushed as Per Trust Patient VIP score on removal: ____ Group Directive/ Reason for removal: Policy Removed by: R L (Please state time, initials (Signature, date & designation) 28 & designation) Status: Implementation Version: 02 Start Date: 27/07/06 Review Date: 27/07/07
  • 29. Appendix 2 Detection and Advice Scale for Peripheral Phlebitis Action guidelines. Number Signs Picture Also refer to local policy No pain or signs Continue to observe and 0 of phlebitis document at each shift. Remove & replace Pain / redness cannula in altenative 1 around insertion site. Observe both sites site and document. Remove & replace Pain, swelling, cannula in alternative redness 2 site. Observe both sites Palpable and document. Treat venous cord where necessary. Pain, swelling, Remove, send tip for induration, culture and sensitivity. redness If pyrexia present take 3 Palpable blood cultures from venous cord alternative site. above 3cms Document and complete Presence of pus Clinical Incident Form. Remove, send tip for All the above culture and sensitivity. 4 Presence of Implement plan as tissue damage above. Complete clinical incidence form Produced by IV Strategy Group June 2007. Modified from BD Training Package and Andrew Jackson (RCN Standards for Infusion Therapy 2005) 29
  • 30. Visual Infusion Phlebitis Score No signs of phlebitis POLICY STATEMENT IV site appears healthy 0 OBSERVE CANNULA All patients with an intravenous access device in place must have the IV site checked at least once every 24 hours for signs of infusion phlebitis. The One of the following is evident: Possibly first signs of phlebitis subsequent score and action(s) taken (if ♦ Slight pain near IV site any) must be documented. The cannula site must also be observed: ♦ OR Slight redness near IV site 1 OBSERVE CANNULA ♦ When bolus injections are administered ♦ When IV flow rates are checked or altered Early stages of phlebitis ♦ When solution containers / giving Two of the following are evident: sets / lines are changed ♦ Pain at IV site ♦ If occlusion occurs ♦ ♦ Erythema Swelling 2 RESITE CANNULA CONSIDER TREATMENT All of the following signs are Medium stage of phlebitis The incidence of infusion phlebitis varies, evident: the following 'Good Practice Points' may ♦ Pain along path of cannula RESITE CANNULA assist in reducing the incidence of infusion phlebitis: ♦ ♦ Erythema Induration 3 CONSIDER TREATMENT Observe cannula site at least daily Secure cannula with a proven intravenous dressing (Opsite IV3000 or Tegaderm IV) All of the following signs are evident Replace loose &/or contaminated Advanced stage of phlebitis or the start and extensive: of thrombophlebitis dressings ♦ Pain along path of cannula Cannula must be inserted away ♦ Erythema from joints whenever possible Aseptic technique must be followed ♦ Induration 4 RESITE CANNULA CONSIDER TREATMENT Consider re-siting the cannula every ♦ Palpable venous cord COMPLETE IRIS FORM 72 hours Plan and document continuing care Use the smallest gauge cannula most suitable for the patients need All of the following signs are Advanced stage of thrombophlebitis Replace the cannula at the first evident and extensive: indication of infusion phlebitis ♦ Pain along path of cannula RESITE CANNULA (stage 2 on the VIP Score ) ♦ ♦ Erythema Induration 5 INITIATE TREATMENT ♦ Palpable venous cord ♦ Pyrexia COMPLETE IRIS FORM Appendix 3 30