In addition, information regarding indications, contraindications, dosage (age dependent), administration/dilution guidelines, adverse effects, clinical indications (e.g., specialized monitoring required, must be on an IV pump), compatibility, and incompatibility in relation to reconstitution and primary IV solution is specified (Alberta Health Services, 2009). Parenteral Hydration in Patients With Advanced Cancer: A Multicenter, Double-Blind, Placebo-Controlled Randomized Trial. Remove air from prefilled NS syringe and attach to the same IV port. One RCT, one multicentre pilot, 2 case series and 1 case report studied the pediatric population. The other nurses took so many other steps. 7. No studies compare SC fluids alone against IV; Existing trials have potential bias-sponsored by a pharmaceutical company producing rHf, HDC effective as IV rehydration of older adults with mild to moderate dehydration, Advantages of HDC include the same number of or fewer complications, cost savings, greater patient comfort, and less nursing time to start and maintain the infusion. If running primary IV solution is medication (e.g., heparin, morphine, pantaloc, or insulin) or blood or blood products, do not flush. Cost-effectiveness of recombinant human hyaluronidase-facilitated subcutaneous versus intravenous rehydration in children with mild to moderate dehydration, A systematic data review of the cost of rehydration therapy, Applied Health Economics and Health policy. This means theyre sent directly into your vein using a needle or tube. WebDobutamine and milrinone are IV medications given through an infusion pump into your vein. Although practiced since 1865, there has been a slow uptake, in part due to a lack of familiarity with the technique among physicians and healthcare professionals and perceived suboptimal outcomes (e.g., hypovolemic shock) due to inappropriate use of hydration solutions [12, 13]. Drug Administration Patients with an IV are more likely to be agitated than with SC [33, 43]. When a medication dose is given a range (e.g., morphine 2 mg IV q 2 -4 hours p.r.n. Not all medications can be given via the direct IV route. In one review specifically designed to evaluate patient acceptance of SCI versus intravenous medication administration, acceptability or preference for subcutaneous was found in 4 of 6 studies, ranging from 4491% preferring SCI over intravenous with no significant difference found in one study and one showing a small preference for intravenous [38]. A slow rate allows medications to be administered correctly. WebIn general, only one drug should be added to any infusion container and the components should be compatible. Infusion Therapy: Uses, Benefits, and Side Effects Data synthesis has led to an overall weak recommendation for subcutaneous hydration for pediatric patients and inconclusive for the palliative care/terminally ill population. Bethesda, MD 20894, Web Policies There is insufficient evidence to recommend Ringer lactate solutions [16]. Other opportunities for research which would help substantiate the practice of subcutaneous therapy include: the optimal subcutaneous access device properties (e.g., gauge, length, metal/cannula, and dwell time), type of hydration solutions/medications and additives and infusion delivery system. What is the expected therapeutic effect of the medication? 9. Administration protocol varied across studies. 1. After preparing the medication, always label the medication syringe with the patient name, date, time, medication, and concentration of the dose (e.g., morphine 2 mg/ml), dose, and your initials. Results: Problems associated with intravenous infusion therapy include contamination of fluids Data source: Albert Health Services, 2009; Lynn, 2011; Perry et al., 2014, Table 7.9 Preparation Questions for Intravenous Medications. 2015. Top Story | ANC (26 June 2023) - Facebook Always assess the patients understanding of the medication. One small prospective cohort study reported superiority in the SC group in urea (p = 0.001), creatinine (p < 0.001) and sodium (p < 0.05), with an overall clinical improvement rate of 77%. Sublingual buprenorphine faster onset of pain relief compared to subdermal buprenorphine. This prevents the IV medication from travelling up the IV line. A hypersensitivity reaction can occur immediately or be delayed, and requires supportive measures. A meta-analysis supports this finding, reporting that children and adult patients (n = 238) receiving IV hydration were more likely to experience an insertion failure (RR 14.79, 95% CI 2.87 to 76.08; GRADE rating: moderate) [33]. Math calculations may be required to determine the correct dose to prepare the medication. An official website of the United States government. Gomes NS, Silva A, Zago LB, Silva E, Barichello E. Nursing knowledge and practices regarding subcutaneous fluid administration. Recently published vascular access planning tools are either oriented primarily to the acute care setting or do not address the option of subcutaneous access [9, 10]. Several medications were only studies in healthy volunteers, where disease specific concerns dont exist or in the palliative care setting where advance illness may skew the assessment. Home-based SCIg injections tolerated and preferred more than IVIg by pediatric and adult patients. Administering a medication intravenously eliminates the process of drug absorption and breakdown by directly depositing it into the blood. Data is inconclusive yet to the use of SC hydration in the palliative care population. What supervision is required? The search yielded 1042 potential systematic reviews; 922 were excluded through abstract and duplicate screen. Ketamine for pain in adults and children with cancer: a systematic review and synthesis of the literature, Subcutaneous immunoglobulin for primary and secondary immunodeficiencies: an evidence-based review. Specific infusion rates and diluents vary based on medication and patient characteristics and could potentially impact tolerance. HDC is considered a simple, safe, and effective practice for hydroelectrolytic replacement and/or drug therapy, Intravenous Therapy: A Review of Complications and Economic Considerations of Peripheral Access, Continuous subcutaneous infusion of opiates at end-of-life, A proactive approach to combating venous depletion in the hospital setting, The One Million Global Catheters PIVC worldwide prevalence study, Developing a venous assessment tool in IV chemotherapy administration. For a list of high-alert medications, see Suggested Online Resources. Ker et al.s meta-analysis [33] found no evidence that the number of patients reporting pain differed between IV and SC (RR 1.01, 95% CI 0.83 to 1.22; n = 262; p = 0.94). Anti-epileptics were evaluated based on blood levels and seizure control and found to be adequate [16, 61]. Data sources: Own data and the accessible medical literature according to current electronic information sources were exploited. Rochon et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement, Subcutaneous hydration in geriatric patients-what is the evidence? There were fewer case of erythema (RR 0.43, 95% CI 0.31 to 0.61) and edema at the insertion site (RR 0.42, 95% CI 0.25 to 0.72; n = 453; p = 0.001). Subcutaneous infusions were reported compared to epidural and intravenous of various opioids finding them to be equivalent or equivalent in efficacy, safety and acceptability [48]. Comment: This drug should be given as a 1-hour infusion. However, each either had a narrow scope addressing one treatment (e.g., Fisher and colleagues review of iron overload management, [15]) or provided limited literature search or limited evidence (e.g., Duems-Noreiga and Blascos [16] review of subcutaneous fluid and drug delivery). The primary outcomes of interest investigated included: Secondary outcomes included: indications for subcutaneous infusion therapy; medication/ solution type; infusion rates, volumes and duration; subcutaneous access sites; dwell times; and infusion control devices used. Dosing and Infusion Rates - PRIVIGEN Using a timer ensures safe medication administration. The authors recommended using slower infusion rates to permit gradual fluid transfer into the intravascular space, rather than using hyaluronidase. Patients with cirrhosis may require a reduction in dosage. Grade A indicates the interventions desirable effects outweigh undesirable effects with adequate supporting evidence [18]. BG owns and is employed as Senior Consultant and Director of Education by Clinical Pharmacy Partners, an educational and consulting firm for infusion therapy providers and clinicians. The reviews showed statistically significant improvement in mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), right arterial pressure (RAP) and cardiac index (CI). Prostacyclin for pulmonary hypertension in adults. The AMSTAR 2 quality scores of the included reviews are described in S4 Table. Deferiprone is still indicated for treating iron overload in people with thalassaemia major when DFO is contraindicated or inadequate. Webinitiate infusion at ordered rate inform patient to notify nurse/ring call bell in case of adverse reaction Patient states ^Wow! Gaudet LM, Singh K, Weeks L, Skidmore B, Tsertsvadze A, Ansari MT. cellulitis and lymphangitis) rates were higher in patients with IVs than SCI (RR 3.70, 95% CI 1.06 to 12.88; n = 211; p = 0.04) [33]. Expert opinion/consensus and bench research, abstracts, and editorials/correspondence were excluded [18]. The value of these studies shows safety and efficacy against placebo or oral but greater value would come from direct comparisons with intravenous so it would be easier to assess if intravenous and the associated risks could be avoided if oral is not an option. Remove used medication syringe. There is minimal or no discomfort for the patient in comparison to SC and IM injections. SCI remains underused, and there is an urgent need for more clinical studies to promote decision-making and to guide clinical practice among professionals. IV Drug Infusion For pain management, SCI of morphine was compared with epidural infusions and found to be acceptable and effective with fewer hypotension concerns with subcutaneous than epidural [59, 60]. Medication administration (e.g., PCA) SC vs IV: acceptability, safety. Potassium chloride in amounts considered to be maintenance fluids (10 mEq/L and 20 mEq/L) was added to the solution on an as-needed basis in 2 studies [16, 43]. Total treatment time (from first catheter insertion attempt to end of infusion) was reported in a pediatric study as significantly shorter than the IV route [50]. Volume of hydration in terminal cancer patients. Studies under-report the mechanism (site, mode, frequency and volume) by which artificial hydration is provided, creating a paucity of evidence-based guidance by which to practice. Catheter dislodgments, in which the catheter/needle is pulled out, were more likely to occur with IV than SC in the elderly population (RR 3.78, 95% CI 1.16 to 12.34, p = .03) [34]. WebInfusion therapy refers to any administration of medications in the form of a fluid and that is not administered orally. IV medications act rapidly. 4/6 studiespatient preference for SC over IV because SC at home and time saving, Patient preferred treatment will influence adherence and patient experience/satisfaction, 1 study showed comparable efficacy and safety profiles (IV SC PCA), Unclear if other studies are SC injections or SCI. The Institute for Safe Medication Practices (ISMP) (2014) has created a list of high-alert medications that bear the heightened risk of significant harm when they are used in error. The use of hypodermoclysis for rehydration in terminally ill cancer patients. 2 studies reported successful rehydration with rHFSC fluids alone. If running primary IV solution is medication (e.g., heparin, morphine, pantaloc, insulin, or blood or blood products), do not flush. Systematic review of systematic reviews (PROSPERO CRD42018046504). Chopra V, Flanders SA, Saint S, Woller SC, OGrady NP, Safdar N, et al. A review of SC hydration in neonatal palliative population found no articles studying this population, although a survey of French nurses working in these two settings found 86% were interested in establishing protocols for the SC route for analgesia, anxiolysis or terminal sedation [67]. SCI: mechanisms, locations, duration, quantity, and type, Advanced illness population Sample size 12290, 1 postal survey of doctors n = 1054. Infusion rates varied. Review route of administration and IV site. Inject medication at the recommended rate according to agency policy. A Prospective Study of Hypodermoclysis Performed by Caregivers in the Home Setting. This finding was echoed by a qualitative study which found that 71% of nurses were unaware of this technique and 100% reported not having received any organizational guidance [39]. Ker K, Tansley G, Beecher D, Perner A, Shakur H, Harris T, et al. WebMedications given by IV are usually administered intermittently to treat emergent concerns. 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Always assess when the last dose was given. Cabaero-Martnez MJ, Velasco-lvarez ML, Ramos-Pichardo JD, Ruiz Miralles ML, Priego Valladares M, Cabrero-Garca J. Perceptions of health professionals on subcutaneous hydration in palliative care: A qualitative study. We adopted the systematic review of systematic reviews [17] methodology from the Joanna Briggs Institutes to conduct this review [18]. 11. Use a push-pause method to inject the medication. 1. Review the preparation questions for intravenous medication in Table 7.9 prior to the medication administration. Table 5 provides a summary of the outcomes of the findings from studies and recommendation grades informed by the strength of evidence. This reduces transmission of microorganisms. IV medications act rapidly. Moureau NL, Trick N, Nifong T, Perry C, Kelley C, Carrico R, et al. Short report _A randomized controlled trial of local injections of hyaluronidase versus placebo in cancer patients receiving subcutaneous hydration, Hypodermoclysis to treat dehydration: A review of the evidence, Subcutaneous dextrose for rehydration of elderly patientsAn evidence-based review. WebIt has been reported that microorganisms can gain access to IV infusions during administration, by external sources of contamination such the influx of unfiltered air, the Venous depletion is a growing concern for several patient populations. A Randomized Clinical Trial of Recombinant Human Hyaluronidase-Facilitated Subcutaneous Versus Intravenous Rehydration in Mild to Moderately Dehydrated Children in the Emergency Department. doi:10.1371/journal.pmed.1000097. A systematic search was conducted November 2018 and updated in June 2020 of reviews from 1990 (as recommended by Aromataris et al. Clean the lowest port on the IV tubing with an alcohol swab in a circular motion for 15 seconds. We also acknowledge previous National Science Foundation support under grant numbers 1246120, 1525057, and 1413739. In the December 3, 2020 newsletter, ISMP published an article to remind practitioners that up to half of the medication in a 50 mL small-volume intermittent (See Rationale for Flushing with NS after Administering an IV Medication.). (The PDTM may also be referred to as a parenteral drug monograph [Alberta Health Services, 2009].) A protocol for pediatrics was to insert the SC set and then flush it with 140/150 units hyaluronidase prior to starting the infusion and repeating the dose once every 24 hours during infusion, as needed [27, 34]. 9 RCTs; 2 studied treprostinil vs Placebo. Always ensure the needle insertion site is patent, free from redness and swelling. No studies compared the safety or efficacy of these specific hydration solutions. Infusion Treatments for Rheumatoid Arthritis Federal government websites often end in .gov or .mil. In one large systemic review, 5 of 94 studies reported preference for subcutaneous over IV with reasons varying from less side effects, to less time involved, less pain with access/administration or overall comfort [16]. Given the evidence supporting the safety and efficacy of subcutaneous therapy, we concur with researchers who call for standardized policies and procedures to help optimize both study results and uptake of this practice [46]. Web1. Some IV solutions may not be stopped. Confounding, selection, performance, detection and attrition bias assessed; selected items from the McMaster Quality Assessment Scale of Harms; overall risk of bias ratings: SC immunoglobulin versus IV: effectiveness, safety, efficiency, Patients with primary or secondary immune-deficiency, GRADE, Swedish Council on Health Technology Assessment, SC anti-oxidant treatment vs placebo: effectiveness, Adults with amyotrophic lateral sclerosis, Prostacyclin or one of its analogues in: effectiveness. Lower Cmax, Time-dependent kill gives potential benefit to use of SC administration with increase in Tmax, High risk of resistance with the medication via any route so reserve use, Delayed Tmax and lower Cmax reduces bactericidal power unless used as synergy with beta lactam, Local minor effects may limit use although favorable clinical results, Local reactions reduced with warm compresses, SC continuous infusion bioavailability 90%, Continuous less adverse effects than oral; higher QOL scores; no bone density, Continuous infusion tolerated better than bolus. Discussion includes a consideration of the quality of the evidencee.g., limitation of small number of studies with small sample sizes, few blinded RCTs and diverse methodologies. Reporting of long-term outcomes was limited and inconclusive. 8. Estimation of costs in the older studies is outdated. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Weeks is adjunct faculty at Cedar Crest College in Allentown, Pa., and a per diem staff nurse at Somerset Medical Center in Somerville, N.J.. After preparing the medication, always label the medication syringe with the patient name, date, time, medication, and dose. Duems Noriega and Arino-Blasco [16] report that these local reactions are frequent but easily avoidable (through rate and volume control, proper needle placement [avoiding muscle] and aseptic technique). Intravenous medications by direct IV route can be given three ways: Checklist 60 reviews the steps to administer an IV medication through a saline lock. A score of overall confidence (high, moderate, low and critically low) was assigned by the reviewers to depict the accuracy and comprehensiveness of the data summary and critical methodological flaws [21]. In one of the included palliative care study, 48% reported continuous overnight infusions at 60120 mL/hour, and 21% received a bolus of 500 mL over one hour, one to three times per day. Limitations to the use of SC hydration include those who require high volumes or rapid rehydration or medications not appropriate for SC use. Allow to dry. 8. The JBI grades of recommendation were used to derive the grading score to inform the strength of recommendation for the intervention (Joanna Briggs Institute Levels of Evidence and Grades of Recommendation Working Party, 2013) [22]. 15. Additional Strategies to Improve Complete Delivery of Small In a multi-centre pediatric study, most participating centers did not have protocol or training for inpatient staff [50]. How do you complete this procedure? This project was partially supported via an unrestricted project grant provided by Becton Dickinson, Canada. Vancomycin Dosage 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. With certain medications, creatinine clearance must be assessed prior to administering. After preparing the medication, always label the medication syringe with the patient name, date, time, medication and dose concentration (e.g. Always assess when the last medication dose was given. Haloperidol and furosemide are used off-label and there are no well-designed studies supporting their subcutaneous use. The title and abstract of each article were scanned (independently by one reviewer: DS) and full copies of articles of potentially eligible reviews were obtained. Reactions were more limited with the SCIG infusion versus the intravenous route with local skin whelps and irritation being the most frequent complaint. Alternative rehydration methods: A systematic review and lessons for resource-limited care. Infusion Review the advantages and disadvantages of IV medications. Development of the UK Vessel Health and Preservation (VHP) framework: a multi-organisational collaborative, The 2016 infusion therapy standards of practice. SCI is an effective alternative for rehydration in patients with mild-moderate dehydration. Rochon and colleagues [23] determined that the use of hyaluronidase to promote subcutaneous fluid is unresolved. The investigation of the use of potassium chloride in hydration solutions was limited to three studies [16, 23, 43]. The .gov means its official. Data source: Canadian Institute for Health Information, 2009; Clayton et al., 2010; Perry et al., 2014. and transmitted securely. 8600 Rockville Pike The elderly and the young may be more sensitive to adverse effects of certain intravenous medications. Once an intravenous medication is delivered, it cannot be retrieved. I understand that. >bPfpp0 P0 t2#( Ru- " R B `> ) M / Use of microfilters within the scope of infusion Uncertain if oral chelation therapy reduces the risk of serious adverse effects compared to SCI of DFO. No reliable indication of the likely effect of ketamine, at any dose, as an adjuvant to opioids in cancer pain can be provided. Full texts of these reviews were then screened independently by two reviewers (MC and DB) against the review selection criteria. If swelling, pain, or redness exists, remove IV cannula and restart new IV site. You move quickly. You will need a watch with a second hand to time the rate of administration. Accessibility StatementFor more information contact us atinfo@libretexts.org. Limited studies included in systematic reviews looked at common therapies administered intravenous and subcutaneous including anti-emetics and treatments for pulmonary hypertension. WebIntroduction You have been informed by your healthcare provider that you will need to receive intravenous (IV) infusions of a medication to treat your health condition. Methodologically rigorous research remains scarce, HDC with electrolyte-containing fluids is safe, Hyaluronidase to promote absorption remains unresolved, Limited evidence suggests potassium chloride may, with caution, be safely added to SCI, HDC may be ideally suited for the treatment of dehydration as metabolic imbalances do not have to be corrected immediately. Patients with cirrhosis may require a reduction in dosages. Pinch IV tubing above the lowest access port or use blue slider clamp.
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